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Rectourethral Fistula

A rectourethral fistula (RUF) is an epithelialized communication between the rectum and the urethra, prostatic fossa, or bladder neck. It is rare and operatively demanding. Acquired cases often follow prostate cancer treatment — radical prostatectomy or energy-based therapy (radiation, brachytherapy, cryotherapy, HIFU) — but other causes are important. Transperineal reconstruction with vascularized tissue interposition is a commonly reported approach; closure estimates depend on radiation exposure, tissue injury, prior treatment and the definition of success.[1][2][3][4]

For the female-perineum equivalent and the broader interposition-flap framework, see Rectovaginal Fistula. For the operative steps and donor-site anatomy of the gracilis flap itself, see Gracilis Flap. For operative selection across all repair routes, see the Male Fistula Repair database.

Epidemiology​

The following are historical study-specific incidence estimates, not directly comparable contemporary risks for choosing a prostate-cancer treatment.[4][5][6][7][8][9]

EtiologyIncidence
Radical prostatectomy0.34% (retropubic) – 1.04% (perineal)[5]
Brachytherapy monotherapy0.19–0.2%[6][7]
Brachytherapy + EBRT (combined)2.9%[4]
Salvage brachytherapy8.8%[4]
Primary whole-gland cryotherapy1.2% (~0.55% in modern era)[9]
HIFU — single session1.17%[8]
HIFU — repeat sessions13.6%[8]
Salvage HIFU4.5%[8]

In the largest multi-institutional series (201 patients), 48.2% of RUFs followed radical prostatectomy alone and 51.8% followed energy ablation.[4]

Etiology and Mechanism​

CauseNotes
Radical prostatectomyUnrecognized rectal injury during posterior dissection at Denonvilliers' fascia; ~54% of post-RP RUFs had a rectal lesion primarily closed at the index operation; perineal approach 3.06× the risk of retropubic[5]
Radiation / ablationIschemic necrosis of the rectourethral septum weeks–months after treatment. Post-treatment rectal biopsy, argon-plasma coagulation, and TURP all materially escalate fistula risk after brachytherapy[6][7]
TraumaPenetrating perineal / pelvic injury (blast, gunshot, stab); pelvic fracture[14][15]
Crohn's disease~0.3% of Crohn's patients; 6–11% of all GU fistulas in Crohn's[13]
Cryptoglandular / perirectal sepsisPerianal abscess eroding into urethra
Iatrogenic non-prostateRectal surgery, transanal excision

Classification​

Muñoz etiologic (1998)[11]​

  • Benign: Crohn's, trauma, perirectal sepsis, iatrogenic
  • Malignancy-related: neoplasm at fistula site, radiation-induced, surgery-induced, combined

Mundy & Andrich complexity (2011)[17]​

  • Simple — post-surgical (prostatectomy), no cavitation, no bladder neck contracture; amenable to primary repair
  • Complex — post-irradiation or post-ablation, cavitation (tissue loss creating a rectourethral cavity), bladder neck contracture, or extensive ischemia; requires interposition, often permanent diversion. Cavitation is most common after salvage HIFU following combined EBRT + brachytherapy

Clinical Presentation​

Symptoms develop days to weeks after surgery, weeks to months after radiation/ablation.[1][5][12][18]

SymptomFrequency
Pneumaturia — often the earliest finding~24%
Fecaluria — pathognomonic~10% as presenting symptom
Urine per rectum~48%
Recurrent UTI~21%
Dysuria~21%
Concurrent urethral stricture / BNC14% non-irradiated; 26% irradiated[4][19]

A small fistula without fecaluria has a meaningful chance of conservative closure; fecaluria strongly favors considering fecal diversion, alongside sepsis, defect size and planned repair.[5]

