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Interposition Flap Options for Vaginal Fistula Repair

Choose tissue interposition according to the fistula's location, vascularity, tissue loss, prior repairs and the patient's functional priorities. A vascularized flap brings its own blood supply; a free graft must take on a suitable recipient bed. Sealants, scaffolds and platelet preparations are different adjuncts. None substitutes for exposure, viable tissue, control of infection, tension-free reconstruction and appropriate drainage.[2][3][4]

This overview compares the roles and evidence for these options. Operative steps belong in the dedicated Martius, O'Conor, extravesical, Latzko and Sims–Simon pages.

When Does a Flap Help?​

Interposition can separate closure lines, fill dead space and replace deficient vascularized tissue. These advantages must be weighed against harvest morbidity, added dissection, bulk and whether the flap reaches without tension or pedicle compromise. Radiation, recurrence, urethral loss and vaginal stenosis often increase the need for additional tissue, but no single flap is mandatory for every fistula in these categories.[2][4][5]

Randomized evidence exists for simple VVF. Singh et al. randomized 126 patients to flap or no flap within the clinically selected vaginal or abdominal route. Vaginal closure occurred in 27/29 with Martius versus 27/28 without; abdominal closure in 34/35 with omentum versus 33/34 without. Neither comparison was statistically significant. Mean follow-up was 39.6 months; 9/29 Martius recipients reported harvest-site numbness or pain versus none without Martius. The trial excluded complex and complicated fistulas, including previous failed repairs and radiation-associated cases. Its small groups and few failures do not establish equivalence or justify withholding tissue from an ischemic, deficient repair.[51]

The 2026 Cochrane item is a review protocol, not a completed synthesis showing that flaps improve closure or sexual function.[1] Most complex-fistula evidence remains observational:

EvidenceWhat it supports—and does not establish
Mörgeli: 50 nonradiogenic urogenital fistulas, including 34 VVFAll 47 modified Sims–Simon repairs succeeded; the 47 were not an exclusively VVF cohort. This demonstrates selected flap-free feasibility.[6]
Miklos: 44 laparoscopic extravesical VVF repairsOverall closure was 43/44; 42/43 repairs without omentum succeeded. The systematic review also comprised heterogeneous, predominantly small observational reports; nonsignificant comparisons do not prove equivalent techniques.[7][8]
Evans: retrospective abdominal VVF seriesIn benign cases, closure was 10/10 with versus 12/19 without interposition. The often-quoted 12/12 flap total includes two malignant cases. Selection and small numbers prevent a universal flap mandate.[9]
Rangnekar: 46 urinary–vaginal fistulas, including 34 VVF and 12 urethrovaginalRecurrent-fistula closure was 11/12 with Martius versus 3/7 without. This was not a randomized comparison.[10]
Eilber: 207 vaginal VVF repairs, 159 with previous repairInterposition was used in 120: 83 peritoneal, 34 Martius and 3 full-thickness labial. Reported success was 96%, 97% and 33%, respectively; very different selection and denominators preclude ranking these flaps.[11]

The ERUS robotic report is expert consensus informed by published series. It supports individualized reconstruction; it is not a randomized demonstration that robotic repair or routine interposition is superior.[12]

Native Vaginal-Wall Reconstruction​

Local vaginal tissue may provide an additional layer without a separate labial, thigh or abdominal donor incision. It still requires adequate vascularity and mobility and can cause local scarring or distortion. Named variants should not be ranked by success percentages from unrelated case series.

  • Shoukry vaginal flap reinforcement: a local vaginal flap reinforces the repair. All 20 low VVFs closed at mean 16 ± 9 months in the reported series; comparative benefit and sexual-function preservation were not established.[37]
  • Wang flap-transfer coverage: separates the fistula repair from the vaginal incision line. Primary healing occurred in 34/37; the three recurrences closed after repeat repair. The abstract does not establish long-term durability or superiority over other vaginal repairs.[17]
  • Tang annular vaginal flap: a retrospective comparison of 17 transvaginal and 40 transvesical repairs reported initial success of 82.3% and 75%, respectively. Route selection was not randomized. This report does not justify adopting a universal single-layer closure or omitting an independently assessed bladder closure.[38]
  • Vaginal cuff flap: a robotic salvage case with radiation-associated VVF and RVF also required hyperbaric treatment and a later endoluminal closure before sustained healing. The 30-month result cannot be attributed to cuff interposition alone.[39]

Latzko partial colpocleisis de-epithelializes tissue around the fistula and imbricates the underlying tissue; it does not bury intact vaginal epithelium as its reinforcing layer. Vaginal shortening depends on the defect and extent of closure. Discuss vaginal access, length and sexual goals before choosing the repair; newer local flaps do not guarantee preserved function. See the Latzko technique.

