Skip to main content

Interposition Flap Options for Vaginal Fistula Repair

The role of interposition flaps in vesicovaginal fistula (VVF) and rectovaginal fistula (RVF) repair is one of the most debated topics in fistula surgery — routine use remains controversial, with no high-quality RCT data to definitively resolve the question.[1][2] The current consensus is that flaps should be individualized: probably unnecessary for most simple non-irradiated fistulae, but valuable for recurrent, radiation-induced, and complex fistulae with tissue loss or poor vascularity.[2][3]

This page consolidates every interposition option used in vaginal-fistula repair. For technique-level pages, see Martius Flap for VVF, O'Conor (Transvesical), Extravesical Repair, Latzko, and Sims-Simon. For the underlying anatomy of individual flaps see the foundations entries — Martius, Omental, Gracilis, VRAM.

Rationale for Tissue Interposition​

Four functions when placed between bladder/rectum and vaginal closures:[1][4][5]

  1. Additional blood supply — bring well-vascularized non-irradiated tissue to a potentially ischemic repair (neovascularization).
  2. Physical barrier — prevent overlapping suture lines from communicating.
  3. Dead-space obliteration — reduce seroma / hematoma in the vesicovaginal or rectovaginal space.
  4. Structural reinforcement — add bulk and strength when native tissue is deficient.

Flaps may also reduce dyspareunia by reducing postoperative vaginal scarring.[1]

The Flap-vs-No-Flap Debate​

Against routine flap use​

  • Obstetric fistulae — tissue interposition has been almost completely abandoned, with large series reporting closure >90% with graftless repair even for complex obstetric fistulae.[2]
  • Simple iatrogenic fistulae — graftless repair achieves 86–100%.[2]
  • Mörgeli & Tunn 2021 — modified Sims-Simon, n = 47, 100% without any flap, median OR 40 min.[6]
  • Miklos & Moore 15-yr — laparoscopic extravesical, n = 44, 98% without omental flap.[7]
  • Lap / robotic SR — no statistical difference with vs without interposition.[8]
  • Donor-site morbidity (seroma, hematoma, numbness, pain, labial distortion for Martius; ileus for omental).

For routine flap use​

  • Evans 2001 — 100% (12/12) with interposition vs 63% (12/19) without for benign transabdominal VVF; recommended flaps in all transabdominal repairs.[9]
  • Rangnekar 2000 — Martius for recurrent fistulae 91.7% vs 42.9% without flap.[10]
  • Eilber & Raz 10-yr — interposition in 58% (all complex / recurrent / radiation-induced); peritoneal 96%, Martius 97%.[11]
  • EAU Robotic Section consensus — tissue interposition seems to be beneficial.[12]

Consensus. Individualize by complexity, tissue quality, etiology, and prior repair history.[2][3]

Native Vaginal-Wall Flaps​

These techniques use the vaginal wall itself as the reconstructive element — no external donor site, no labial incision, no donor-site morbidity. They sit between "no flap at all" and an imported tissue interposition (Martius, omental, gracilis, VRAM).

Vaginal flap reinforcement (Shoukry technique)​

A rectangular vaginal flap is created proximal to the fistula and used as a third tissue layer during transvaginal repair, without harvesting from outside the operative field.[37]

  • Circumferential incision around the fistula; complete tract excision.
  • Rectangular vaginal flap raised proximal to the fistula.
  • Standard one- or two-layer bladder closure.
  • Distal edges of the vaginal flap mobilized and the flap interposed between the bladder closure and the vaginal epithelium as a third layer.
  • Vagina closed over the interposed flap.
  • Outcomes: 20 patients with low VVFs — 100% at 16 ± 9 mo; no added morbidity; no postoperative complications.
  • Why it matters. Adds a third layer without any external donor — avoids Martius-harvest morbidity (numbness, pain, labial distortion) entirely.

Vaginal flap transfer coverage (Wang technique)​

A lateral free vaginal flap is transferred to cover the fistula, with the principle that the fistula is displaced away from the incision suture line.[17]

  • Prone split-leg position improves exposure.
  • Lateral vaginal-wall flap mobilized.
  • Fistula transferred beneath the flap so the fistula opening is no longer aligned with the suture line — the key principle.
  • Flap sutured in place, covering the fistula site.
  • Outcomes: 37 patients — 91.9% primary healing; the 3 recurrences had significantly reduced fistula size and were all cured with a secondary repair using the same technique. 100% ultimate success.
  • Pros. Maintains vaginal length; the prone split-leg position improves exposure; no external donor site; biomechanically sound principle of separating the fistula from the suture line.

