Key words
birth trauma - delivery - gynecology
Schlüsselwörter
Frauenheilkunde - Geburtstrauma - Stuhlinkontinenz
Abbreviations
RVF:
rectovaginal fistula
MR:
magnetic resonance tomography
CT:
computer tomography
ES:
endosonography
Introduction
Rectovaginal fistula (RVF) are rare diseases. The most common cause of RVF is obstetric
trauma, with traumatic devascularization of the perineal region resulting in the development
of RVF. Treatment of RVF requires a multidisciplinary approach involving colorectal
surgeons, urologists and gynecologists. Various approaches are used, depending on
the localization, size and etiology of the RVF. Closure of the fistula with interposition
of a pedicled tissue flap (of fat or muscle) is a useful surgical approach to reconstruct
the perineal space and provide neovascularization. One approach for the repair of
rectovaginal fistula in the lower and middle third of the vagina is the modified Martius
procedure.
This surgical approach for RVF repair is described here in detail, together with our
own results after modified Martius procedure.
Rectovaginal Fistula – Etiology
Rectovaginal Fistula – Etiology
Rectovaginal fistulas (RVF) are epithelialized connections between the intestine and
vagina; they account for nearly 5 % of all anorectal fistula [1]. Around 88 % of RVF are caused by obstetric trauma with disruption of the rectovaginal
septum. 0.1 % of patients who required an episiotomy during vaginal delivery go on
to develop RVF [2]. Older publications describe a higher incidence of obstetric trauma, as reflected
in a current study by Brown and colleagues who discuss the decrease in RVF repair
in the United States [3], [4]. The incidence of postpartum trauma and RVF, especially complex RVF, is notably
higher in third world countries, due to the poor quality of the available medical
care and the extent of sexual violence [3].
In addition to obstetric trauma, other causes of RVF are colorectal and pelvic surgery
(in up to 10 % of cases in rectal surgery, especially with the use of staplers, neoadjuvant
and adjuvant radiochemotherapy increasing the rate), irradiation causing obliterating
endarteritis with devascularization of the perineal region, malignant disease (e.g.,
rectal, vaginal and bladder carcinoma involving direct invasion), local inflammatory
processes, diverticulitis, chronic inflammatory bowel disease (about 0.2–2.1 % of
all RVF [3], [5]), and congenital RVF [6], [7]. Perineal trauma can also result in RVF [8]. As the cause of RVF in many cases is obstetric trauma, postpartum RVF are frequently
associated with sphincter lesions, and sphincter reconstruction is routinely performed
during the same operation [9].
Rectovaginal Fistula – Symptoms and Diagnosis
Rectovaginal Fistula – Symptoms and Diagnosis
While the diagnosis can often be easily confirmed by distal examination of the rectum,
treatment, especially of recurrent fistula, makes this disorder very complex. Small
fistula can be asymptomatic. The progress of RVF is accompanied by severe clinical
manifestations: loss of gas and feces from the vagina, diarrhea, tenesmus, frequent
urination, abdominal cramps, rectal bleeding, back pain or anorectal burning sensation
[2]. In about 90 % of cases, the patientʼs medical history together with a clinical
examination including proctoscopy and vaginal exploration lead to the diagnosis of
RVF [10]. If the diagnosis remains unclear, no fistula is found, or malignant disease as
the cause of fistula cannot be excluded, the next diagnostic step is imaging using
magnetic resonance tomography (MR), computer tomography (CT), colon contrast study
or endosonography (ES). MR and ES have the highest diagnostic value for colorectal
fistula and additionally allow potential sphincter lesions to be evaluated [8], [11], [12]. CT with rectal contrast
filling is the second choice, although CT is very accurate in diagnosing abscess formations
or malignancies as complicating comorbidities of RVF [13]. The advantage of ES is its availability and the fact that it offers the option
of evaluating sphincter lesions, which are important when choosing the surgical procedure
[11], [14].
Rectovaginal Fistula – Classification
Rectovaginal Fistula – Classification
Rothenberger et al. differentiated RVF into simple and complex RVF as follows [15]:
-
Simple RVF are located in the lower and middle-third of the vagina; their diameter
is less than 2.5 cm and they are typically caused by trauma or infection.
-
Complex RVF are located in the upper third of the vagina, have a diameter of more
than 2.5 cm and are caused by inflammatory bowel disease (Crohnʼs disease), irradiation
or malignancy [15].