Diagnostic Evaluation​

StepRole
CystourethroscopyMaps urethral / prostatic-fossa opening; identifies concurrent stricture or BNC[12]
Proctoscopy / sigmoidoscopyRectal opening; surrounding mucosa[12]
VCUGConfirms tract, demonstrates rectal extravasation[12]
CT with rectal contrastTract anatomy, abscess, periureteral pathology
MRI pelvisBest soft-tissue characterization; tissue quality and radiation-injury extent[12]
Examination under anesthesiaOften necessary to fully define anatomy and tissue quality[12]
Biopsy of fistula edgeObtain when examination, imaging or the cancer history raises concern for recurrence; avoid unnecessary trauma in irradiated tissue[12]

Management​

The algorithm is etiology-driven, with the dominant axis being non-irradiated vs irradiated/ablation-induced.[1][4][12][20]

1. Conservative management (selected non-irradiated patients)​

For small fistulas without fecaluria — urethral catheter ± suprapubic tube, bowel rest, antibiotics for sepsis. Spontaneous closure occurred in 3 of 13 (23%) post-prostatectomy RUFs (none of whom had fecaluria) in one series, and in 47% in an algorithm-based cohort (27% before diversion, 20% after).[5][16] Spontaneous closure is rare after radiation/ablation.[20]

2. Fecal diversion​

Fecal diversion may use colostomy or ileostomy. Consider it for substantial fecal contamination, sepsis, a large defect, failed conservative management or protection of a planned repair; selection and timing are individualized. Performed in 65–84% of patients before definitive repair.[4] Diversion alone closes ~33% of post-prostatectomy RUFs and ~46% of post-traumatic RUFs.[5][15]

Interpret the endpoint correctly: the Lahey series reported that 97% of nonirradiated patients had their bowel undiverted after repair. This is a restoration-of-continuity outcome, not evidence that 97% underwent fistula repair without a preceding stoma; initial diversion remains individualized.[2]

3. Surgical repair — first repair is the best repair​

Subsequent repairs are progressively harder; success drops with each attempt.[21][27]

Surgical approach selection​

ApproachBest fitSuccess
Transperineal + gracilis flap ± BMGOften selected for complex reconstruction and compromised tissueSelected cohort estimates; see denominators below[1][2][3][4]
Transsphincteric (York-Mason)Selected defects suitable for direct posterior closure, often nonirradiatedSeparate first-repair closure, eventual closure and bowel function; see below[10][27][28][29][33]
Transanal (advancement flap, MITAR, robotic TAMIS)Selected local repairs; the 1.5-cm threshold belongs to the Nicita MITAR seriesSmall, heterogeneous series; no established platform ranking[25][35]
Transabdominal / roboticComplex irradiated; needs salvage prostatectomy, omental flap, proctectomy, or concurrent VUAS repairVariable[26][30][36]

A. Transperineal repair with gracilis flap (Lahey / Vanni–Zinman–Buckley)​

The reference operation for both non-irradiated and irradiated RUF.[1][3][12][23]

Steps:

  1. Exaggerated lithotomy
  2. Vertical or inverted-U perineal incision
  3. Dissection through the perineal body to the fistula tract
  4. Separation of rectum from urethra / prostatic fossa
  5. Excision of the tract
  6. Two-layer rectal closure
  7. Urethral closure — primary or with buccal mucosal graft (BMG) onlay when there is a concurrent urethral stricture or significant urethral tissue loss
  8. Gracilis harvest from the medial thigh on the medial circumflex femoral pedicle, tunneled subcutaneously to the perineum, interposed between rectal and urethral suture lines
  9. Suprapubic + urethral catheter
  10. Cystogram at 3–4 weeks before catheter removal

Outcomes:

SeriesNNon-irradiatedIrradiated
Vanni 201074100%84%[2]
Kaufman / Lahey 20169898%86%[32]
Harris multi-institutional 201720199%87%[4]
Sbizzera Eur Urol 20222120/21 overallMixed cohort; not an irradiated-only estimate[22]
Muñoz-Duyos 20179100%—[31]

Concurrent urethral stricture (BMG patch onlay): present in 11% of non-irradiated and 28% of irradiated RUFs; in a series of 23 patients with concurrent posterior urethral stenosis, simultaneous urethroplasty + RUF repair achieved 87% fistula closure at median 56 months.[2][19]

