Rectovaginal Fistula: What is the Role of Martius Flap and Gracilis Muscle Interposition in the Therapeutic Strategy?

BACKGROUND:While numerous treatments exist for management of rectovaginal fistula, none has demonstrated its superiority. The role of diverting stoma remains controversial. Few series include Martius flap in the armamentarium. OBJECTIVE:Determine the role of gracilis muscle interposition and Martius flap in the surgical management of rectovaginal fistula. DESIGN:Retrospective cohort study of a pooled prospectively maintained database from 3 centers. SETTINGS/PATIENTS:All consecutive eligible patients with rectovaginal fistula undergoing Martius flap and gracilis muscle interposition were included from 2001 to 2022. MAIN OUTCOMES:Success was defined by absence of stoma and rectovaginal fistula. RESULTS:Sixty-two patients were included with 55 Martius flap and 24 gracilis muscle interposition performed after failures of 164 initial procedures. Total length of stay was longer for gracilis muscle interposition by 2 days (p = 0.01) without a significant difference in severe morbidity (20% vs. 12%, p = 0.53). 27% of Martius flap were performed without stoma, without impact on overall morbidity (p = 0.763). Per-patient immediate success rates were not significantly different between groups (35% vs. 31%, p = 1.0). Success of gracilis muscle interposition after failure of Martius flap was not significantly different from an initial gracilis muscle interposition (p = 1.0). The immediate success rate rose to 49.4% (49% vs. 50%, p = 1.0) after simple perineal procedures. After a median follow-up of 23 months, there was no significant difference detected in success rate between the two procedures (69% vs. 69%, p = 1.0). Smoking was the only negative predictive factor (p = 0.02). LIMITATIONS:By its retrospective nature, this study is limited in its comparison. CONCLUSION:This novel comparison between Martius flap and gracilis muscle interposition suggests that Martius flap presents several advantages, including shorter length of stay, similar morbidity, and success. Proximal diversion via a stoma for Martius flap does not appear mandatory. Gracilis muscle interposition could be reserved as a salvage procedure after Martius flap failure. See Video Abstract.