In addition, Fry et al. categorized perineal injuries as injuries with or without
fistula and differentiated the vaginal location by classifying perineal damage into
five subgroups as follows [16]:
-
perineal injury without fistula
-
perineal injury with fistula in the lower third of the vagina
-
no perineal injury, but fistula in the lower third of the vagina
-
no perineal injury, but fistula in the middle third of the vagina
-
no perineal injury, but fistula in the upper third of the vagina [16]
Rectovaginal Fistula – Treatment
Rectovaginal Fistula – Treatment
While there are many therapeutic approaches for RVF, they depend on the fistulaʼs
localization and the patientʼs comorbidities. Lower RVF are usually reconstructed
using an anal, perineal or vaginal approach. Transabdominal approaches are used for
the repair of higher fistulas [3]. Anatomic fistula repair alone is associated with lower success rates compared to
combined procedures with the adjunctive interposition of healthy, vascularized tissue
[17]. In most therapeutic approaches healthy tissue is transposed into the perineal space
between the rectal and vaginal layer to enhance blood supply and granulation tissue,
obliterate “dead” space, protect the sutures of anatomic fistula repair of the different
layers, and prevent rectal and vaginal stenosis. The rate of spontaneous healing is
low, making it important to ensure that RVF repair is adequate, as the success rate
decreases with the number of prior operations [18], [19].
Martius Flap
The Martius procedure for the surgical repair of urethrovaginal fistula was first
described by Heinrich Martius in 1928. He used the bulbocavernosus/bulbospongiosus
muscle for reconstruction [20]. Over time, the Martius flap was modified and became a more extensive procedure,
which used a vascularized adipose tissue flap from the labium majus between the bulbospongiosus
and ischiocavernosus muscle with or without the muscle. The Martius procedure and
its modifications are also used for extraperitoneal repair of fistula in the perineal
region, either urogynecological [21], [22], [23] or rectovaginal fistula [7], [24], [25], [26], [27], as well as to treat stress urinary incontinence by lifting the bladder neck [28], in tethered vagina syndromes, rectal strictures, or vaginal stenosis [22].
Our cadaveric dissections showed that the pedicled flap of the modified Martius procedure
is composed of fibroadipose tissue from the interspace between the bulbocavernosus
and ischiocavernosus muscle which receives its blood supply latero-ventrally from
external pudendal artery branches and latero-dorsally from internal pudendal artery
branches ([Fig. 4]). The modified Martius procedure for urogynecological indications (e.g. for vesicovaginal
fistulas) uses an anterior vascular pedicle, while Martius procedures for colorectal
indications (including RVF repair) use a posterior vascular pedicle what allows rotation
either forwards or backwards depending on the indication of surgery [22].
Fig. 1 Clinical examination of the rectovaginal fistula.
Fig. 2 Principles of fistula repair using a modified Martius flap: healthy tissue provides
neovascularization of the perineal space and divides the single sutures of the primary
fistula repair (modified from Given et al. [34]).
Fig. 3 Operative technique. After a horizontal perineal incision, the spatium rectovaginale
is mobilized, the fistula is dissected, and the posterior vaginal wall and rectal
mucosa are closed with single sutures. Only one operating field is used for RVF repair
in the Martius procedure. After precise measurement (6 cm from the perineum, 45 degrees
in an anterior-cranial direction and 8 cm cranially), the second vertical labia majora
incision is made to dissect the posterior pedicled adipose tissue flap. The modified
Martius flap is then pivoted dorsally under the ischiocavernosus muscle and sutured
without tension in the spatium rectovaginale to separate vaginal and rectal sutures.
Fig. 4 Cadaveric studies of the blood supply of a pedicled Martius flap. Arrows indicating
small dorsal blood supply, derived from the internal pudendal artery.
In their retrospective analysis, Pinto et al. described an overall success rate of
87 % after a follow-up of 20 months for fistulas treated with one or more surgical
procedures. Depending on the underlying disease, they described success rates of 66 %
if the fistula was caused by obstetric trauma, 70 % if it developed postoperatively
and 44 % for RVF caused by Crohnʼs disease [29]. The literature reports overall success rates of 33–100 % for the Martius procedure
in the surgical repair of mainly recurrent RVF [3], [30]. The majority of studies in the current literature consist of small retrospective
analyses or case series. In the German guidelines for the treatment of RVF, Ommer
et al. reviewed the studies dealing with the Martius procedure for RVF repair. Only
seven of the cited studies analyzed more than 10 patients; they reported primary healing
rates of 65 % (patients with Crohnʼs disease) and of 75 % (patients without Crohnʼs
disease) to 100 % [3]. Most studies reported high healing rates with this procedure, indicating that the
(modified) Martius flap can
be recommended for the surgical management of complicated and recurrent RVF [3].
Modified Martius Flap – Operative Technique
Modified Martius Flap – Operative Technique
To keep the operative site clean, a temporary transurethral urinary catheter is placed
preoperatively ([Fig. 1] shows the preoperative examination). The patient is placed in a modified lithotomy
position and the first incision is made horizontally in the perineal region to dissect
the posterior vaginal wall from the rectum and mobilize the rectovaginal fascia. The
next step consists of repairing the rectal mucosa using single 3–0 PDS sutures ([Fig. 3]). In cases with anorectal sphincter involvement, the sphincter muscles should be
repaired by sphincteroplasty, using an end-to-end or overlapping suture technique
as previously described to prevent incontinence [31].