Single-layer annular vaginal flap (Tang technique)​

A simplified transvaginal closure that eliminates separate bladder closure entirely.[38]

  • Vaginal epithelium incised in an annular (circumferential) pattern around the fistula.
  • Vaginal flap mobilized circumferentially; fistula tract freshened.
  • Bladder defect not closed separately — the annular vaginal flap is advanced and closed as a single layer over the fistula, relying on vaginal fibromuscular tissue as the barrier.
  • Outcomes: 17 transvaginal patients — 82.3% first-time success; significantly shorter OR time, less blood loss, shorter LOS, lower cost, and fewer minor complications vs the transvesical group (p <0.05).
  • Best fit. Simple, small fistulae. The 82.3% success — lower than the multilayer techniques — argues against using it for complex disease.

Vaginal cuff flap (Sayegh — robotic)​

A flap of the vaginal apex harvested during robotic transabdominal repair, particularly useful when the omentum is unavailable.[39]

  • During robotic repair, the vaginal apex (cuff) is dissected.
  • After VVF excision and bladder closure, a flap of vaginal-cuff tissue is harvested and interposed between the bladder and vaginal closures.
  • Outcomes. Reported in a complex case (radiation-induced combined VVF + RVF after ovarian debulking and radiotherapy) — no fistula recurrence at 30 mo, though the patient required adjunctive hyperbaric oxygen and a subsequent transvesical endoluminal closure.
  • Why it matters. Demonstrates that the vaginal cuff itself is a feasible interposition tissue when traditional flaps (omentum, Martius) are unavailable — particularly in post-oncologic surgery patients who have undergone omentectomy.

Latzko partial colpocleisis — the original "vaginal flap"​

The Latzko procedure (1942) is fundamentally a vaginal-wall flap technique — it uses the vaginal epithelium surrounding the fistula as advancement flaps imbricated over the fistula without excising the tract. See Transvaginal Latzko Repair for full detail. The principal trade-off vs the Shoukry / Wang / Tang techniques above: the Latzko shortens the vagina (partial colpocleisis by definition), whereas the modern native-vaginal-wall flap variants preserve length.[1]

Transvaginal Flaps​

1. Martius labial fat-pad flap​

The most commonly used transvaginal interposition. See dedicated Martius Flap for VVF page for full anatomy, harvest technique, and outcome detail.

Quick reference:

  • Anatomy — fibroadipose tissue of the labium majus; dual blood supply (external + internal pudendal); strong intrinsic fibrous component.[13]
  • Indications — distal / mid-vaginal fistulae; recurrent (most dramatic benefit); radiation-induced; significant tissue loss; urethral involvement; poorly vascularized tissues.[2]
  • Success — 80–97% across series.
  • Donor morbidity (Lee 2013, n = 122, mean 7-yr): no perioperative complications; 81% normal sensation, 14% numbness, 5% pain, 7% labial distortion.[15]
  • Modified Martius (Marina 2021) — preserves posterior pedicle with wider dissection; good long-term function and aesthetics.[14]

2. Peritoneal flap​

  • Anatomy. Pelvic peritoneum harvested transvaginally from the cul-de-sac or vesicouterine fold.
  • Technique. After transvaginal vesicovaginal-space dissection, peritoneal cavity is entered posteriorly; a peritoneal flap is mobilized and brought down between the bladder and vaginal closures.[11]
  • Indication. Proximal / apical fistulae, especially when too high for a Martius to reach.
  • Success. Eilber & Raz n = 83 — 96%, comparable to Martius (97%) with minimal morbidity.[11]
  • Pros. Easily created transvaginally; no additional incision; no donor-site morbidity.
  • Cons. Less bulk than Martius; not suitable for distal fistulae.

The peritoneal flap is the preferred transvaginal interposition for proximal fistulae, particularly after failed prior repair.[11]

3. Full-thickness labial flap​

  • Indication. Insufficient vaginal epithelium — provides both interposition and epithelial coverage.[11]
  • Success. Only 33% (1/3) in the Eilber & Raz series — likely reflects extreme case complexity rather than an inherent flaw.

4. Genito-gluteal fold fat-pad flap (Heo 2008)​

Alternative to the Martius:[16]

  • Easier dissection, lower donor-site morbidity, larger flap dimension.
  • Particularly useful for vaginal-cuff-area fistulae.
  • 100% (2/2) in initial report, no recurrence at 1 yr.