Transvaginal Interposition and Vaginal Replacement​

Martius labial fat-pad flap​

The modified Martius flap uses vascularized labial fibrofatty tissue. It is distinct from a bulbocavernosus muscle flap. An anterior or posterior pedicle can be retained according to the required reach; protect the vascular plexus and avoid a tight tunnel. Cadaveric work and clinical reports support this anatomy, while technical videos illustrate specific operative variants.[4][13][14]

Donor symptoms deserve explicit counseling. Lee et al. identified 122 eligible reconstructions but assessed 97 after exclusions: 79 had normal sensation, five reported pain and 13 numbness at mean 85 months. Only 26 completed the sexual-function questionnaire; these data do not establish that Martius prevents dyspareunia.[15] See Martius for VVF for selection and harvest.

Peritoneal and local fat-pad options​

A mobilized peritoneal flap can reach selected proximal repairs when accessible, as in the Eilber series. The choice depends on prior surgery, peritoneal availability and safe mobilization; that series did not prove less morbidity than Martius.[11] A genito-gluteal fold fat-pad flap closed two radiation-associated VVFs at one year in Heo's report. This is a specialist alternative supported by a very small experience.[16]

Replacing vaginal lining as well as adding tissue​

A fasciocutaneous flap or skin-containing reconstruction may be needed when vaginal lining is missing or severely stenotic. In Gupta's seven complex urogenital cases, one radiation-associated VVF required subsequent colpocleisis to achieve dryness. Margolis described four full-thickness Martius reconstructions combined with medial-thigh skin: all skin grafts took initially, but one VVF recurred. Early graft take, fistula closure and return to intercourse are separate outcomes.[40][41]

The Singapore pudendal-thigh flap supplies skin for vaginal reconstruction. Pope's technical report describes its use in obstetric vaginal stenosis. Browning's series included 45 women undergoing fistula repair and 24 with leakage after an already closed fistula; reported dryness was compared with historical expectations, not a concurrent control group. Those findings do not establish a continence mechanism or a universal benefit from vaginal augmentation.[27][28] A separate 69-patient series used Singapore, gracilis or both according to the defect; it cannot identify an independently superior flap.[23]

Abdominal Interposition​

Omentum can supply mobile vascularized tissue between repaired organs when its pedicle and reach are suitable. It is useful in selected abdominal repairs, but the simple-VVF trial does not support automatic harvest for every abdominal fistula. Published laparoscopic and robotic technical cases show feasibility, not superiority or absence of bowel-related morbidity.[5][18][51]

Peritoneal flaps, including the “rainbow-shaped” technique, offer another local option. Yang's 15-patient series reported closure in all patients at mean 7.8 months; it did not compare this flap with omentum or flap-free repair.[19] Sigmoid epiploic tissue has also been described in the abdominal reconstructive literature. Available length, tissue viability and the neighboring bowel determine feasibility; none of these options should be assumed to match omentum in a deficient or irradiated bed.[5][12]

Muscle and Myocutaneous Flaps for Complex Defects​

Gracilis and rectus-based flaps can provide vascularized bulk when local tissue is insufficient. Plan harvest and pelvic inset jointly with the reconstructive team, accounting for previous abdominal operations, stomas, radiation, functional loss and the need for a skin paddle. See the foundations gracilis and VRAM anatomy pages.

Paprottka reported 13 flaps in 12 patients with heterogeneous urogenital fistulas: eight gracilis and five VRAM. At long follow-up, the ten survivors included three VRAM recipients with some urinary leakage and seven gracilis recipients described as continent. These small, selected groups do not establish better continence with gracilis.[20] Ryan's six-patient report combined urinary fistulas and nonhealing wounds; Chong's 16 patients underwent reconstruction after oncologic pelvic/perineal resection. Neither supplies a stand-alone VVF closure rate.[21][22]

The VRAM-versus-gracilis proportional meta-analysis concerned vulvoperineal reconstruction after cancer surgery. Its pooled donor-complication proportions came from different series, not a head-to-head VVF trial, and should not determine flap choice by themselves.[24]

Two unusual salvage reports require particular care:

  • Horch described one woman receiving two consecutive rectus-based reconstructions for radiation-associated vesicovaginal and pouch-vaginal fistulas.[25]
  • Sværdborg described a rectus muscle flap without a skin paddle in three radiation-associated VVFs, with reported closure at five to eight years. Their modification omitted direct closure of the fistula defects; this small specialist experience is not a general instruction to leave bladder or vaginal defects open.[26]

