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

BACKGROUND:Although numerous treatments exist for the management of rectovaginal fistula, none has demonstrated its superiority. The role of diverting stoma remains controversial. A 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.PATIENTS:All consecutive eligible patients with rectovaginal fistula undergoing Martius flap and gracilis muscle interposition were included from 2001 to 2022.MAIN OUTCOME MEASURES:Success was defined by the 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). Twenty-seven percent of the Martius flap interpositions were performed without a stoma, which did not have an impact on overall morbidity (p = 0.763). Per patient immediate success rates were not significantly different between groups (35% vs 31%, p > 0.99). The success of gracilis muscle interposition after the failure of the Martius flap was not significantly different from an initial gracilis muscle interposition (p > 0.99). After simple perineal procedures, the immediate success rate rose to 49.4% (49% vs 50%, p > 0.99). After a median follow-up of 23 months, no significant difference was detected in success rate between the 2 procedures (69% vs 69%, p > 0.99). Smoking was the only negative predictive factor (p = 0.02).LIMITATIONS:By its retrospective nature, this study is limited in its comparison.CONCLUSIONS: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 similar success rate. 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.