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Martius Labial Fat-Pad Flap for Vesicovaginal Fistula

The modified Martius flap transfers a vascularized, pedicled labial fat pad between the urinary and vaginal closures. It can provide coverage when local tissue is scarred, deficient or difficult to separate. Its use should reflect tissue quality, fistula location, prior repairs and donor-site morbidity. Successful uncontrolled series do not establish that every VVF benefits from interposition.[2][4]

For general anatomy and harvest, see Martius Flap. The flap supplements a selected vaginal repair, including Latzko or Sims-Simon closure; it does not replace a tension-free urinary closure.

Selection: simple versus compromised repairs​

Consider interposition for recurrent fistula, substantial scarring or tissue loss, urethral involvement, and selected radiation-associated defects. These are clinical selection factors supported mainly by series and reconstructive experience, rather than a graded demonstration of benefit in each subgroup. Radiation injury can affect a broader field than the visible fistula, and adding a flap does not guarantee closure or restore a severely damaged bladder.[2][3][8]

For a simple fistula with healthy, mobile tissue, routine Martius interposition has not shown a clear closure advantage in the available small randomized comparison. Obstetric origin alone neither requires nor excludes a flap; ischemic tissue loss, urethral damage and repair history matter.[2][14]

Randomized evidence: Singh 2019​

Among 126 women with simple VVF, the route was selected by anatomy and flap use was randomized within each route. In the vaginal group, closure occurred in 27/29 with Martius versus 27/28 without a flap (P = 1); mean follow-up for the study was 39.6 months. Altered labial sensation occurred in 9/29 Martius recipients versus none of 28 controls. This small trial did not establish equivalence, and excluded recurrent, radiation-associated, malignant and other complex fistulas. It supports selective rather than automatic interposition in the population studied.[14]

The 2026 Cochrane publication cited below is a review protocol, not completed comparative results.[1]

Anatomy and harvest principles​

The historical operation included bulbocavernosus muscle. The modern modified flap is principally fibroadipose tissue, with a fibrous covering and septa; preserve the underlying bulb and muscle during harvest.[5][15]

The labial fat pad receives anterior external-pudendal and posterior internal-pudendal contributions. An inferiorly based flap is commonly raised by dividing the superior attachment while retaining a broad inferior vascular base. Pedicle and side selection depend on perfusion, prior incisions and the arc required to reach the defect without tension.[15]

A neurovascular mapping study of 10 cadavers, published online in 2025, describes regional variations within the fat pad. It does not demonstrate that a right-sided flap is clinically safer or that a particular approach prevents sensory injury; do not convert exploratory cadaveric measurements into a mandatory harvest rule.[7]

Operative framework​

After defining the fistula and protecting adjacent ureters or urethra as appropriate, complete the selected urinary repair and assess the need for interposition. The following framework complements the general harvest page and published technique descriptions; dimensions and suture choices depend on the recipient defect.[9][15]

  1. Expose the fat pad. Place a labial incision of sufficient length for the required flap. Develop the plane outside the fat pad while preserving viable labial skin and avoiding the underlying bulbospongiosus, ischiocavernosus and vestibular bulb.
  2. Mobilize while protecting perfusion. Retain a broad pedicle and enough tissue to cover the repair. Check reach before dividing attachments; a fixed incision length or flap size is not appropriate for every patient.
  3. Create a generous tunnel. Connect the donor wound with the vaginal recipient bed beneath the epithelium. Avoid a narrow tunnel that compresses or kinks the flap.
  4. Interpose and secure. Position the flap over the urinary closure and fix it to suitable surrounding tissue with absorbable sutures. Preserve perfusion and avoid excessive bulk, tension or constriction.
  5. Cover and close. Cover the flap with viable vaginal epithelium without tension. Achieve donor-site hemostasis and close in layers; drain use depends on dead space and the operative circumstances.[15]

Related technical demonstrations include Martius use for rectovaginal repair; their operative anatomy can be informative, but their outcomes should not be presented as VVF results.[6]

What the major cited series actually show​

StudyPopulation and resultInterpretation
Eilber 2003207 VVF patients; 120 received interposition: 83 peritoneal, 34 Martius and 3 full-thickness skin flaps. Reported closure was 96%, 97% and 33%, respectively.[4]Flaps were selected for different defects. These are not randomized comparisons; the skin-flap percentage represents only 3 patients.
Rangnekar 200046 urinary-vaginal fistulas: 34 VVF and 12 urethrovaginal. Martius was used in 13 VVF and 8 urethrovaginal repairs; closure was 13/13 and 7/8, compared with 17/21 and 1/4 without Martius.[3]Small, nonrandomized groups. Recurrent and multiple-fistula subgroup results mix fistula locations and cannot quantify a causal flap benefit.
Elkins 199037 fistulas in 35 patients, including both vesicovaginal and rectovaginal defects; reported overall success 86.5%.[5]Mixed reconstructive experience, not a VVF-only comparative estimate.
Pushkar 2009Of 216 women with radiation-associated VVF, 210 underwent vaginal repair; 86 received Martius and 75 Latzko. Initial closure was 101/210, rising to 169/210 after repeat procedures.[8]48.1% initial and 80.4% eventual success describe all 210 vaginal repairs, not the 86 Martius repairs.

Closure, continence, sexual function and freedom from further surgery are separate outcomes. A closed fistula does not establish that the bladder or urethral outlet functions normally.

