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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​

EtiologyIncidence
Radical prostatectomy0.34% (retropubic) – 1.04% (perineal)[5]
Brachytherapy monotherapy0.2–0.26% (1 of 640; 12 of 4,690)[6][7]
Brachytherapy + EBRT (combined)2.9% (2 of 69)[7]
Salvage brachytherapy8.8% (4 of 45)[7]
Primary whole-gland cryotherapy1.2% (~0.55% in modern era)[9]
HIFU — single session1.17%[8]
HIFU — repeat sessions13.6% (3 of 22)[8]
Salvage HIFU4.5% (1 of 22)[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 in one series of 2,447 (7 of 675 vs 6 of 1,772; p = 0.074, not statistically significant)[5]
Radiation / ablationIschemic necrosis of the rectourethral septum may follow radiation or ablation; in Netsch's eight HIFU-associated cases, fistulas developed 1–4 weeks after treatment, whereas seven fistulas in Theodorescu's brachytherapy series developed at 9–12 months.[7][8] Post-treatment rectal biopsy of radiation ulcers, argon-plasma coagulation, and TURP may increase fistula risk after brachytherapy; avoid biopsy of an anterior radiation-type rectal lesion over the prostate.[6][7] The 2025 BSG practice guidance states that argon plasma coagulation is contraindicated on the anterior rectal wall after prostate brachytherapy because of fistula risk.[46]
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 (historical literature estimates)[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; often calls for vascularized interposition; permanent diversion may be needed when tissue damage or organ function makes restoration unsuitable.[2][38] Cavitation is most common after salvage HIFU following combined EBRT and brachytherapy

Clinical Presentation​

After prostatectomy, RUF can present days to weeks postoperatively.[1][5][12][10] In Netsch's eight HIFU cases, fistulas developed at 1–4 weeks; in Theodorescu's seven brachytherapy cases, fistulas developed at 9–12 months; and Shah's seven-patient brachytherapy series reported mean symptom onset at 27.3 months.[7][8][47] The frequencies below come from one post-prostatectomy series of 29 men.[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 / BNCIn Harris's separate 201-patient repair cohort, 14% after radical prostatectomy alone versus 26% after energy ablation[4]; concurrent posterior urethroplasty was performed in another RUF cohort[19]

In Thomas's 13-patient post-prostatectomy series, all three men selected for conservative care healed and none had fecaluria; immediate repair without colostomy failed in the one man with fecaluria.[5] Sepsis, defect size and planned repair also inform diversion decisions.[12]

Diagnostic Evaluation​

StepRole
CystourethroscopyMaps urethral / prostatic-fossa opening; identifies concurrent stricture or BNC[12]
Proctoscopy / sigmoidoscopyRectal opening; surrounding mucosa[12]
RUG and VCUGVCUG confirms the fistula tract and demonstrates rectal extravasation.[12] Combined RUG and VCUG assess the fistula site and possible concomitant urethral stricture before repair.[23]
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 versus irradiated or ablation-induced.[1][4][12][20]

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

For selected small nonirradiated fistulas without fecaluria, consider urethral catheter drainage with or without a suprapubic tube and bowel rest. If pelvic sepsis includes a drainable collection, use antimicrobials and radiologic or surgical drainage when indicated.[46] In Thomas's 13-patient post-prostatectomy series, all three men selected for conservative treatment (3/3; 3/13 of the full cohort) healed spontaneously; none had fecaluria.[5] In Keller's 30-man algorithm cohort, 14/30 (47%) healed spontaneously: 8/30 (27%) without fecal diversion and 6/30 (20%) after fecal diversion.[16] In Leong's brachytherapy cohort, none of 12 fistulas healed without surgery.[6] Conservative treatment failed in all eight HIFU cases in Netsch's series.[8] An earlier brachytherapy series reported closure in 2 of 7 fistulas with urinary diversion and hyperbaric oxygen therapy.[7]