After the rectal defect is proven to be repaired, the exact localization where the
modified Martius flap will be dissected from the labia majora area is measured (6 cm
from the perineum, 45 degrees in an anterior-cranial direction and 8 cm cranially;
[Fig. 3]). A second, 8-cm vertical incision is made at this site ([Fig. 3]) and the vascular pedicled flap of adipose tissue is prepared from anteromedial
to posterolateral ([Fig. 3]) with careful preservation of the small dorsolateral arteries ([Fig. 4]). As mentioned above, the fibroadipose tissue creating the modified Martius flap
receives its blood supply from a small vascular branch network derived anterolaterally
from the external pudendal artery and posterolaterally from the internal pudendal
artery ([Fig. 4]). In the repair of RVF it is important to use the posterolateral internal pudendal
artery for the vascular pedicle to ensure sufficient flap length to reach dorsally
into the spatium rectovaginale.
After dissection and mobilization of the vascular pedicled modified Martius flap,
the flap must be placed in the spatium rectovaginale. From the perineal incision a
subcutaneous tunnel is prepared under the bulbospongiosus muscle close to the ramus
descendens of the pubic bone so that the flap can be inserted between the vagina and
rectum to fill up the “dead” space, achieve neovascularization of the perineal region,
and separate the sutures of anatomic fistula repair to achieve optimal wound healing
([Fig. 2]). The vascular pedicled flap should be handled with care; rotation or twisting should
be avoided during transposition to ensure optimal blood supply. The adipose tissue
flap is fixed to the external surface of the anal sphincter with single tension-free
3–0 PDS sutures, followed by hemostasis control and wound closure using single 3–0
Prolene sutures ([Fig. 3]). Wound closure must be gentle to allow uncomplicated drainage of postoperative
seroma to guard against infection ([Fig. 3]).
As a diverting colostomy is an appropriate method to prevent infectious complications
in the perineal region which can impair wound healing, especially in the management
of recurrent RVF, a temporary transversostomy is done during the same session in addition
to RVF repair [17], [29].
Case Report
A 32-year-old patient suffered from complex persistent and therapy-resistant RVF (diameter
approximately 3 cm; [Fig. 1]). Traumatic vaginal delivery in 2009 led to perineal injury with subsequent development
of a RVF, degree II according to Fryʼs classification. Initial management consisted
of surgery with insertion of a fistula plug and plastic reconstruction of the posterior
vaginal wall. Three months after initial surgery the fistula persisted, and the surgical
procedure was repeated. After a further nine months RVF still persisted, and surgery
was again performed with plastic reconstruction of the posterior vaginal wall together
with interposition of a rectal mucosal flap and interposition of a bioprosthetic mesh
(SURGISIS® mesh) into the rectovaginal space [32], but this did not prevent the patient from again developing RVF.
Forty-eight months after the initial obstetric trauma and persistent RVF, the patient
underwent surgery with a modified Martius approach as described above. The procedure
was carried out by an interdisciplinary team of general surgeons and urologists in
a pelvic floor center. Operation time was 132 minutes for fistula repair and creation
of a diverting transversostomy. No intraoperative or postoperative complications were
noted according to the Clavien-Dindo classification [33]. Both perineal and pudendal wounds healed per primam, no perineal sepsis or wound
infection was observed, and the temporary transversostomy was removed four months
after RVF repair. No recurrence of RVF was observed at a follow-up of 15 months. The
functional and cosmetic results were excellent with high patient satisfaction and
greatly improved quality of life.
Conclusion
The Martius procedure for RVF repair is limited to a single operating field. It is
a safely feasible procedure which offers good cosmetic and functional results by enhancing
blood supply in the perineal region. RVF repair should not be performed in inflamed
tissue, so a diverting transversostomy should be considered to prevent perineal sepsis,
depending on the etiology of RVF and local conditions. A diverting colostomy can be
performed together with the Martius procedure in the same session.
Martius procedure for RVF repair offers the additional benefit of dividing vaginal
and rectal layers after suturing and improves wound healing through neovascularization.
It can be safely performed with good postoperative results, even for the repair of
complex fistula which have been treated surgically multiple times previously. Long-term
follow-up of our patient indicates a low recurrence rate of RVF after repair using
a Martius approach together with a temporary transversostomy and that patients benefit
from the good functional and cosmetic results and a dramatically improved quality
of life.
Consent
Informed consent was obtained from the patient and is available for review from the
editor of this journal.
