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the surgical procedures on female urethra are rare occurrences that usually result from urethrovaginal fistula , urethral diverticulas or urethral damage during anti  incontinence procedures . in the developing world , the vast majority of urethrovaginal fistulae result from obstructed labor . due to advances in obstetric care , urologists in the developed world encounter urethrovaginal fistulae rarely , and
many of the fistulas seen are secondary to vaginal surgery . in the developed world , the more common causes of urethral injury include trauma , iatrogenic injury at urethral diverticulectomy , bladder neck suspension , endoscopic surgery and gynecologic surgery , such as vaginal hysterectomy or anterior vaginal repair .
urethral erosion can result from synthetic materials used in these procedures or from anti  incontinence surgery [ 2 , 3 ] , or it may be due to long  term indwelling catheters in neurologically impaired or comatose patients [ 4 , 5 ] . the risk of development of genitourinary fistulas after radical surgery and radiotherapy is significantly decreased nowadays . these fistulas may involve urethovesical junction and the mid  urethra .
the management of these cases remains a challenge for dedicated specialists because of the fibrosis and vascular deficiency .
the incidence of urethral injury with pelvic fractures ranges from 0 to 6% and is predominantly caused by high  speed motor vehicle accidents .
there is a traumatic absence of the proximal urethra occurring within context of various labor injuries in africa .
surgical treatment procedures include direct primary anatomical repair and interpositional tissue restorations . in each case
, the interposed tissue serves to create an additional layer in the repair , to fill dead space , and to bring in new blood supply to the area . in 1928
, heinrich martius presented an interpositional tissue flap from the bulbocavernosus muscle accompanied with fibroadipose tissue from labia majora pudenda .
it has been widely accepted and adopted for the repair of urethrovaginal , vesicovaginal and rectovaginal fistulae [ 10 , 11 ] , for damaged urethra reconstruction , vaginal or rectal stenosis , and post radiation rectal or vaginal fistulae , with high success rate .
we conducted a cohort study for the evaluation of functional and anatomical outcomes of vaginal urethral reconstruction with the martius procedure .
since 2001 , 37 women underwent vaginal reconstructions with utilization of the martius flap in our clinic .
these patients were suffering from urethrovaginal fistulae in some cases associated with radiation , urethral diverticulas and urethral damage after anti  incontinence procedures , mainly synthetic tape protrusion into urethal lumen .
the type of surgery patients underwent was selected based on the protocols that were accepted in our hospital at the time at which the patients were treated .
we took a detailed history and performed an in  depth physical exam prior to surgery that included : vaginal exam , urethrocystoscopy and ultrasound .
starting in june 2011 , we retrospectively reviewed medical records of the identified patients after approval of the institutional ethics committee before the study .
patients were contacted again via telephone , and when available , they were asked to rate their self 
the surgical technique described by martius   starts with a lateral incision on the labia majora pudenda .
when choosing the side , the shortest distance to the covering area has to be considered because of less tension , a better blood supply of the flap , and better recovery with less recurrence .
when a longitudinal incision on the labia majora is done , a well vascularized labial fat is exposed ( figures 1 and 2 ) .
the mobilization of the graft should be done taking into consideration the external and internal pudendal blood supply .
, the flap is tunneled by a curve clamp under the vaginal wall , from labia to vaginal incision ( figure 3 ) .
we use absorbable sutures for fixing the flap over the fistula repair site . normally , the labial flap has excellent mobility and significant bulk effect .
this bulk effect is often quite necessary , but should be considered before flap harvesting .
this is why the vaginal wall should be mobilized enough in order to cover the flap without tension .
routinely , we do not use any drain in the harvest site , but a penrose drain might be an option to prevent hematoma accumulation if bleeding is present .
the flap is tunneled by a curve clamp under the vaginal wall , from labia to vaginal incision .
the mean age of the patients was 46.8 years ( range from 28 to 68 years , sd 10.3 ) .
sixteen women underwent vaginal surgery with martius flap due to radiation induced genitourinary fistula . among these patients ,
5 women had their first attempt at fistula closure . the other 12 cases ( 75% ) were secondary or tertiary procedures .
two patients had a history of martius flap harvesting , and 2 women were treated with omentum flaps during previous procedures .
ten women were operated for urethrovaginal fistulas that were caused by pelvic injuries and previous vaginal surgeries , such as marsupialisation of urethral diverticula and anterior colporrhaphies .
objective outcomes after vaginal reconstruction with martius flap six women among our patients have been operated on due to urethral damage after anti  incontinence procedures .
urethral damage with the protrusion of a mid  urethral synthetic sling was found in 2 women .
bladder outlet obstruction after anti  incontinence procedures is often treated with removal of the sling . in four cases sling division and urethrolysis performed because of intergrowth of the sling into the urethra wich ruseulted in urethral damage .
perioperative and postoperative complications related to the harvesting of the martius flap are reported in the table 2 .
these bleedings were usually well controlled with cautery and we also used penrose drainage to help avoid hematoma formation in specific cases .
early postoperative complications were limited to wound infection , hematoma and lymphorrhea from the labial incision .
perioperative and postoperative complications related to the harvesting of the martius flap ( grade ii by clavien classification of surgical complication ) the patients self perception was evaluated via telephone communication . at the time of study ,
when the cosmetic appearance of the labial incision was discussed , 4 women considered it as a problem while others believed that it was identical to other side or there were only minimal changes when compared to the contralateral . despite a current view
, 2 patients from 24 complained about a periodical pain in the operated labia , which did not require pain relievers .