5. Vaginal flap transfer coverage (Wang 2023)​

Lateral free flap of vaginal tissue mobilized to transfer the fistula away from the incision suture line, maintaining vaginal length:[17]

  • 91.9% primary healing (34/37); 100% after secondary repair.
  • Maintains vaginal length; separates fistula from the suture line; no external donor site.

6. Labia majora fasciocutaneous flap​

A fasciocutaneous flap incorporating both the labial fat pad and overlying skin — provides epithelial coverage in addition to interposition bulk. Indicated when the vaginal wall itself is deficient.[40]

  • Indications. Non-capacious rigid vagina; irradiated and inflamed surrounding tissues; urethrovaginal fistula with anterior vaginal-wall loss and vaginal stenosis; vesicolabial fistula.
  • Outcomes. Gupta 7 patients with complex fistulae — all radiation-induced VVF patients had no leak postoperatively (except 1 who required subsequent colpocleisis). The patient with urethrovaginal fistula and vaginal stenosis achieved continence with a capacious vagina.
  • Key advantage over standard Martius. The fasciocutaneous component provides epithelial coverage, critical when vaginal-wall tissue is deficient and cannot be closed primarily.

7. Full-thickness Martius graft with skin paddle​

A modification for large obstetric fistulae with massive vaginal-wall destruction — the standard Martius fat pad is harvested with an attached full-thickness medial-thigh skin patch.[41]

  • Bulbocavernosus fat pad harvested in the usual manner.
  • Full-thickness skin patch from the medial thigh attached to the fat pad.
  • Composite graft transferred to the vaginal defect; the skin component provides epithelial coverage for vaginal reconstruction.
  • Outcomes. Margolis n = 4 — 100% graft take by POD 10; adequate vaginal depth and caliber in all; sexual function resumed in 3/4 (one had recurrent VVF).

Transabdominal Flaps​

6. Omental flap (workhorse for transabdominal repair)​

The tissue of first choice for transabdominal VVF repair.[5] See Omental Flap (foundations) for general anatomy.

  • Pedicle. Right or left gastroepiploic — long reach into the deep pelvis.
  • Technique. Mobilize off the transverse colon; bring down into pelvis; suture between bladder and vaginal closures.[18] In robotic / laparoscopic surgery, mobilize laparoscopically before docking the robot.
  • Indications. All transabdominal VVF repairs (Evans recommendation), radiation-induced fistulae, recurrent, large or complex.
  • Success. 95–100% with transabdominal repair.[5][9]
  • Cons. Postop ileus, abdominal pain; unavailable after omentectomy; adds dissection and OR time.

7. "Rainbow-shaped" peritoneal flap (Yang 2025)​

Robotic alternative to omental flap:[19]

  • Crescent-shaped peritoneal flap from the pelvic sidewall.
  • Rotated and sutured between bladder and vaginal closures.
  • 100% (15/15); mean OR 137 min; EBL 14 mL.
  • Avoids omental-harvest morbidity while still providing vascularized interposition.

8. Sigmoid epiploicae​

Epiploic appendages of the sigmoid colon — small flap volume, readily available, no major dissection. Limited series-level data.

Myocutaneous Flaps (Complex / Salvage)​

9. Gracilis muscle flap​

See Gracilis Flap (foundations) for general anatomy.

  • Pedicle. Medial circumflex femoral artery (dominant, ~10 cm below pubic tubercle); minor pedicles from superficial femoral. Harvested as muscle-only or myocutaneous.[20][21][22]
  • Technique. Medial-thigh longitudinal incision; mobilize from distal pes anserinus insertion; preserve dominant pedicle; tunnel subcutaneously to perineum / vagina; interpose between bladder/rectum and vaginal closures or fill the fistula defect.
  • Indications. Very large defects with significant tissue loss; radiation-induced fistulae (non-irradiated tissue from outside the radiation field); multiple failed prior repairs; obstetric VVF with extensive tissue loss in combination with Singapore flap.[20][23]
  • Outcomes. Paprottka 8 gracilis flaps — all fistulae successfully eradicated at mean 6.3 yr; continence restored in all.[20]
  • OR time. Mean 3:11 hr.
  • Donor morbidity. Thigh weakness (usually compensated by other adductors); wound complications. Significantly lower donor-site complications than VRAM (16% vs 57.6% in proportional meta-analysis).[24]

10. Vertical Rectus Abdominis Myocutaneous (VRAM) flap​

See VRAM Flap (foundations) for general anatomy.