B. York-Mason transsphincteric repair​

Technique:[10][12][28][29][33]

  1. Prone jackknife
  2. Parasacral incision from coccyx to anal verge
  3. Posterior-midline (6 o'clock) division of external and internal sphincter complex
  4. Direct exposure of the anterior rectal wall and fistula
  5. Tract excision; urethral closure; rectal closure
  6. Anatomic re-approximation of the divided sphincter complex in labeled layers
  7. Optional dartos / gluteal-fat interposition[24][28]

Outcomes:

SeriesNSuccessContinence
van der Graaf 202512 total; 8 nonirradiated first fistula repairsAll eight in that subgroup closedFive had colostomy reversal, with LARS scores 0–20; median 5.1 years applies to the eight-patient subgroup[10]
Dafnis 20182018/20 closed13 had stoma reversal and were reported continent; median follow-up 84.7 months[29]
McKibben 20181716/17 closedAmong ten questionnaire respondents, two had rare fecal incontinence; mean Wexner 1.4/20[28]
Falavolti 201339Overall over 50%; approximately 90% with one previous operationThe abstract does not justify a specific success rate after two failed fistula repairs[27]
Dal Moro 201114All initially closed; one Crohn-associated recurrence at 11 yearsTwenty years describes the experience period, not each patient's follow-up[33]

Where York–Mason fits: selected, usually nonirradiated RUFs suitable for closure through a posterior exposure. Radiation warrants particular caution and may favor another route with vascularized interposition, but is not an absolute prohibition. The two irradiated patients in the 2025 report cannot establish a rule based on radiation timing. Fecal continence is not guaranteed.[10][34]

C. Minimally invasive approaches​

  • MITAR (through a Parks' retractor) — 12 selected patients, all closed at median 21 months; one early complication. Fistulas larger than 1.5 cm, sepsis and fecaluria were excluded; radiation-induced fistulas were not studied[25]
  • Robotic TAMIS — two selected nonirradiated patients, both with diverting loop ileostomy, had no recurrence at at least 15 months. This is feasibility evidence[35]
  • Robotic/laparoscopic transabdominal repair — a selected 15-patient series included nine robotic and six laparoscopic operations; all closed at 12 months, with nine postoperative complications reported. Separate reports address simultaneous fistula and outlet-stricture reconstruction[30][36]
  • Transanal endoscopic surgery (TEO/TEM) — one RUF series achieved closure in only 2/8 repairs. All four mesh recipients and two of four non-mesh recipients recurred; this uncontrolled comparison does not prove that mesh caused failure[37]

4. Radiation/ablation-induced RUF — the difficult subset​

Radiation and ablation RUFs differ fundamentally and need a different mental model:[1][4][17][20][34][38]

  • Higher concurrent urethral stricture / BNC (26% vs 14%)
  • Higher post-repair urinary incontinence (35% vs 16%)
  • Higher permanent fecal diversion (31–86% vs 0–3%)
  • Higher permanent urinary diversion (up to 93% vs 6% in one series)
  • Consider vascularized interposition and tissue quality carefully. The cited 17% versus 87% comparison was primary-repair success in irradiated/ablated versus nonirradiated patients, not repair without versus with a flap[20]
  • Salvage prostatectomy may be required when a discrete prostate remains[17][26]
  • Proctectomy with coloanal pull-through (Turnbull–Cutait) for severe rectal injury[39][40]
  • Permanent dual diversion (fecal + urinary) should be discussed early as a legitimate primary option — required in ~50% of radiation/ablation patients in one multi-institutional series[38]

Concurrent Posterior Urethral Reconstruction​

Posterior urethral stenosis is present in ~18% of RUF patients and complicates repair. In a Cleveland Clinic series of 23 patients, simultaneous posterior urethroplasty + RUF repair achieved 87% fistula closure; 78% of urethroplasty was anastomotic and 22% used BMG. Postoperative urinary incontinence in 61%, with 30% ultimately needing artificial urinary sphincter — but no isolated stricture recurrences requiring instrumentation.[19]