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] With temporary colostomy plus transurethral catheterization, 3/9 post-prostatectomy RUFs closed without fistula surgery; with colostomy plus suprapubic cystostomy, 14/30 post-traumatic RUFs closed.[5][15]

Interpret the endpoint correctly: the Lahey series reported that 97% of nonirradiated patients had their bowel undiverted after repair.[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)​

Transperineal repair with gracilis interposition is a commonly reported option, particularly for complex or irradiated RUF; route selection depends on fistula anatomy, tissue viability and concurrent urethral disease.[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. Use primary closure when feasible; select anastomotic posterior urethroplasty or BMG onlay for concurrent stenosis or tissue loss according to the urinary defect.[2][19]
  8. Gracilis harvest from the medial thigh, identifying and preserving its dominant proximal vascular pedicle (arterial origin varies); tunnel the flap to the perineum and interpose it between rectal and urethral suture lines.[43]
  9. Suprapubic and urethral catheter
  10. Cystogram at 3–4 weeks before catheter removal

Outcomes:

SeriesNNon-irradiatedIrradiated
Vanni 2010 (68 gracilis, 6 other muscle flaps)74100% closure with one procedure (35 nonradiated)84% single-stage closure (39 radiation/ablation induced)[2]
Kaufman / Lahey 2016 (expanded 1998–2015 series overlapping Vanni 2010; median follow-up 14.5 months)9898% (48/49) closed with one procedure (non-radiation induced)86% (42/49) closed with one procedure (radiation/ablation induced)[2][32]
Harris multi-institutional 2017 (mixed approaches; not a radiation-stratified estimate)20199% ultimate success after prostatectomy alone87% ultimate success after energy ablation (not an irradiated-only estimate)[4]
Sbizzera Eur Urol 2022 (overall 20/21 closed)21Not reported separatelyNot reported separately[22]
Muñoz-Duyos 20179100%—[31]

In a separate single-center retrospective cohort of 53 prostate-treatment RUFs (53% radiation, 34% surgery, 13% TURP), gracilis interposition yielded primary healing in 28/53 (53%) and eventual healing after additional procedures in 43/53 (81%); 20/53 (38%) had postoperative complications.[48]

Concurrent urethral stricture: present in 11% of non-irradiated and 28% of radiation/ablation-induced RUFs; in a series of 23 patients with concurrent posterior urethral stenosis, simultaneous urethroplasty and 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. Excise the tract and close the urethral and rectal defects in the standard York–Mason approach; the Montsouris variant uses a 2 o'clock transanal incision, closes the anterior rectal wall in nonoverlapping layers and leaves the urethra unclosed.[49]
  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 among the 18 successful repairs[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 operation[27]—
Dal Moro 201114All initially closed; one Crohn-associated recurrence at 11 yearsTwenty years describes the experience period[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. In a 2026 multicenter retrospective comparison (57 patients; York-Mason 27, transperineal gracilis 30), gracilis repair had higher first-attempt success (77% versus 44%) and overall success (94% versus 70%), and complex fistula morphology predicted York-Mason failure; the groups were not randomized and follow-up differed (median 53 versus 27 months).[10][34][41]

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 or 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[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 after energy ablation than radical prostatectomy alone (26% versus 14%)[4]
  • In Harris's 201-patient multicenter repair cohort, post-repair urinary incontinence was 35% after energy ablation versus 16% after radical prostatectomy alone[4]
  • Higher permanent fecal diversion after radiation/ablation (31–86% versus 0–3% without radiation/ablation across two series)[2][20]
  • Permanent urinary diversion. In Linder's selected 45-patient series, 27/29 (93%) patients with radiation/ablation-associated RUF underwent permanent urinary diversion compared with 1/16 (6%) patients without radiation/ablation; primary repair was attempted in only 6/29 radiation/ablation patients.[20]
  • Consider vascularized interposition and tissue quality carefully. The cited 17% versus 87% comparison was primary-repair success in irradiated or ablated (1 of 6) versus nonirradiated (13 of 15) patients[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 and urinary) should be discussed early as a legitimate primary option, required in about 50% of radiation or ablation patients in one multi-institutional series[38]

