Use of Martius flaps in complex female urethral surgery and the tethered vagina syndrome

Cent European J Urol 2014; 67: 208-209 10.5173/ceju.2014.02.art21 The paper by Kaysan et al. [1] is timely, given the vast increase in the eroded and transected urethras which are increasingly being reported as a consequence of the midurethral sling operation. A Martius transposition graft is an important tool for management of such problems. From a practical perspective, a vascularized fat graft without the bulbocavernosus muscle attached is sufficient as an interposition flap. Deeper dissection and transposition of the bulbocavernosus only creates the potential for bleeding, hematomas, and infections. It is not necessary in our experience. We would draw attention to the “skin–on” Martius graft which offers several advantages to the simple fat graft, not least of which is restoration of vaginal skin volume and elasticity, an absolute requirement in patients who have the “Tethered Vaginal Syndrome” [2, 3, 4]. In patients with radiation necrosis, adding healthy skin to the fat graft may be helpful to the healing process. In regards to damage inflicted by the TVT to the urethra, a “skin–on” Martius graft allows another tape to be applied over the skin to cover the urethra after the urethral fistula has been repaired [5]. A “skin–on” Martius graft is especially helpful in patients with the “Tethered Vaginal Syndrome”, Figure 1. The “Tethered Vaginal Syndrome” is not a well recognized condition. It was first reported in 1990 [2]. It is an entirely iatrogenic condition that needs to be considered in patients with scarring after vaginal operations or after Burch colposuspension. The incontinence is severe. Urinary stress incontinence is very mild or absent. It is somewhat equivalent to ‘motor detrusor instability’ (MDI). The classical symptom is commencement of uncontrolled urine leakage as soon as the patient’s foot touches the floor, indeed, often commencing as the patient rolls over to get out of bed. The patient does not complain of bed–wetting during the night. The symptoms are caused by loss of elasticity in the bladder neck area of the vagina: the ‘zone of critical elasticity’ (ZCE). Because scar tissue contracts with time, it may present twenty years after vaginal repair or bladder neck elevation. This condition can be cured by plastic surgery, whose aim is to restore elasticity to the bladder neck area of the vagina.