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Martius Flap Harvest Site: Patient Self-Perception
0022-5347/02/1675-2098/0 THE JOURNAL OF UROLOGY® Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 167, 2098 –2099, May 2002 Printed in U.S.A.
MARTIUS FLAP HARVEST SITE: PATIENT SELF-PERCEPTION STEVEN P. PETROU,*,† JOYCE JONES
AND
RAUL O. PARRA
From the Department of Urology, Mayo Clinic, Jacksonville, Florida
ABSTRACT
Purpose: We elucidated patient perception of the external genitalia after Martius flap harvesting. Materials and Methods: We identified 8 women in whom a Martius interposition flap was used in association with transvaginal urethrolysis. Patients were contacted by an independent nurse and asked to evaluate the cosmetic appearance of the labium majus harvest site. They were also queried on any associated pain, numbness or altered sensation, or perceived interference with vaginal sexual relations. Results: Of the 8 patients 2 (25%) believed that the harvest site appeared to be identical to its preoperative appearance, 2 (25%) believed that there were only minimal changes from the preoperative appearance, 1 (12%) believed that it appeared markedly different from the contralateral side and 3 (38%) stated that they had never performed self-examination. Of the 8 patients 1 (13%) complained of dyspareunia, 3 (38%) had intermittent discomfort in the harvest area 1 year after the operation and 5 (62%) perceived permanently decreased sensation or numbness at the harvest site. Conclusions: The Martius flap is not associated with a significant amount of perceived cosmetic disfigurement. It has relatively little effect on sexual relations. Postoperatively discomfort is minimal but there may be associated numbness or decreased sensation at the harvest site. KEY WORDS: vagina, reconstructive surgical procedure; urethra, surgical flaps
The Martius flap was initially described by Martius in 1928 for vaginal reconstructive surgery.1 It has been applied for complex fistula repair and as an interposition graft after surgical procedures for urethrolysis.2– 6 We investigated selfperception of the Martius harvest site after the operation to optimize preoperative counseling in regard to long-term postoperative expectations for vaginal reconstruction by this technique.
ence with coital relations due to associated pain, 3 (38%) experienced lingering pain over the harvest site 1 year after the operation and 5 (62%) reported associated numbness or decreased sensation. The patients who noticed a cosmetic change noted that the labium majus was rougher than before the operation.
MATERIALS AND METHODS
In 1928 Martius first described a pedicled fat flap harvested from the labia majora used to repair a large vesicovaginal fistula of the bladder neck.1 In the original description the Martius flap consisted of the domain “of a labium majus of one side, a fat muscle flap as thick as a thumb and almost as long as a small finger, which contains the bulbocavernosus muscle, placed around the neck of the bladder and fixed by a suture on the other side.”1 Since that time, the Martius procedure has been performed for complex fistulas, including those due to radiation.2– 6 Elkins et al performed anatomical studies and concluded that, as currently performed, the Martius flap is not truly obtained from the bulbocavernosus muscle, but instead is mainly composed of fibroadipose tissue from the labium majus.4 They noted a dual blood supply for the Martius graft: namely blood supplied posterior and inferior from the posterior labial branches of the internal pudendal artery and vein, and anterior and superior from the branches of the external pudendal vessels. They reviewed 37 complex fistula repairs in 35 patients. Of 8 patients who underwent surgical procedures in the United States 2 (25%) reported dyspareunia over the graft site. In the similar study of Webster et al 2 of 12 patients (17%) reported decreased sensation at the labial harvest site.3 In that study the Martius flap served as a posturethrolysis interposition flap in 7 of the 12 cases (58%). The rate of painful intercourse in our series approximates that observed by Lemack and Zimmern in their analysis of sexual function after vaginal surgery for stress incontinence7 and that reported by Elkins et al in their patients who underwent vesicovaginal fistula repair in the United States.4 Onco-
DISCUSSION
We retrospectively reviewed medical records and identified 8 women in whom a unilateral Martius interpositional flap was placed as part of suprameatal transvaginal urethrolysis for correcting bladder outlet obstruction after an antiincontinence operation (see figure). Mean patient age was 56 years (range 29 to 76). Patients were contacted after surgery by an independent nurse in a separate phone consultation apart from routine postoperative care. They were asked to rate the cosmetic appearance of the harvest site on a 5-point scale (table 1). When a patient believed that the harvest site was cosmetically changed, she was asked to describe verbally her assessment of the changes. In addition, patients were queried on any associated pain, numbness or altered sensation, or interference with vaginal sexual relations. RESULTS
Mean followup between the operation and the telephone interview was 17 months (range 4 to 31). Table 2 shows the results of individual interviews. Of the 8 patients 2 (25%) stated that the site appeared normal with no difference from its preoperative appearance (score of 1). Another 2 patients (25%) stated that it appeared almost normal (score of 2 and 3, respectively), and 1 (12%) stated that it appeared markedly different (score of 5), while 3 (38%) stated that they had never examined the harvest site. Only 1 patient reported interfer-
Accepted for publication December 14, 2001. * Requests for reprints: Department of Urology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, Florida 32224. † Financial interest and/or other relationship with Bard. 2098
2099
MARTIUS FLAP HARVEST SITE
TABLE 2. Patient self-evaluation of harvest site after surgical procedures using a Martius flap Pt. No.—Age
Cosmetic Score*
Pain
Decreased Sensation
Coital Interference
1—75 2—71 3—75 4—44 5—29 6—42 7—39 8—76 * Scale 1 to 5.