Concurrent Posterior Urethral Reconstruction​

In one reconstructive cohort, 23 of 130 men with RUF (18%) underwent concurrent posterior urethroplasty for stenosis or tissue loss. In a Cleveland Clinic series of 23 patients, simultaneous posterior urethroplasty and 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]

Long-Term Functional Outcomes​

Even after successful closure, functional sequelae are common and must be discussed preoperatively.[4][18][19][20][28] In Kaufman's 98-patient transperineal cohort, later urethral diverticulum, stricture, urinary incontinence and bowel problems sometimes required further surgery; continued follow-up was advised.[32]

OutcomeRate
Post-repair urinary incontinence16% after radical prostatectomy alone in Harris’s cohort; 61% (14/23) after concurrent posterior urethroplasty in Khouri’s cohort[4][19]
Stoma reversal / bowel continuity restoredKaufman: 45/48 (94%) nonradiated versus 30/46 (65%) radiated/ablated; Hanna: 91% nonirradiated versus 55% irradiated; Sbizzera: 10/12 (83%) diverted patients in a mixed cohort[32][34][22]
Eventual AUS placement7/23 (30%) in a concurrent posterior urethroplasty series[19]
Permanent fecal diversion0–3% without radiation/ablation; 31–86% after radiation/ablation across two series[2][20]
Permanent urinary diversion1/16 (6%) without radiation/ablation versus 27/29 (93%) after radiation/ablation in one severe-case series[20]
Fecal continence after York-MasonOften preserved in selected series[28][29]; Wexner is scored /20 and St Mark’s /24
Patient satisfactionMean 9/10 (SD 2) among 18 of 21 Sbizzera gracilis-repair patients completing the questionnaire, despite 11/18 reporting significant urinary incontinence[22]
Decision regretMedian 0/100 (IQR 0–10) among 17/29 questionnaire respondents[18]

A 2026 open-repair series enrolled 29 mostly nonirradiated men. Among 23 included in survival analysis, estimated 5-year recurrence-free survival was 96% and disease-related reintervention-free survival was 75% (median follow-up 50 and 58 months, respectively). Validated questionnaires from 17 men showed restored voiding function, mild fecal but moderate urinary incontinence, high satisfaction and low decisional regret.[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 or simple: York-Mason (or MITAR in selected cases)
    • Non-irradiated, larger or complex: transperineal gracilis, with or without BMG
    • Pelvic-fracture urethral injury with RUF: a fistula below the verumontanum may be corrected by a progressive perineal approach. The EAU guideline reserves combined abdominoperineal reconstruction for complicated injuries, including RUF .[45]
    • Irradiated / ablation-induced: consider vascularized interposition and the route needed for reconstruction; add BMG only when the urinary defect requires it. When posterior outlet damage coexists, assess bladder capacity, compliance, necrosis and local symptoms before selecting restoration or urinary diversion.[45] Salvage prostatectomy or permanent diversion depends on tissue destruction, function and goals.
  6. Failed repair: reassess radiation exposure, residual tissue, bladder and rectal function for a selected repeat reconstruction; discuss permanent fecal and/or urinary diversion when the pelvis is devastated or further repair is unlikely to succeed. Reserve pelvic exenteration for selected severe cases.[11][38][44]

Operative Principles​

  • The first repair is the best repair[21][27]
  • Etiology dictates complexity. Non-irradiated and irradiated or ablation-induced 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. For extensive perineal or retroprostatic dead space, such as after pelvic exenteration, radiation, or pressure-related tissue loss, rotation of the inferior segment of the gluteus maximus as a vascularized buttress over the repair has been described, preserving the superior segment and the gluteal neurovascular pedicle[42]
  • 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 or ablation patient[20][38]