Concurrent posterior urethral stenosis does not automatically exclude restorative surgery.[19]

Long-Term Functional Outcomes​

Even after successful closure, functional sequelae are common and must be discussed preoperatively.[4][18][19][20][28]

OutcomeRate
Post-repair urinary incontinence16% (non-irradiated) → 61% (in concurrent urethroplasty cohorts)
Eventual AUS placement~30% in concurrent-urethroplasty series
Permanent fecal diversion0–3% (non-irradiated); 31–86% (irradiated)
Permanent urinary diversion6–20% (non-irradiated); up to 93% (irradiated, severe)
Fecal continence after York-MasonOften preserved in selected series; Wexner is scored /20 and St Mark’s /24 and should not be combined
Patient satisfactionHigh (mean 9/10) despite incontinence
Decision regretNegligible (median 0/100)

A 2026 long-term outcomes study (median follow-up 50 months) reported 96% 5-year recurrence-free survival after open RUF repair, with restored voiding function, mild fecal incontinence, high patient satisfaction, and negligible decisional regret — though moderate urinary incontinence persisted in some.[18]

Algorithm Summary​

  1. Confirm diagnosis — cystoscopy, proctoscopy, VCUG, MRI; biopsy suspicious tissue when recurrence is a concern
  2. Characterize — size, location, etiology, concurrent stricture / BNC, tissue quality, cavitation
  3. Conservative trial for small fistula without fecaluria (catheter ± SP tube, bowel rest)
  4. Plan fecal diversion individually, particularly with sepsis, substantial contamination or complex reconstruction
  5. Definitive repair
    • Non-irradiated, small/simple → York-Mason (or MITAR in selected cases)
    • Non-irradiated, larger or complex → Transperineal + gracilis ± BMG
    • Irradiated / ablation-induced → consider vascularized interposition and the route needed for reconstruction; add BMG only when the urinary defect requires it. Salvage prostatectomy or permanent diversion depends on tissue destruction, function and goals
  6. Failed repair / devastated pelvis → permanent fecal and/or urinary diversion; pelvic exenteration as last resort[11][38]

Operative Principles​

  • The first repair is the best repair[21][27]
  • Etiology dictates complexity — non-irradiated and irradiated/ablation RUFs are different operations with different expectations
  • Vascularized tissue interposition (gracilis, omentum, dartos) is often valuable in irradiated or complex repairs; select it according to tissue viability, dead space and the reconstruction rather than treating every fistula identically
  • Multidisciplinary planning with colorectal surgery is the rule
  • Treat concurrent urethral pathology simultaneously when feasible[19]
  • Counsel about post-repair incontinence and possible AUS as part of the preoperative conversation
  • Permanent diversion is not failure — it is the right operation for the right radiation/ablation patient[20][38]

Surgical Video Resources​

See Also​

Videos​

GU Recon Lecture Series: Radiated Rectourethral Fistula Repair
Alex Vanni, MD (2020)

References​

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2. Vanni AJ, Buckley JC, Zinman LN. "Management of surgical and radiation induced rectourethral fistulas with an interposition muscle flap and selective buccal mucosal onlay graft." J Urol. 2010;184(6):2400–2404. doi:10.1016/j.juro.2010.08.004

3. Hechenbleikner EM, Buckley JC, Wick EC. "Acquired rectourethral fistulas in adults: a systematic review of surgical repair techniques and outcomes." Dis Colon Rectum. 2013;56(3):374–383. doi:10.1097/DCR.0b013e318274dc87

4. Harris CR, McAninch JW, Mundy AR, et al. "Rectourethral fistulas secondary to prostate cancer treatment: management and outcomes from a multi-institutional combined experience." J Urol. 2017;197(1):191–194. doi:10.1016/j.juro.2016.08.080

5. Thomas C, Jones J, Jäger W, et al. "Incidence, clinical symptoms and management of rectourethral fistulas after radical prostatectomy." J Urol. 2010;183(2):608–612. doi:10.1016/j.juro.2009.10.020