3 Not examined 1 Not examined 1 2 5 Not examined
No Yes No Yes No No Yes No
Yes Yes No Yes No No Yes Yes
No No No No No No Yes No
CONCLUSIONS
Unilateral Martius flap harvest. Reprinted by permission of Mayo Foundation.
TABLE 1. Rating scale for patient self-evaluation of the cosmetic appearance of the labium majus harvest site of a Martius flap Score 1 2 3 4 5 Not examined
Description Normal Almost normal Perhaps different Different from other side Very different from other side Pt. never examined herself
logical vulvar surgical procedures reportedly increase sexual problems and depression significantly.8 Often such sexual problems are related to the fear of cancer recurrence.8 In addition, the ability to achieve vaginal intercourse postoperatively is not a guarantee of a satisfactory sexual response because of the potential multifactorial basis of sexual dysfunction.7 We did not note a significant rate of sexual dysfunction after the operation. However, the potential alteration in body image after Martius flap harvesting should be considered, particularly in younger and sexually active patients, although almost half in our series did not examine the genital appearance. When comparing our series with that of Webster et al,3 we noted a higher rate of postoperative numbness or decreased sensation as well as pain. This finding may have been related to suprameatal transvaginal urethrolysis, which was performed in all of our patients concomitantly with the Martius flap procedure. Potential nerve damage associated with this technique has been debated in the literature.9
Using a Martius flap does not seem to have a significant negative impact on patient body image and it appears to have only minimal impact on vaginal intercourse. There is a potential for a loss of sensation over the harvest site, which may be related to a procedure performed in association with Martius flap harvesting. The effect of Martius flap surgery on female sexual function warrants future examination. REFERENCES
1. Martius, H.: Die operative Wiederherstellung der vollkommen fehlenden Harnrohare und des Schliessmuskels derselben. Zentralb Gynakol, 52: 480, 1928 2. Webster, G. D., Sihelnik, S. A. and Stone, A. R.: Urethrovaginal fistula: a review of the surgical management. J Urol, 132: 460, 1984 3. Webster, G. D., Guranick, M. L. and Amundsen, C. L.: Use of the Martius labial fat pad as an adjunct in the management of urinary fistulae and urethral obstruction following antiincontinence procedures. J Urol, suppl., 163: 76, abstract 335, 2000 4. Elkins, T. E., DeLancey, J. O. and McGuire, E. J.: The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol, 75: 727, 1990 5. White, A. J., Buchsbaum, H. J., Blythe, J. G. et al: Use of the bulbocavernosus muscle (Martius procedure) for repair of radiation-induced rectovaginal fistulas. Obstet Gynecol, 60: 114, 1982 6. Boronow, R. C.: Repair of the radiation-induced vaginal fistula utilizing the Martius technique. World J Surg, 10: 237, 1986 7. Lemack, G. E. and Zimmern, P. E.: Sexual function after vaginal surgery for stress incontinence: results of a mailed questionnaire. Urology, 56: 223, 2000 8. Green, M. S., Naumann, R. W., Elliot, M. et al: Sexual dysfunction following vulvectomy. Gynecol Oncol, 77: 73, 2000 9. Petrou, S. P., Brown, J. A. and Blaivas, J. G.: Re: Suprameatal transvaginal urethrolysis (letter to the editor). J Urol, 162: 2104, 1999
Vol. 167, 2098 –2099, May 2002 Printed in U.S.A.
