2022-VA-864-ESGO Rectovaginal fistula repair by Martius flap after exclusive chemo-radiation in advanced cervical cancer patient. A case report. (20th October 2022) - Capozzi, Vito Andrea
Abstract : Introduction/Background: Rectovaginal fistula (RVF) is an abnormal communication between rectum and vagina. Common causes are: pelvic irradiation, obstetric trauma, Crohn's disease and postsurgical complications. Conservative treatments are usually performed in patients unfit for surgery and are characterized by high recurrence rate.Common surgical approach includes fistula debridment and repair or flap interposition. Simple anatomic fistula repair is associated with lower success rates compared to vascularized flap interposition. The Martius flap (MF) is a vascularized muscle- adipose flap obtained from the bulbocavernosus muscle. Blood supply is provided by pudendal artery branches.MF is a safely procedure which offers good cosmetic and functional results improving wound healing through neovascularization. Before surgery, a protective ileostomy is usually required. Methodology: Case presentation: a 72-year-old woman with squamous cervical cancer, IIB FIGO stage, was treated by exclusive chemo-radiation at our department. After three years of negative follow-up, the patient was hospitalized for fecal vaginal discharge. Gynecological examination showed an RVF between the lower one-third of the posterior vaginal wall and rectum. Colonoscopy confirmed the presence of an RVF of 2–3 mm diameter. Previous conservative treatments were ineffective. Therefore, after ileostomy, surgical treatment through a Martius flap was attempted. Surgical steps: 1) Laterolabial skin incision. 2) Labial dissection to identify the muscle- adipose flap 3) Mobilization of the flap. 4) Opening of the lateral vaginal tunnel. 5) Clamping of the superior pedicle. 6) Transfer of MF to the vagina. 7) Suture of MF over the vaginal surgical site. 8) Suture of the subcutaneous layer and skin.Amoxicillin, clavulanic acid, and metronidazole were administered 30 min before and continued seven days after surgery. Results: Postoperative course was uncomplicated: After 6 months follow-up, no recurrence of RVF was observed.The patient reported a great improved quality of life. Conclusion: The MF is an effective and safe procedure for RVF repair.