  • Pedicle. Deep inferior epigastric artery; vertical skin paddle over rectus abdominis; muscle mobilized from anterior rectus sheath; tunneled into pelvis on a distally based pedicle.[20][25][26]
  • Indications. Most complex pelvic fistulae — multiple failed repairs, extensive radiation damage, combined VVF + RVF; simultaneous vaginal reconstruction (skin paddle); pelvic-exenteration defects.
  • Outcomes. Paprottka 5 VRAM flaps — 100%; Horch demonstrated bilateral VRAM for combined pouch-vaginal and vesicovaginal fistulae in irradiated fields.[20][25]
  • OR time. Mean 5:31 hr.
  • Donor morbidity. Higher than gracilis — 57.6% vs 16% donor-site complications in meta-analysis. Abdominal wall weakness, hernia risk, wound complications.[24]
  • Modified VRAM (Sværdborg 2012). For radiation-induced VVFs the distal-half left rectus on deep inferior epigastric vessels is interposed without closure of the mucosal defects — the muscle itself obstructs the fistula. All 3 patients successful at 5–8 yr.[26]

11. Singapore (pudendal-thigh) flap​

  • Pedicle. Posterior labial artery (branch of internal pudendal); fasciocutaneous flap from medial thigh / labiocrural fold; maintains cutaneous innervation.[27]
  • Technique. Skin paddle along the labiocrural / genito-gluteal fold; raise with fasciocutaneous pedicle; rotate into the vagina for epithelial coverage and bulk; no stenting required.[27][28]
  • Indications. Obstetric fistulae with vaginal stenosis; tissue-deficient fistulae; post-fistula-repair incontinence (restoring vaginal elasticity may improve urethral closure); often combined with gracilis for the most complex obstetric fistulae.[27][28][23]
  • Outcomes. Prophylactic with Goh type 4 (n = 45): 46% dry vs expected 19%. Closed-fistula but persistent leak (n = 24): 71% dry vs expected 26%. Pope 2020 (n = 69): 32 Singapore alone, 20 gracilis alone, 17 both — possible advantage of incorporating gracilis even when Singapore alone seemed sufficient.[28][23]
  • Pros. Reliable; safe; easy dissection; minimal supplies (important in low-resource settings); preserves cutaneous innervation.

Vaginal Advancement Flap for Rectovaginal Fistula​

For rectovaginal fistulae, advancement flaps are the dominant repair technique. Two approaches dominate: vaginal advancement flap (VAF) raised from the high-pressure side, and endorectal advancement flap (RAF) raised from the rectal side.

Vaginal Advancement Flap (VAF)​

A flap of vaginal wall (epithelium + fibromuscular layer) is advanced over the closed rectal opening from the high-pressure (vaginal) side.[42][43]

  • Identify the fistula from the vaginal side.
  • Raise a U-shaped or trapezoidal flap of vaginal wall, base positioned distally (toward the introitus) to preserve blood supply.
  • Excise or curette the fistula tract.
  • Close the rectal side of the fistula with interrupted absorbable sutures.
  • Advance the vaginal flap distally to cover the closed rectal defect; suture without tension.
  • Concomitant Martius or gracilis flap may be interposed between the rectal closure and the vaginal flap for reinforcement.

VAF vs RAF — comparative evidence​

Ruffolo SR (Crohn's disease RVF):[43]

ApproachPrimary closureRange
VAF69.4%0–92.9%
RAF54.2%33.3–100%

No statistically significant difference (p = 0.13); recurrence rates similar.

ASCRS 2022 guidelines recommend endorectal advancement flap as the procedure of choice for most RVFs (Grade 1C); the VAF is a valid alternative, particularly when combined with a concomitant pedicled flap.[44]

VAF + concomitant pedicled flap​

Nosti 2013 — Crohn's-disease RVF: no patients failed when a VAF was combined with a concomitant pedicled flap (Martius or gracilis) vs an overall 33% failure rate (2/6). Two patients who failed RAF were subsequently cured with VAF.[42]

Endorectal Advancement Flap (RAF) — context​

Trapezoidal or semicircular flap of rectal mucosa, submucosa, and internal sphincter raised from the rectal side; tract curetted or excised; vaginal side left open for drainage; rectal flap advanced distally to cover the internal opening.[44][45]