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22. Sbizzera M, Morel-Journel N, Ruffion A, et al. "Rectourethral fistula induced by localised prostate cancer treatment: surgical and functional outcomes of transperineal repair with gracilis muscle flap interposition." Eur Urol. 2022;81(3):305–312. doi:10.1016/j.eururo.2021.09.017

23. Voelzke BB, McAninch JW, Breyer BN, Glass AS, Garcia-Aguilar J. "Transperineal management for postoperative and radiation rectourethral fistulas." J Urol. 2013;189(3):966–971. doi:10.1016/j.juro.2012.08.238

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28. McKibben MJ, Fuchs JS, Rozanski AT, et al. "Modified transanosphincteric (York Mason) repair of nonradiated rectourinary fistulae: patient-reported fecal continence outcomes." Urology. 2018;118:220–226. doi:10.1016/j.urology.2018.05.010

29. Dafnis G. "Transsphincteric repair of rectourethral fistulas: 15 years of experience with the York Mason approach." Int J Urol. 2018;25(3):290–296. doi:10.1111/iju.13518

30. Medina LG, Sayegh AS, La Riva A, et al. "Minimally invasive management of rectourethral fistulae." Urology. 2022;169:102–109. doi:10.1016/j.urology.2022.05.060

31. Muñoz-Duyos A, Navarro-Luna A, Pardo-Aranda F, et al. "Gracilis muscle interposition for rectourethral fistula after laparoscopic prostatectomy: a prospective evaluation and long-term follow-up." Dis Colon Rectum. 2017;60(4):393–398. doi:10.1097/DCR.0000000000000763

32. Kaufman DA, Zinman LN, Buckley JC, et al. "Short- and long-term complications and outcomes of radiation and surgically induced rectourethral fistula repair with buccal mucosa graft and muscle interposition flap." Urology. 2016;98:170–175. doi:10.1016/j.urology.2016.06.065

33. Dal Moro F, Secco S, Valotto C, et al. "Twenty-year experience with surgical management of recto-urinary fistulas by posterior sagittal transrectal approach (York-Mason)." Surgery. 2011;150(5):975–979. doi:10.1016/j.surg.2011.04.004

34. Hanna JM, Turley R, Castleberry A, et al. "Surgical management of complex rectourethral fistulas in irradiated and nonirradiated patients." Dis Colon Rectum. 2014;57(9):1105–1112. doi:10.1097/DCR.0000000000000175

35. Hebert KJ, Naik N, Allawi A, et al. "Rectourethral fistula repair using robotic transanal minimally invasive surgery (TAMIS) approach." Urology. 2021;154:338. doi:10.1016/j.urology.2021.05.027

36. Sayegh AS, La Riva A, Perez LC, et al. "Robotic simultaneous repair of rectovesical fistula with vesicourethral anastomotic stricture after radical prostatectomy: step-by-step technique and outcomes." Urology. 2023;175:107–113. doi:10.1016/j.urology.2023.02.007

37. Serra-Aracil X, Labró-Ciurans M, Mora-López L, et al. "The place of transanal endoscopic surgery in the treatment of rectourethral fistula." Urology. 2018;111:139–144. doi:10.1016/j.urology.2017.08.049

38. Martins FE, Felicio J, Oliveira TR, et al. "Adverse features of rectourethral fistula requiring extirpative surgery and permanent dual diversion: our experience and recommendations." J Clin Med. 2021;10(17):4014. doi:10.3390/jcm10174014

39. Lane BR, Stein DE, Remzi FH, et al. "Management of radiotherapy induced rectourethral fistula." J Urol. 2006;175(4):1382–1387. doi:10.1016/S0022-5347(05)00687-7

40. Martín-Pérez B, Dar R, Bislenghi G, et al. "Transanal minimally invasive proctectomy with two-stage Turnbull-Cutait pull-through coloanal anastomosis for iatrogenic rectourethral fistulas." Dis Colon Rectum. 2021;64(2):e26–e29. doi:10.1097/DCR.0000000000001850