Surgical Video Resources​

See Also​

Videos​

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

References​

1. Lo Re M, Pezzoli M, Garcia Rojo E, et al. "A systematic review on the surgical management of acquired rectourethral fistula." Int J Impot Res. 2026;38(3):214–225. doi:10.1038/s41443-025-01100-y

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

6. Leong N, Pai HH, Morris WJ, et al. "Rectal ulcers and rectoprostatic fistulas after (125)I low dose rate prostate brachytherapy." J Urol. 2016;195(6):1811–1816. doi:10.1016/j.juro.2015.12.095

7. Theodorescu D, Gillenwater JY, Koutrouvelis PG. "Prostatourethral-rectal fistula after prostate brachytherapy." Cancer. 2000;89(10):2085–2091. doi:10.1002/1097-0142(20001115)89:10<2085::aid-cncr8>3.0.co;2-q

8. Netsch C, Bach T, Gross E, Gross AJ. "Rectourethral fistula after high-intensity focused ultrasound therapy for prostate cancer and its surgical management." Urology. 2011;77(4):999–1004. doi:10.1016/j.urology.2010.10.028

9. Aminsharifi A, Polascik TJ, Schulman A, et al. "Predictors of rectourethral fistula formation after primary whole-gland cryoablation for prostate cancer: results from the Cryo On-Line Database registry." J Endourol. 2018;32(9):791–796. doi:10.1089/end.2018.0357

10. van der Graaf SH, Wit EMK, Beets GL, et al. "Management in robot-assisted radical prostatectomy patients with recto-urethral fistulas: the York-Mason technique." World J Urol. 2025;43(1):604. doi:10.1007/s00345-025-05996-5

11. Muñoz M, Nelson H, Harrington J, et al. "Management of acquired rectourinary fistulas: outcome according to cause." Dis Colon Rectum. 1998;41(10):1230–1238. doi:10.1007/BF02258219

12. Campbell JG, Vanni AJ. "Complex lower genitourinary fistula repair: rectourethral fistula and puboprostatic fistula." Urol Clin North Am. 2022;49(3):553–565. doi:10.1016/j.ucl.2022.04.012

13. Stamler JS, Bauer JJ, Janowitz HD. "Rectourethroperineal fistula in Crohn's disease." Am J Gastroenterol. 1985;80(2):111–112. PMID 3969998

14. Kucera WB, Jezior JR, Duncan JE. "Management of post-traumatic rectovesical/rectourethral fistulas: case series of complicated injuries in wounded warriors and review of the literature." Mil Med. 2017;182(3):e1835–e1839. doi:10.7205/MILMED-D-16-00148

15. al-Ali M, Kashmoula D, Saoud IJ. "Experience with 30 posttraumatic rectourethral fistulas: presentation of posterior transsphincteric anterior rectal wall advancement." J Urol. 1997;158(2):421–424. doi:10.1016/s0022-5347(01)64493-8

16. Keller DS, Aboseif SR, Lesser T, et al. "Algorithm-based multidisciplinary treatment approach for rectourethral fistula." Int J Colorectal Dis. 2015;30(5):631–638. doi:10.1007/s00384-015-2183-0

17. Mundy AR, Andrich DE. "Urorectal fistulae following the treatment of prostate cancer." BJU Int. 2011;107(8):1298–1303. doi:10.1111/j.1464-410X.2010.09686.x

18. Wagner MC, Klemm J, Roessler N, et al. "Long-term patient-reported outcomes of open urorectal fistula repair after prostate cancer treatment." BJU Int. 2026. doi:10.1111/bju.70233

19. Khouri RK, Accioly JPE, DeWitt-Foy ME, Wood HM, Angermeier KW. "Posterior urethral reconstruction at the time of rectourethral fistula repair: technique and outcomes." Urology. 2024;186:36–40. doi:10.1016/j.urology.2024.02.026