interpositional tissue should be considered whenever the closure lines or the vaginal tissues are of questionable quality or if subsequent sling placement is being considered . rotated vascularized pedicle flaps are an important adjunct to surgical techniques used in the repair of female urethra .
they increase success by enhancing granulation tissue formation , increasing neovascularity to the area , and obliterating dead space .
they also provide a barrier layer between the urethral and bladder suture line and the vaginal suture line .
when tissues are insufficient , a martius flap should be considered to secure the closure , which necessitates careful mobilization of vaginal mucosa . at the same time we should not to expect that the flap will provide an additional support to the urethral wall in order to provide a urinary continence .
various modifications of martius original procedure have been published . in the modifications described by elkins , delancy and mcguire ,
the authors showed the risk of hemorrhage with the classic martius graft technique because it requires a deep plane of dissection to isolate the bulbocavernosus muscle .
the fibroadipose tissue isolated in their dissection possessed sufficient blood supply and strength for success .
additionally , they noted that the dual blood supply to this tissue and the bulbocavernosus muscle ( dorsally via internal pudendal artery and ventrally via external pudendal artery ) enables the surgeon the choice of using a flap with a superior or inferior base .
a mild dyspareunia over the graft site is a potential complication , which may be difficult to avoid and treat .
of the 8 patients , only one woman ( 13% ) complained of dyspareunia , 3 ( 38% ) had intermittent discomfort in the harvest area one year after the operation and 5 ( 62% ) perceived permanently decreased sensation or numbness at the harvest site . according to the authors , the martius flap is not associated with a significant amount of perceived cosmetic disfigurement . at the same time , it has relatively little effect on sexual relations , postoperative discomfort is minimal , but there may be associated numbness or decreased sensation at the harvest site .
the author suggests that it may have been related to suprameatal transvaginal urethrolysis , which was performed in all of the patients concomitantly with the martius flap procedure in that study .
our data showed that decrease of sensation at the harvested areas may appear in one patient from ten in long term follow up .
, many reports of complications associated with synthetic slings and meshes have been published in the literature . in 2011 , the joint committee of the ics 
iuga published a standardized terminology and classification for complications related to synthetic and biological materials in the female pelvic floor surgery .
the most frequent complications include vaginal erosion , mesh shrinkage , infections , pain and urinary tract disorders .
there have also been reports of rare complications , such as urethral necrosis resulting from mid 
additionally , removal of the meshes or mid  urethral slings is always associated with potential risk of iatrogenic urethral or bladder wall damage and development of complex fistulas .
we believe that the martius flap remains a valuable tool in armamentarium of the vaginal surgeons in these particular cases as well .
the use of martius flap supposes to improve the cure rate of genitourinary fistulas and decrease fistula recurrence rate .
there is a limited possibility to design a head to head study to prove that hypothesis . in our previous study , we summarized our experience of the 210 cases of radiation induced fistula closure .
based on it , we revealed that the primary cure rate did not exceed 48% . in another retrospective study of 12 women with urethral damage ,
3 of 4 patients who were repaired primarily without graft had recurrences , compared with only 1 of 8 whose closures were reinforced with a martius labial fat pad . in our study , among the 16 patients with urethral damage associated with radiation therapy , we found that 75% patients ( 12/17 ) had no recurrence in the long term followup . at the same time
also , because of the relative rarity of reconstructive surgery on the female urethra , no large case 
urethral damage with protrusion of mid  urethral synthetic sling is becoming a more common problem .
bladder outlet obstruction after anti  incontinence procedures is often treated with the removal of the sling . both may have intergrowth of the sling into urethra with dense adhesions , which may result in further damage to the urethra during removal .
the definitive excision of a diverticula is to perform a full excision with a full opening of the urethra , but this does carry with it a chance of morbidity , even in experienced hands .
also , because of the relative rarity of reconstructive surgery on the female urethra , no large case 
urethral damage with protrusion of mid  urethral synthetic sling is becoming a more common problem .
bladder outlet obstruction after anti  incontinence procedures is often treated with the removal of the sling .
both may have intergrowth of the sling into urethra with dense adhesions , which may result in further damage to the urethra during removal .
the definitive excision of a diverticula is to perform a full excision with a full opening of the urethra , but this does carry with it a chance of morbidity , even in experienced hands .
martius flap is safe and it is not causing significant complications during vaginal reconstruction . patient reported perception reports showed that the procedure has only minimal impact on the patient body appearance . at the same time , an informed consent for possible neurological disorders , such as decreased sensation and numbness at the flap harvesting area should be obtained .
the heterogeneity of the patients included managed with different techniques is the main limitation of the present study .
introductionobjectives were to evaluate safety and patient reported perception of the martius fibroadipose flap for complex female urethra reconstruction.material and methodspatients operated with a martius flap were contacted again via telephone to rate their self  
 perception on cosmetic appearance , pain or numbness of the flap harvest site.results37 women ( mean age of 46.8 yrs . ) were operated with martius flaps . 
 complications were limited to bleeding from the flap bed in 19% ( 7/37 ) ; hematomas  5.4% ( 2/37 ) ; and lymphorrhea from the labial incision in 13.5% ( 5/37 ) and labial wound infection in 5.4% of cases ( 2/37 ) . for self  
 perception 65% of patients ( 24/37 ) were phone interviewed ( mean follow up  54.2 months ) . 
 only 17% of women ( 4/24 ) complained to cosmetic problems . 
 two patients ( 8% ) complained to a periodical mild pain . and 
 12.5% ( 3/24 ) of the women had decreased sensation or numbness at the labia.conclusionsmartius flap is safe and it is not causing significant complications during female urethral reconstruction . 
 however , an informed consent for decreased sensation and numbness at the flap harvesting area should be obtained .