Skip to main content

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 provides bulk, blood supply and a physical barrier between the suture lines when local tissue is scarred, deficient or difficult to separate. Use reflects tissue quality, fistula location, prior repairs and donor-site morbidity. Evidence for interposition comes largely from uncontrolled series.[2][4]

For general anatomy and harvest, see Martius Flap. The flap supplements a selected vaginal repair, including Latzko or Sims-Simon closure.

Selection: simple versus compromised repairs​

Consider interposition for recurrent fistula, substantial scarring or tissue loss, urethral involvement, and selected radiation-associated defects. Elkins used the graft for large (over 4 cm) obstetric fistulas, fistulas with urethral sloughing and recurrent fistulas. Eilber reserved interposition for fistulas over 2 cm, radiation-induced fistulas and failed previous repairs. These selection factors rest on series and reconstructive experience, and no graded trial shows benefit in each subgroup. Radiation injury can affect a broader field than the visible fistula, and a flap neither guarantees closure nor restores a severely damaged bladder.[2][3][4][5][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.[2][14]

Randomized evidence: Singh 2019​

Among 126 women with simple obstetric or gynecologic VVF of 4 cm or less, 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. Reduced labial sensation or pain occurred in 9/29 Martius recipients (five with numbness and four with pain) versus none of 28 controls. This trial excluded recurrent, radiation-associated, malignant and other complex fistulas.[14]

A 2024 systematic review of 46 studies of vesicovaginal, urethrovaginal and bladder neck-vaginal fistula repair found no significant improvement in fistula cure with interpositional flaps; study quality and heterogeneous fistulas limit application to complex or irradiated repairs.[17] The 2026 Cochrane publication is a review protocol, not completed comparative results.[1]

Anatomy and harvest principles​

Heinrich Martius, a German gynecologist, described labial tissue for urogenital reconstruction in 1928, originally as a bulbocavernosus muscle flap. Elkins, DeLancey and McGuire showed in a cadaveric study that the tissue harvested in the modern flap is fibroadipose tissue of the labium majus and not bulbocavernosus muscle. It has a superficial fibrous tunic similar to the tunica dartos in men and considerable internal fibrous septa. The underlying bulb and muscle are preserved during harvest.[5][15]

The labial fat pad receives blood supply anteriorly from the external pudendal artery and posteriorly from the internal pudendal artery, and the two systems form a plexus within the graft.[5] 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 labial fat pads from 10 cadavers (18 sections per specimen) found the highest vascular density in the lateral part of the right labium and the highest nerve density in the anterior and medial parts bilaterally. The right labium had 8% higher vascular density and 9% higher nerve density than the left. The authors suggest that a right-sided, lateral harvest may yield a safer flap.[7] The cadaver study did not measure clinical outcomes.[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 2026 EAU guideline recommends an interposition graft when repairing a radiation-associated fistula .[18] Maintain continuous bladder drainage until healing is confirmed; the guideline suggests 10–14 days for simple or post-surgical repairs and 14–21 days for complex or post-radiation repairs .[18] 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. Incise the labium majus along its most dependent edge, beginning at the level of the mons pubis and extending posteriorly as far as the flap requires. 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. Wilson and colleagues describe flap lengths of 8–15 cm in general. Check reach before dividing attachments, because the length needed depends on the defect.
  3. Create a generous tunnel. Connect the donor wound with the vaginal recipient bed beneath the epithelium by blunt dissection, widened to admit at least two fingers so the pedicle is not compressed. A narrow tunnel compresses or kinks the flap.
  4. Interpose and secure. Position the flap over the urinary closure and suture it to the perivaginal fascia without tension using 2-0 or 3-0 interrupted absorbable sutures to prevent migration.[16] One chapter suggests fixing the flap at least 1–2 cm beyond the repair.[16] Avoid excessive bulk or constriction.
  5. Cover and close. Cover the flap with viable vaginal epithelium without tension. Achieve donor-site hemostasis and close the labial wound in layers with absorbable suture. Wilson and colleagues place a small suction drain and a pressure dressing, removed at 24 to 48 hours.[15]

Related technical demonstrations include Martius use for rectovaginal repair.[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 (mostly obstetric): 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. In recurrent fistulas, 11/12 healed with Martius versus 3/7 with anatomic repair. In multiple fistulas, 7/8 healed with Martius versus 3/9.[3]Small, nonrandomized groups. Recurrent and multiple-fistula subgroup results mix fistula locations.
Elkins 199037 fistulas in 35 patients, including both vesicovaginal and rectovaginal defects; reported overall success 86.5%.[5]—
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]The 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.

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. 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.[12]
  • The randomized simple-VVF study found numbness in five and pain in four of 29 Martius recipients. Two of 29 also had a donor-site seroma or hematoma, and both had labial distortion. These events warrant donor-site counselling even when the repair closes successfully.[14]

Alternatives and special modifications​

OptionClinical role and limitations
Peritoneal flapEilber used it for proximal fistulas and the Martius flap for distal fistulas. Suitability depends on anatomy and prior surgery.[4]
OmentumAn abdominal interposition option when adequate vascularized tissue can reach; harvest may be open, laparoscopic or robotic.[2]
GracilisAn alternative for selected extensive or recurrent defects; weigh reach, bulk and an additional donor site.[2]
Full-thickness labial flapCan supply epithelial coverage when vaginal skin is deficient. Eilber reserved it for insufficient vaginal epithelium.[4][10]

A radiation-associated recurrent VVF has been reported to close after staged PRP injections and another Latzko repair with Martius interposition.[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. PMID 2314794

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. 2026;37(7):1997–2003. 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

16. Ingber M, Rackley RR. Vesicovaginal and Urethrovaginal Fistula Repair. In: Goldman HB, ed. Complications of Female Incontinence and Pelvic Reconstructive Surgery. 2nd ed. Springer (Humana Press); 2017:231-238. doi:10.1007/978-3-319-49855-3_21

17. Thompson JC, Halder GE, Jeppson PC, et al. "Repair of vesicovaginal fistulae: a systematic review." Obstet Gynecol. 2024;143(2):229–241. doi:10.1097/AOG.0000000000005468

18. European Association of Urology. "EAU Guidelines on Non-neurogenic Female LUTS: Disease management." 2026. Official guideline.