20. Linder BJ, Umbreit EC, Larson D, et al. "Effect of prior radiotherapy and ablative therapy on surgical outcomes for the treatment of rectourethral fistulas." J Urol. 2013;190(4):1287–1291. doi:10.1016/j.juro.2013.03.077

21. Bukowski TP, Chakrabarty A, Powell IJ, et al. "Acquired rectourethral fistula: methods of repair." J Urol. 1995;153(3 Pt 1):730–733. doi:10.1016/s0022-5347(01)67701-2

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

24. Dafnis G. "Transsphincteric repair of rectourethral fistulas in combination with dartos muscle flap interposition following radical prostatectomy." Urology. 2024;191:130–135. doi:10.1016/j.urology.2024.05.041

25. Nicita G, Villari D, Caroassai Grisanti S, et al. "Minimally invasive transanal repair of rectourethral fistulas." Eur Urol. 2017;71(1):133–138. doi:10.1016/j.eururo.2016.06.006

26. Medina LG, Cacciamani GE, Hernandez A, et al. "Robotic management of rectourethral fistulas after focal treatment for prostate cancer." Urology. 2018;118:241. doi:10.1016/j.urology.2018.05.012

27. Falavolti C, Sergi F, Shehu E, Buscarini M. "York Mason procedure to repair iatrogenic rectourinary fistula: our experience." World J Surg. 2013;37(12):2950–2955. doi:10.1007/s00268-013-2199-y

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

41. Long Depaquit T, Michel F, Madec FX, et al. "Comparison of rectourethral fistula repairs: york mason vs. transperineal repair with gracilis flap interposition." World J Urol. 2026;44(1):198. doi:10.1007/s00345-026-06316-1

42. Zinman LN, Buckley JC. The Application of Muscular, Myocutaneous, and Fasciocutaneous Flaps as Adjuncts in Complex Refractory Urethral Disorders. In: Brandes SB, Morey AF, eds. Advanced Male Urethral and Genital Reconstructive Surgery. 2nd ed. Humana Press; 2014:249-271. doi:10.1007/978-1-4614-7708-2_18

43. Macchi V, Vigato E, Porzionato A, et al. "The gracilis muscle and its use in clinical reconstruction: an anatomical, embryological, and radiological study." Clin Anat. 2008;21(7):696–704. doi:10.1002/ca.20685

44. Jeannot P, Roussel E, Dutoit A, et al. "Comparative outcomes of early and late rectourethral fistula: insights from a multicentric retrospective study on multidisciplinary management strategies." Ann Coloproctol. 2026;42(1):103–114. doi:10.3393/ac.2025.00696.0099

45. European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Males. 2026. Guideline.

46. Andreyev J, Adams R, Bornschein J, et al. "British Society of Gastroenterology practice guidance on the management of acute and chronic gastrointestinal symptoms and complications as a result of treatment for cancer." Gut. 2025;74(7):1040–1067. doi:10.1136/gutjnl-2024-333812

47. Shah SA, Cima RR, Benoit E, Breen EL, Bleday R. "Rectal complications after prostate brachytherapy." Dis Colon Rectum. 2004;47(9):1487–1492. doi:10.1007/s10350-004-0603-2

48. Emile SH, Horesh N, Strassmann V, et al. "Outcomes of gracilis muscle interposition for rectourethral fistulas caused by treatment of prostate cancer." Tech Coloproctol. 2023;27(10):937–944. doi:10.1007/s10151-023-02759-5

49. Kasraeian A, Rozet F, Cathelineau X, Barret E, Galiano M, Vallancien G. "Modified York-Mason technique for repair of iatrogenic rectourinary fistula: the Montsouris experience." J Urol. 2009;181(3):1178–1183. doi:10.1016/j.juro.2008.10.160