Rectovaginal Advancement Flaps​

Rectal and vaginal advancement flaps mobilize adjacent tissue over a repaired communication. The rectal side is the higher-pressure side, not the vagina. Selection depends on location, rectal inflammation, sphincter integrity, vaginal tissue and previous repairs. The ASCRS guideline supports endorectal advancement with or without sphincteroplasty for many RVFs, and selective Martius or gracilis interposition in recurrent or otherwise complex cases; these are distinct operations.[44]

Control Crohn's activity and sepsis before elective reconstruction. In Nosti's six Crohn's patients, four vaginal advancement repairs with an additional flap did not recur during short, variable follow-up; this cannot show that interposition abolishes recurrence. Ruffolo's review included 219 flap procedures, with pooled primary closure of 54.2% for rectal and 69.4% for vaginal advancement; the nonsignificant difference did not demonstrate equivalence.[42][43] Li's 57-patient retrospective simple-RVF cohort achieved 66.7% closure after the first endorectal advancement and 70.2% after repeat repair. Its size associations are not universal selection cutoffs.[45]

Grafts, Sealants and Investigational Adjuncts​

These materials do not bring a vascular pedicle. Evidence is largely small uncontrolled series, co-interventions, technical cases or laboratory work.

MaterialEvidence and practical boundary
Fibrin-coated collagen patch (TachoSil)A biologic hemostatic/sealing patch, not a synthetic vascularized flap. Giusti reported 16 repairs with early continence assessment at one month and quality-of-life follow-up at three months; Erdogru reported one recurrent case at six months. Neither establishes long-term comparative benefit.[29][30]
Small intestinal submucosaIn a 23-patient pilot, 21 were dry at six months: 7/7 vaginal and 14/16 abdominal repairs. Absence of reported allergy in that cohort does not prove non-immunogenicity or equivalence to living tissue.[31]
Platelet-rich plasma / fibrinShirvan's combined de-epithelialization, PRP and platelet-rich fibrin protocol yielded clinical cure in 11/12 at six months. Streit-Ciećkiewicz's 16-patient report combined PRP with later Latzko repair; the subsequent eight-patient histology study measured tissue changes. Neither isolates a clinical PRP effect.[32][46][47]
Buccal mucosaTaha reported ten vaginal repairs dry at six months. Rafetto's radiation-associated case combined buccal mucosa with omentum, with early cystographic/endoscopic assessment. These are promising feasibility reports, not proof of durability, infection resistance or superiority to a flap.[48][49]
Amniotic scaffolds / regenerative glueThe cited amnion study used rabbits; the reinforcement study used mechanical testing with a 2-N design threshold. The regenerative bioglue report used pigs. These do not establish human VVF efficacy or a universal tissue-strength requirement.[35][36][50]

A radiation-associated PRP case required multiple repairs and eventual Martius interposition, so its final closure cannot be credited to PRP alone.[34] Similarly, Mourad's 2026 multinational report covered 1,185 female genital fistula repairs, not solely VVF patients; adjuncts were selected disproportionately for complex or recurrent disease. Its results cannot establish the causal benefit of any one graft, sealant or flap.[33]

Planning and Counseling​

Start with the repair that provides safe exposure and viable closure, then decide whether interposition or replacement tissue addresses a specific deficiency. Preserve ureteral safety, vaginal access and desired sexual function. For RVF, evaluate continence and the sphincter before selecting advancement alone. In radiation injury or repeated failure, discuss whether reconstruction, a more extensive flap or diversion best serves the patient's goals.[2][3][12][44]

Report anatomic closure, urinary or fecal continence, donor-site symptoms, sexual function, reoperation and diversion reversal separately, with their actual follow-up. A closed fistula does not guarantee continence, and a small series with no reported complications cannot guarantee safety.

See Also​

Videos​

Vaginal Repair of VVF with Martius Flap Interposition
Preeti Urology & Kidney Hospital (2023)

References​

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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

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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

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46. Streit-Ciećkiewicz D, Futyma K, Miotła P, et al. Platelet-rich plasma as adjuvant therapy for recurrent vesicovaginal fistula: a preliminary report. J Clin Med. 2019;8(12):2122. doi:10.3390/jcm8122122

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50. Kim HJ, Turner D, Shi R, et al. Preclinical evaluation of a regenerative immiscible bioglue for vesico-vaginal fistula. Acta Biomater. 2021;125:183–196. doi:10.1016/j.actbio.2021.02.037

51. Singh V, Mehrotra S, Bansal A, Akhtar A, Sinha RJ. 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