  • ASCRS recommendation: procedure of choice for most RVFs (Grade 1C).
  • Success 41–78% by etiology, technique, and definition of healing.
  • Li 2025 (n = 57 simple RVFs): first-repair success 66.7%, overall 70.2%. Fistula diameter >1 cm was an independent risk factor for failure (p <0.05).[45]
  • Failure factors: Crohn's disease, prior radiation, sphincter defects, recurrent fistula, prior failed repair attempts.[44][45]
  • Low RVF caveat. RAF can produce mucosal ectropion. An alternative flap from the anoderm and perianal skin combined with sphincteroplasty achieved 100% healing (7/7) in this setting.[44]

Key Principles for Vaginal Flap Selection​

  1. Separate the fistula from the suture line. The single most important principle in vaginal-flap repair, emphasized by the Wang technique and applicable to all the native-vaginal-wall variants.[17]
  2. Preserve vaginal length when sexual function matters — Wang transfer, Shoukry reinforcement, and Singapore flap all do; classic Latzko colpocleisis does not.[17][37]
  3. Native vaginal-wall flaps suffice for most simple VVF. Shoukry 100%, Mörgeli & Tunn 100% (no flap at all) — argue against routine external donor flaps in non-irradiated, non-recurrent fistulae.[37][6]
  4. External donor flaps (Martius, gracilis, Singapore) are for complex cases — recurrent, radiation-induced, tissue-deficient, vaginal-stenosis settings benefit from importing well-vascularized tissue from outside the operative field.
  5. For RVF, VAF and RAF are comparable — ASCRS recommends RAF as the default but adding a pedicled flap (Martius or gracilis) to a VAF appears to abolish the failure rate in Crohn's disease.[42][43]
  6. Tailor by individual factors — fistula location, size, etiology, tissue quality, prior repair history, vaginal-reconstruction need. The fundamentals (tension-free closure, well-vascularized tissue, watertight seal) are constant across all techniques.

Novel / Emerging Materials​

12. TachoSil (collagen-fibrinogen-thrombin patch)​

  • Technique. Two layers (4 × 4 cm each) placed between bladder and vaginal closures after fistula excision and layered repair.
  • Outcomes. Giusti laparoscopic extravesical n = 16 — 100%. Also reported in laparoscopic transvesical recurrent VVF repair.[29][30]
  • Pros. No tissue harvest; off-the-shelf; straightforward and atraumatic.
  • Cons. Synthetic; cost; limited long-term follow-up beyond 3 mo in the largest series.

13. Small intestinal submucosa (SIS)​

  • Technique. Acellular collagen matrix patch interposed between closures.
  • Outcomes. Farahat pilot in complicated VVFs (failed prior repair, excessive scarring, or fistula ≥1.5 cm) — 91.3% (21/23). Nonimmunogenic, biodegradable, no allergic / inflammatory reactions.[31]
  • Pros. Off-the-shelf; no donor-site morbidity; nonimmunogenic.
  • Cons. Pilot evidence; limited long-term data.

14. Platelet-rich plasma (PRP) and platelet-rich fibrin (PRF)​

Used both standalone and as adjunct.[32][33][34]

  • Standalone (Shirvan 2013). Cystoscopic de-epithelialization of the fistula edges, peri-fistula PRP injection, PRF glue interposition. 91.7% (11/12) clinical cure at 6 mo. No complications.
  • Adjunct. Kołodyńska — radiation-induced recurrent VVF cured on third Latzko + Martius + PRP after two prior failures.
  • Multinational experience (Mourad 2026). 1,185 fistula repairs across 12 countries over 16 years; adjuncts (PRP, SIS, fibrin glue, buccal grafts) used in 71% of complex / recurrent repairs — 72% closure in this challenging subgroup.

15. Amniotic membrane​

Preclinical only:[35][36]

  • Freeze-dried amnion as a mesenchymal-stem-cell scaffold in a rabbit VVF model significantly increased PDGF, VEGF, FGF, occludin, claudin-4 expression.
  • Single-layer amniotic membrane alone is too weak for surgical implantation (<5 N tensile); mechanical reinforcement strategies under investigation.

16. Buccal mucosal graft​

Used in the Mourad multinational series as one of several adjuncts for complex / recurrent repair.[33] More commonly used in urethral reconstruction; provides epithelial coverage and is well-suited for tissue-deficient fistulae. Limited VVF-specific data.

