Martius flaps for low rectovaginal fistulae: a systematic review and proportional meta-analysis

Introduction: Rectovaginal fistulae (RVF) are notoriously challenging to treat. Martius flap (MF) is a technique employed to manage RVF, among various other procedures, with none being universally successful. We aimed to assess the outcomes of RVF managed with MF interposition. Methods: A PRISMA-compliant meta-analysis searching for all studies specifically reporting on the outcomes of MF for RVF was performed. The primary objective was the mean success rate, secondary objectives included complications and recurrence. The MedCalc software (version 20.118) was used to conduct proportional meta-analyses of data. Weighted mean values with 95% CI are presented and stratified according to aetiology where possible. Results: Twelve non-randomized (11 retrospective, 1 prospective) studies, assessing 137 MF procedures were included. The mean age of the study population was 42.2 +/- 15.7 years. There were 45 primary and 92 recurrent RVF. The weighted mean success rate for MF when performed for primary RVF was 91.4% (95% CI: 79.45- 98.46; I-2= 32.1%; p=0.183) and that for recurrent RVF was 77.5% (95% CI: 62.24- 89.67; I-2= 58.1%; p=0.008). The weighted mean complication rate was 29% (95% CI: 8.98- 54.68; I-2= 85.4%; p<0.0001) and the overall recurrence rate was 12.0% (95% CI: 5.03- 21.93; I-2= 52.3%; p=0.021). When purely radiotherapy-induced RVF were evaluated, the mean overall success rate was 94.6% (95% CI: 83.33- 99.75; I-2= 0%; p=0.350). Conclusion: MF interposition appears to be an effective treatment modality for RVF. Future randomized studies should be conducted to confirm these findings and to compare MF with other surgical techniques.