Donor-site morbidity and counselling​

Discuss numbness, pain, hematoma or seroma, infection, labial asymmetry and possible sexual symptoms. Rates depend on the operation, measurement and follow-up population.[12][13][14]

  • Lee 2013: 97 of 122 eligible women undergoing several types of vaginal reconstruction were analyzed at a mean of approximately 7 years. Seventy-nine reported normal sensation, 13 numbness and 5 pain. Nine reported labial distortion; the abstract's accompanying percentage does not match the analyzed denominator, so a precise percentage is not reproduced here. Only 20 of the 97 had VVF repair, and sexual-function data came from a smaller respondent subset.[13]
  • Petrou 2002: eight women undergoing urethrolysis with Martius interposition reported five cases of numbness, three of intermittent discomfort and one of dyspareunia at about one year. This small urethrolysis series is not a VVF-specific complication rate.[12]
  • The randomized simple-VVF study found numbness in five and pain in four of 29 Martius recipients. These data support explicit donor-site counselling even when the repair closes successfully.[14]

Alternatives and special modifications​

OptionClinical role and limitations
Peritoneal flapMay be accessible for a proximal vaginal repair; suitability depends on anatomy and prior surgery. Eilber's selected series cannot establish equivalence or lower morbidity versus Martius.[4]
OmentumAn abdominal interposition option when adequate vascularized tissue can reach; harvest may be open, laparoscopic or robotic. It does not inherently require laparotomy.[2]
GracilisAn alternative for selected extensive or recurrent defects; weigh reach, bulk and an additional donor site rather than comparing unrelated success percentages.[2]
Full-thickness labial flapCan supply epithelial coverage when vaginal skin is deficient. The three cases in Eilber's series do not define its general success rate.[4][10]

A radiation-associated recurrent VVF has been reported to close after staged PRP injections and another Latzko repair with Martius interposition. The multiple cointerventions in that single case do not establish an added benefit of PRP or justify routine use.[11]

See Also​

Videos​

Vaginal Repair of VVF with Martius Flap Interposition
Preeti Urology & Kidney Hospital (2023)
Vesicovaginal Fistula: Vaginal Repair with Martius Graft
Dr Deeksha Pandey (2023)

References​

1. Okada Y, Matsushita T, Hasegawa T, et al. Surgical interventions for treating vesicovaginal fistula in women [protocol]. Cochrane Database Syst Rev. 2026;1:CD015413. doi:10.1002/14651858.CD015413

2. Kapriniotis K, Loufopoulos I, Gresty HCM, Greenwell TJ, Ockrim JL. The utility of Martius fat pad in the repair of urogenital fistulae: review of current evidence. BJU Int. 2024;134(3):365–374. doi:10.1111/bju.16350

3. Rangnekar NP, Imdad Ali N, Kaul SA, Pathak HR. Role of the Martius procedure in the management of urinary-vaginal fistulas. J Am Coll Surg. 2000;191(3):259–263. doi:10.1016/s1072-7515(00)00351-3

4. Eilber KS, Kavaler E, Rodríguez LV, Rosenblum N, Raz S. Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition. J Urol. 2003;169(3):1033–1036. doi:10.1097/01.ju.0000049723.57485.e7

5. Elkins TE, DeLancey JO, McGuire EJ. The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol. 1990;75(4):727–733.

6. Leach DA, Gebhart JB. Martius labial fat pad graft (use in rectovaginal fistula repair). Int Urogynecol J. 2020;31(11):2427–2429. doi:10.1007/s00192-020-04315-3

7. Rothenberger RW, Feroz R, Hogarth N, et al. Neurovascular mapping of the labial fat pad: implications for optimal Martius flap harvest. Int Urogynecol J. 2025. doi:10.1007/s00192-025-06383-9

8. Pushkar DY, Dyakov VV, Kasyan GR. Management of radiation-induced vesicovaginal fistula. Eur Urol. 2009;55(1):131–137. doi:10.1016/j.eururo.2008.04.044

9. Marina T, Lago V, Padilla P, Matute L, Domingo S. Vesicovaginal fistula repair by modified Martius flap: a step-by-step surgical technique video. Ann Surg Oncol. 2021;28(2):1002–1006. doi:10.1245/s10434-020-09020-5

10. Carr LK, Webster GD. Full-thickness cutaneous Martius flaps: a useful technique in female reconstructive urology. Urology. 1996;48(3):461–463. doi:10.1016/S0090-4295(96)00193-8

11. Kołodyńska A, Streit-Ciećkiewicz D, Kot A, Kuliniec I, Futyma K. Radiation-induced recurrent vesicovaginal fistula — treatment with adjuvant platelet-rich plasma injection and Martius flap placement: case report and review of literature. Int J Environ Res Public Health. 2021;18(9):4867. doi:10.3390/ijerph18094867

12. Petrou SP, Jones J, Parra RO. Martius flap harvest site: patient self-perception. J Urol. 2002;167(5):2098–2099. doi:10.1016/S0022-5347(05)65093-8

13. Lee D, Dillon BE, Zimmern PE. Long-term morbidity of Martius labial fat pad graft in vaginal reconstruction surgery. Urology. 2013;82(6):1261–1266. doi:10.1016/j.urology.2013.08.032

14. Singh V, Mehrotra S, Bansal A, et al. Prospective randomized comparison of repairing vesicovaginal fistula with or without the interposition flap: result from a tertiary care institute in northern India. Turk J Urol. 2019;45(5):377–383. doi:10.5152/tud.2019.85233

15. Wilson A, Pillay S, Greenwell T. How and why to take a Martius labial interposition flap in female urology. Transl Androl Urol. 2017;6(Suppl 2):S81–S87. doi:10.21037/tau.2017.04.38