Modified Martius Flap for repair of a postradiation Rectovaginal Fistula (RVF). A case report.

Abstract

Introduction: A rectovaginal fistula (RVF) is an abnormal connection between the rectum’s lower part and vagina’s posterior wall. It takes up approximately 6% of the overall anorectal fistulas, which are responsible for patients’ psychosocial collapse due to the incapacitating symptoms observed amongst the patients. Case presentation: The study case presented was of a 33-year-old woman previously diagnosed with squamous carcinoma of the cervix FIGO IIIA (2017) treated through means of curative radiochemotherapy, utero-vaginal intracavitary brachytherapy (GammaMed plus iX 14 Gy/PTV-HR/ 2 weeks). In April 2021, she presented herself at the surgery unit claiming exclusion of fecal through the vagina and constant perineal pain. As a result of the clinical examination of the Milligan perineal area (vaginal touch, rectal touch), and presenting a positive Carey test (the methylene blue test – positive, bubble air test – positive), it was confirmed a recto-vaginal connection, positioned at around 3-4 cm from the EAS. This was followed by a loco-regional exploration through pelvic MRI scan which confirmed a lower recto-vaginal connection (fistula), situated at approximative 3 cm from the EAS, with a diameter of 8 mm (Rothenberger I). Conclusions: There are a lot of metrics in the specialized literature that emphasize the versatility and feasibility of the Martius/mMartius procedure regarding the resolution of the RVF located in the lower, respectively median sphere. This metrics are also sustained by the anatomic flexibility of the perineal area regarding the loco-regional vasculature. An important aspect of this procedure is also related to the RVF’s etiology, and that is because the local surgical intervention needs to be performed in minimum inflammatory circumstances, when the tissues do not present any tumoral impregnation.