Flap Selection Algorithm​

Clinical scenarioRecommended flapRationale
Simple, non-irradiated, primary VVFNo flap>90% with graftless repair; flap adds morbidity without proven benefit.[1][2]
Recurrent VVF (transvaginal)Martius (distal) or Peritoneal (proximal)Dramatic benefit in recurrent (91.7% vs 42.9%); peritoneal comparable to Martius with less morbidity.[10][11]
Radiation-induced VVF (transvaginal)MartiusBrings non-irradiated, well-vascularized tissue; 80–97%.[2]
Proximal / apical VVF (transvaginal)PeritonealEasily created; 96%; minimal morbidity; Martius may not reach.[11]
Distal / mid-vaginal VVF (transvaginal)MartiusWithin reach of labial pedicle; 97%.[11]
Transabdominal repair (any)OmentalTissue of first choice; 100% vs 63% without (Evans).[1][9]
Robotic extravesicalPeritoneal or None98–100% without omental flap; peritoneal avoids omental morbidity.[7][12]
Very large defect / extensive tissue lossGracilis ± SingaporeBulk; non-irradiated tissue; lower donor morbidity than VRAM.[20][24]
Multiple failed repairs / radiation / combined fistulaeVRAMMaximum bulk; simultaneous vaginal reconstruction; last resort before diversion.[1][25]
Obstetric VVF with vaginal stenosisSingapore ± GracilisVaginal reconstruction; restores elasticity; improves continence.[27][23]

Comparative Summary​

FlapApproachSuccessDonor morbidityOR time addedBest for
No flapAny86–100% (simple); lower for complexNoneNoneSimple non-irradiated primary
MartiusTransvaginal80–97%14% numbness; 5% pain; 7% labial distortionModerateDistal / mid-vaginal; recurrent; radiation
PeritonealTransvaginal or abdominal96%MinimalMinimalProximal / apical; recurrent
OmentalTransabdominal95–100%Ileus; abdominal painModerateAll transabdominal; radiation
TachoSilLap / robotic100% (n = 16)NoneMinimalTissue-flap alternative
SISAny91.3% (n = 23)NoneMinimalComplex; off-the-shelf alternative
GracilisPerineal / abdominalHigh in salvageThigh weakness; 16% donorSignificant (3+ hr)Large defects; radiation; salvage
VRAMAbdominal100% (small series)57.6% donor; hernia riskMajor (5+ hr)Most complex; combined fistulae; vaginal recon
SingaporePerinealVariableMinimalModerateObstetric with vaginal stenosis
PRP / PRFMIS91.7% standaloneNoneMinimalSmall fistulae; surgical adjunct

Key Controversies​

  • Is the Martius flap truly necessary for non-irradiated fistulae? Kapriniotis BJU Int 2024 — probably unnecessary for most obstetric fistulae and most simple iatrogenic fistulae within healthy tissues; retains value in select higher iatrogenic, radiation, tissue-loss, and urethral-involving fistulae.[2]
  • Should all transabdominal repairs include an omental flap? Evans strongly recommended (100% vs 63%); Miklos & Moore showed 98% extravesical success without flap; lap / robotic SR — no statistical difference. Discrepancy may reflect differences in technique (three-layer closure may compensate) and patient selection.[7][8][9]
  • Can synthetic materials replace tissue flaps? TachoSil 100% (n = 16) and SIS 91.3% (n = 23) show promise; PRP / PRF emerging as both standalone and adjunct. Long-term follow-up still limited.[29][31][32][33]
  • What is the role of flaps in robotic surgery? EAU Robotic Section: tissue interposition seems beneficial. Trend toward extravesical without omental harvest. Rainbow-shaped peritoneal flap is a middle ground — vascularized interposition without omental morbidity.[12][19]

See Also​

References​

1. Okada Y, Matsushita T, Hasegawa T, et al. Surgical interventions for treating vesicovaginal fistula in women. 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. Rafetto AN, Wei N, Linder BJ. Principles and techniques of vesicovaginal fistula repair. Int Urogynecol J. 2026. doi:10.1007/s00192-026-06576-w

4. 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

5. Woo HH, Rosario DJ, Chapple CR. The treatment of vesicovaginal fistulae. Eur Urol. 1996;29(1):1–9. doi:10.1159/000473709

6. Mörgeli C, Tunn R. Vaginal repair of nonradiogenic urogenital fistulas. Int Urogynecol J. 2021;32(9):2449–2454. doi:10.1007/s00192-020-04496-x

7. Miklos JR, Moore RD. Laparoscopic extravesical vesicovaginal fistula repair: our technique and 15-year experience. Int Urogynecol J. 2015;26(3):441–446. doi:10.1007/s00192-014-2458-y