MARTIUS FLAP HARVEST SITE: PATIENT SELF-PERCEPTION STEVEN P. PETROU,*,† JOYCE JONES
AND
RAUL O. PARRA
From the Department of Urology, Mayo Clinic, Jacksonville, Florida
ABSTRACT
Purpose: We elucidated patient perception of the external genitalia after Martius flap harvesting. Materials and Methods: We identified 8 women in whom a Martius interposition flap was used in association with transvaginal urethrolysis. Patients were contacted by an independent nurse and asked to evaluate the cosmetic appearance of the labium majus harvest site. They were also queried on any associated pain, numbness or altered sensation, or perceived interference with vaginal sexual relations. Results: Of the 8 patients 2 (25%) believed that the harvest site appeared to be identical to its preoperative appearance, 2 (25%) believed that there were only minimal changes from the preoperative appearance, 1 (12%) believed that it appeared markedly different from the contralateral side and 3 (38%) stated that they had never performed self-examination. Of the 8 patients 1 (13%) complained of dyspareunia, 3 (38%) had intermittent discomfort in the harvest area 1 year after the operation and 5 (62%) perceived permanently decreased sensation or numbness at the harvest site. Conclusions: The Martius flap is not associated with a significant amount of perceived cosmetic disfigurement. It has relatively little effect on sexual relations. Postoperatively discomfort is minimal but there may be associated numbness or decreased sensation at the harvest site. KEY WORDS: vagina, reconstructive surgical procedure; urethra, surgical flaps
The Martius flap was initially described by Martius in 1928 for vaginal reconstructive surgery.1 It has been applied for complex fistula repair and as an interposition graft after surgical procedures for urethrolysis.2– 6 We investigated selfperception of the Martius harvest site after the operation to optimize preoperative counseling in regard to long-term postoperative expectations for vaginal reconstruction by this technique.
ence with coital relations due to associated pain, 3 (38%) experienced lingering pain over the harvest site 1 year after the operation and 5 (62%) reported associated numbness or decreased sensation. The patients who noticed a cosmetic change noted that the labium majus was rougher than before the operation.
MATERIALS AND METHODS
In 1928 Martius first described a pedicled fat flap harvested from the labia majora used to repair a large vesicovaginal fistula of the bladder neck.1 In the original description the Martius flap consisted of the domain “of a labium majus of one side, a fat muscle flap as thick as a thumb and almost as long as a small finger, which contains the bulbocavernosus muscle, placed around the neck of the bladder and fixed by a suture on the other side.”1 Since that time, the Martius procedure has been performed for complex fistulas, including those due to radiation.2– 6 Elkins et al performed anatomical studies and concluded that, as currently performed, the Martius flap is not truly obtained from the bulbocavernosus muscle, but instead is mainly composed of fibroadipose tissue from the labium majus.4 They noted a dual blood supply for the Martius graft: namely blood supplied posterior and inferior from the posterior labial branches of the internal pudendal artery and vein, and anterior and superior from the branches of the external pudendal vessels. They reviewed 37 complex fistula repairs in 35 patients. Of 8 patients who underwent surgical procedures in the United States 2 (25%) reported dyspareunia over the graft site. In the similar study of Webster et al 2 of 12 patients (17%) reported decreased sensation at the labial harvest site.3 In that study the Martius flap served as a posturethrolysis interposition flap in 7 of the 12 cases (58%). The rate of painful intercourse in our series approximates that observed by Lemack and Zimmern in their analysis of sexual function after vaginal surgery for stress incontinence7 and that reported by Elkins et al in their patients who underwent vesicovaginal fistula repair in the United States.4 Onco-
DISCUSSION
We retrospectively reviewed medical records and identified 8 women in whom a unilateral Martius interpositional flap was placed as part of suprameatal transvaginal urethrolysis for correcting bladder outlet obstruction after an antiincontinence operation (see figure). Mean patient age was 56 years (range 29 to 76). Patients were contacted after surgery by an independent nurse in a separate phone consultation apart from routine postoperative care. They were asked to rate the cosmetic appearance of the harvest site on a 5-point scale (table 1). When a patient believed that the harvest site was cosmetically changed, she was asked to describe verbally her assessment of the changes. In addition, patients were queried on any associated pain, numbness or altered sensation, or interference with vaginal sexual relations. RESULTS
Mean followup between the operation and the telephone interview was 17 months (range 4 to 31). Table 2 shows the results of individual interviews. Of the 8 patients 2 (25%) stated that the site appeared normal with no difference from its preoperative appearance (score of 1). Another 2 patients (25%) stated that it appeared almost normal (score of 2 and 3, respectively), and 1 (12%) stated that it appeared markedly different (score of 5), while 3 (38%) stated that they had never examined the harvest site. Only 1 patient reported interfer-
Accepted for publication December 14, 2001. * Requests for reprints: Department of Urology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, Florida 32224. † Financial interest and/or other relationship with Bard. 2098
2099
MARTIUS FLAP HARVEST SITE
TABLE 2. Patient self-evaluation of harvest site after surgical procedures using a Martius flap Pt. No.—Age
Cosmetic Score*
Pain
Decreased Sensation
Coital Interference
1—75 2—71 3—75 4—44 5—29 6—42 7—39 8—76 * Scale 1 to 5.