8. Miklos JR, Moore RD, Chinthakanan O. Laparoscopic and robotic-assisted vesicovaginal fistula repair: a systematic review of the literature. J Minim Invasive Gynecol. 2015;22(5):727–736. doi:10.1016/j.jmig.2015.03.001

9. Evans DH, Madjar S, Politano VA, et al. Interposition flaps in transabdominal vesicovaginal fistula repairs: are they really necessary? Urology. 2001;57(4):670–674. doi:10.1016/s0090-4295(01)00933-5

10. 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

11. 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

12. Randazzo M, Lengauer L, Rochat CH, et al. Best practices in robotic-assisted repair of vesicovaginal fistula: a consensus report from the European Association of Urology Robotic Urology Section Scientific Working Group for Reconstructive Urology. Eur Urol. 2020;78(3):432–442. doi:10.1016/j.eururo.2020.06.029

13. 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.

14. 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

15. 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

16. Heo C, Eun S, Baek R, Minn K. Vesicovaginal fistula repair with genito-gluteal fold fat pad flap. J Plast Reconstr Aesthet Surg. 2008;61(3):323–325. doi:10.1016/j.bjps.2007.09.005

17. Wang X, Gao Z, Li L, et al. Clinical efficacy of flap transfer coverage in the treatment of vesicovaginal fistula. Int Urogynecol J. 2023;34(8):1797–1802. doi:10.1007/s00192-023-05465-w

18. Watts KL, Ho R, Ghavamian R, Abraham N. Robot-assisted extravesical vesicovaginal fistula repair utilizing laparoscopically mobilized omental flap interposition. Int Urogynecol J. 2017;28(4):641–644. doi:10.1007/s00192-016-3218-y

19. Yang Y, Chenchen H, Shiliang W, Yuke C, Cheng S. Robot-assisted vesicovaginal fistula repair with "rainbow-shaped" peritoneal flap: a single-center experience. Arch Gynecol Obstet. 2025;311(6):1697–1703. doi:10.1007/s00404-024-07919-y

20. Paprottka FJ, Krezdorn N, Lohmeyer JA, et al. Plastic reconstructive surgery techniques using VRAM or gracilis flaps in order to successfully treat complex urogenital fistulas. J Plast Reconstr Aesthet Surg. 2016;69(1):128–137. doi:10.1016/j.bjps.2015.08.026

21. Chong TW, Balch GC, Kehoe SM, Margulis V, Saint-Cyr M. Reconstruction of large perineal and pelvic wounds using gracilis muscle flaps. Ann Surg Oncol. 2015;22(11):3738–3744. doi:10.1245/s10434-015-4435-1

22. Ryan JA, Gibbons RP, Correa RJ. Urologic use of gracilis muscle flap for nonhealing perineal wounds and fistulas. Urology. 1985;26(5):456–459. doi:10.1016/0090-4295(85)90153-0

23. Pope R, Hollier PC, Brown RH, et al. A retrospective review to identify criteria for incorporating the Singapore flap and gracilis muscle flap into obstetric fistula repair. Int J Gynaecol Obstet. 2020;148(Suppl 1):37–41. doi:10.1002/ijgo.13038

24. Eseme EA, Scampa M, Viscardi JA, et al. Surgical outcomes of VRAM vs gracilis flaps in vulvo-perineal reconstruction following oncologic resection: a proportional meta-analysis. Cancers (Basel). 2022;14(17):4300. doi:10.3390/cancers14174300

25. Horch RE, Gitsch G, Schultze-Seemann W. Bilateral pedicled myocutaneous vertical rectus abdominus muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds. Urology. 2002;60(3):502–507. doi:10.1016/s0090-4295(02)01823-x

26. Sværdborg M, Birke-Sørensen H, Bek KM, Nielsen JB. A modified surgical technique for treatment of radiation-induced vesicovaginal fistulas. Urology. 2012;79(4):950–953. doi:10.1016/j.urology.2011.10.077

27. Pope RJ, Brown RH, Chipungu E, Hollier LH, Wilkinson JP. The use of Singapore flaps for vaginal reconstruction in women with vaginal stenosis with obstetric fistula: a surgical technique. BJOG. 2018;125(6):751–756. doi:10.1111/1471-0528.14952

28. Browning A, Williams G, Petros P. Skin-flap vaginal augmentation helps prevent and cure post-obstetric-fistula-repair urine leakage: a critical anatomical analysis. BJOG. 2018;125(6):745–749. doi:10.1111/1471-0528.14953

29. Giusti G, Lucci Chiarissi M, Abate D, et al. Early repair of post-hysterectomy vesicovaginal fistulae through a laparoscopic transperitoneal extravesical approach: experience of a single center. Urology. 2018;119:44–48. doi:10.1016/j.urology.2018.05.021

30. Erdogru T, Sanli A, Celik O, Baykara M. Laparoscopic transvesical repair of recurrent vesicovaginal fistula using a fleece-bound sealing system. Arch Gynecol Obstet. 2008;277(5):461–464. doi:10.1007/s00404-007-0499-x

31. Farahat YA, Elbendary MA, Elgamal OM, et al. Application of small intestinal submucosa graft for repair of complicated vesicovaginal fistula: a pilot study. J Urol. 2012;188(3):861–864. doi:10.1016/j.juro.2012.05.019

32. Shirvan MK, Alamdari DH, Ghoreifi A. A novel method for iatrogenic vesicovaginal fistula treatment: autologous platelet-rich plasma injection and platelet-rich fibrin glue interposition. J Urol. 2013;189(6):2125–2129. doi:10.1016/j.juro.2012.12.064

33. Mourad MS, Malallah M, Mahfouz W, et al. Sixteen years of multinational experience in female genital fistula repair: integrating traditional and innovative surgical approaches across 12 countries. Neurourol Urodyn. 2026;45(3):583–590. doi:10.1002/nau.70226

34. 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

35. Kurniawati EM, Santoso B, Rantam FA, et al. Does freeze-dried amnion useful as scaffold for mesenchymal stem cell for repair of vesicovaginal fistula? An overview of proliferative and remodeling phase in the wound healing process. Eur J Obstet Gynecol Reprod Biol. 2022;274:113–116. doi:10.1016/j.ejogrb.2022.05.017

36. Maljaars LP, Guler Z, Roovers JWR, Bezuidenhout D. Mechanical reinforcement of amniotic membranes for vesicovaginal fistula repair. J Mech Behav Biomed Mater. 2023;139:105680. doi:10.1016/j.jmbbm.2023.105680

37. Shoukry MS, Hassouna ME, El-Salmy S, Abdel-Karim AM. Vaginal flap re-enforcement of vesicovaginal fistula repair. Int Urogynecol J. 2010;21(7):829–833. doi:10.1007/s00192-010-1124-2

38. Tang M, Li P, Wang C, Zhang Q, Meng X. Clinical application of single-layer annular vaginal flap in transvaginal repair for vesicovaginal fistula. World J Urol. 2023;41(1):249–255. doi:10.1007/s00345-022-04222-w

39. Sayegh AS, La Riva A, Perez LC, et al. Robotic-assisted vesicovaginal fistula repair using a vaginal cuff flap. Int Urogynecol J. 2022;33(9):2581–2585. doi:10.1007/s00192-022-05144-2

40. Gupta P, Kalra S, Dorairajan LN, et al. Labia majora fasciocutaneous flap reconstruction in complex urogynecological fistulas with vaginal deficit — a versatile approach. Urology. 2022;167:241–246. doi:10.1016/j.urology.2022.05.017

41. Margolis T, Elkins TE, Seffah J, Oparo-Addo HS, Fort D. Full-thickness Martius grafts to preserve vaginal depth as an adjunct in the repair of large obstetric fistulas. Obstet Gynecol. 1994;84(1):148–152.

42. Nosti PA, Stahl TJ, Sokol AI. Surgical repair of rectovaginal fistulas in patients with Crohn's disease. Eur J Obstet Gynecol Reprod Biol. 2013;171(1):166–170. doi:10.1016/j.ejogrb.2013.08.011

43. Ruffolo C, Scarpa M, Bassi N, Angriman I. A systematic review on advancement flaps for rectovaginal fistula in Crohn's disease: transrectal vs transvaginal approach. Colorectal Dis. 2010;12(12):1183–1191. doi:10.1111/j.1463-1318.2009.02029.x

44. Gaertner WB, Burgess PL, Davids JS, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula. Dis Colon Rectum. 2022;65(8):964–985. doi:10.1097/DCR.0000000000002473

45. Li X, Shao W, Sun G. A single-center retrospective analysis of endorectal advancement flaps used for the treatment of simple rectovaginal fistulas. Scand J Gastroenterol. 2025;60(4):307–311. doi:10.1080/00365521.2025.2468493