3 Not examined 1 Not examined 1 2 5 Not examined
No Yes No Yes No No Yes No
Yes Yes No Yes No No Yes Yes
No No No No No No Yes No
CONCLUSIONS
Unilateral Martius flap harvest. Reprinted by permission of Mayo Foundation.
TABLE 1. Rating scale for patient self-evaluation of the cosmetic appearance of the labium majus harvest site of a Martius flap Score 1 2 3 4 5 Not examined
Description Normal Almost normal Perhaps different Different from other side Very different from other side Pt. never examined herself
logical vulvar surgical procedures reportedly increase sexual problems and depression significantly.8 Often such sexual problems are related to the fear of cancer recurrence.8 In addition, the ability to achieve vaginal intercourse postoperatively is not a guarantee of a satisfactory sexual response because of the potential multifactorial basis of sexual dysfunction.7 We did not note a significant rate of sexual dysfunction after the operation. However, the potential alteration in body image after Martius flap harvesting should be considered, particularly in younger and sexually active patients, although almost half in our series did not examine the genital appearance. When comparing our series with that of Webster et al,3 we noted a higher rate of postoperative numbness or decreased sensation as well as pain. This finding may have been related to suprameatal transvaginal urethrolysis, which was performed in all of our patients concomitantly with the Martius flap procedure. Potential nerve damage associated with this technique has been debated in the literature.9
Using a Martius flap does not seem to have a significant negative impact on patient body image and it appears to have only minimal impact on vaginal intercourse. There is a potential for a loss of sensation over the harvest site, which may be related to a procedure performed in association with Martius flap harvesting. The effect of Martius flap surgery on female sexual function warrants future examination. REFERENCES
1. Martius, H.: Die operative Wiederherstellung der vollkommen fehlenden Harnrohare und des Schliessmuskels derselben. Zentralb Gynakol, 52: 480, 1928 2. Webster, G. D., Sihelnik, S. A. and Stone, A. R.: Urethrovaginal fistula: a review of the surgical management. J Urol, 132: 460, 1984 3. Webster, G. D., Guranick, M. L. and Amundsen, C. L.: Use of the Martius labial fat pad as an adjunct in the management of urinary fistulae and urethral obstruction following antiincontinence procedures. J Urol, suppl., 163: 76, abstract 335, 2000 4. Elkins, T. E., DeLancey, J. O. and McGuire, E. J.: The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol, 75: 727, 1990 5. White, A. J., Buchsbaum, H. J., Blythe, J. G. et al: Use of the bulbocavernosus muscle (Martius procedure) for repair of radiation-induced rectovaginal fistulas. Obstet Gynecol, 60: 114, 1982 6. Boronow, R. C.: Repair of the radiation-induced vaginal fistula utilizing the Martius technique. World J Surg, 10: 237, 1986 7. Lemack, G. E. and Zimmern, P. E.: Sexual function after vaginal surgery for stress incontinence: results of a mailed questionnaire. Urology, 56: 223, 2000 8. Green, M. S., Naumann, R. W., Elliot, M. et al: Sexual dysfunction following vulvectomy. Gynecol Oncol, 77: 73, 2000 9. Petrou, S. P., Brown, J. A. and Blaivas, J. G.: Re: Suprameatal transvaginal urethrolysis (letter to the editor). J Urol, 162: 2104, 1999