Male Fistula Repair
This atlas links procedures for rectourethral, bowel–bladder, urosymphyseal and urethrocutaneous fistulae. Determine the actual organs involved, cause, tissue quality, obstruction and baseline urinary/bowel function before choosing a repair. Prostate cancer treatment is a major cause of acquired rectourethral and urosymphyseal fistulae; bowel–bladder communications also arise from diverticulitis, Crohn's disease and malignancy. Diverticulitis is not inflammatory bowel disease.[1][2][3]
Identify the Communication
| Clinical clue | Evaluation focus |
|---|---|
| Pneumaturia, fecaluria or urine per rectum after prostate treatment | Evaluate for RUF using directed urinary/rectal endoscopy and urethrography; assess prior radiation, outlet stenosis and continence.[1] |
| Pneumaturia or recurrent UTI with bowel disease | Define the bowel source, abscess or obstruction and exclude malignancy; symptoms alone do not distinguish all bowel–urinary fistulae.[3][4] |
| Pubic/groin pain and difficulty walking after radiation or outlet instrumentation | Consider urosymphyseal fistula and osteomyelitis; MRI is particularly useful for defining the communication and soft-tissue/bone involvement.[2] |
| Urine through penile, scrotal or perineal skin | Map the urethrocutaneous tract and assess associated stricture, prior reconstruction, skin quality and infection.[5] |
Rectourethral Fistula: Selecting an Approach
No single route is best for every RUF. Small uncomplicated fistulae may justify a monitored drainage trial; significant symptoms, infection or tissue damage change the urgency and diversion plan. Fecaluria is a severity clue, not an automatic instruction to create a colostomy and wait three to six months.[1]
| Option | Features relevant to selection |
|---|---|
| Transperineal repair | Provides access for tissue interposition and simultaneous urethral reconstruction; often used for complex or irradiated fistulae. |
| York–Mason | Transsphincteric access for selected fistulae with suitable tissue; limited urethral exposure and sphincter-related morbidity matter. |
| Transanal advancement / minimally invasive repair | Selected accessible defects; working space, tissue viability and limited ability to reconstruct the outlet constrain use. |
| Transabdominal / combined repair | High communication, abdominal pathology, unusable bladder or need for complex bowel/urinary reconstruction. |
| Definitive diversion ± extirpative surgery | May best match severe tissue destruction, poor organ function, prior unsuccessful reconstruction, operative fitness and patient preferences. |
The route considerations above derive from reconstructive reviews, not randomized comparisons.[1][6] Radiation increases risk but does not imply inevitable failure. Reported results vary substantially between selected reconstructive series and cohorts with severe tissue destruction. Use the fecal-diversion evidence tables for explicit populations and denominators.
Repair does not guarantee urinary or fecal continence. Document baseline function and discuss later continence treatment separately. See fistula principles and male SUI procedures.
Enterovesical / Colovesical Fistula
Treat the underlying bowel disease and associated sepsis. ASCRS 2020 recommends elective colectomy for diverticulitis complicated by fistula; timing, anastomosis and diversion depend on clinical circumstances.[4] Bladder treatment depends on the actual defect. Ferguson's 74-patient benign, nonirradiated cohort used catheter drainage without formal bladder repair in 68% after bowel resection; this is not permission to leave an obvious bladder defect, cancer or radiation injury untreated.[3]
Crohn's entero-urinary disease warrants combined gastroenterology and surgical planning. Selected patients can respond to anti-TNF treatment, but this is not an automatic first step regardless of abscess, obstruction or sepsis. In Taxonera's 97-patient retrospective cohort, 45% of the 33 anti-TNF-treated patients achieved sustained remission without surgery; more than 80% of the entire cohort ultimately required surgery.[7]
Urosymphyseal / Puboprostatic Fistula
This communication often coexists with pubic osteomyelitis after radiation and subsequent outlet instrumentation. Patel's review included 248 cases: 93% had prior prostate radiotherapy, but nonirradiated cases also occurred. Conservative treatment frequently failed, particularly after irradiation. These selected reports support early multidisciplinary reconstructive assessment, not a claim that conservative treatment never succeeds.[2]
Choose among infection control and urinary drainage, debridement with bladder/outlet preservation, or extirpative surgery with diversion according to the remaining organ function, bone and soft-tissue damage and patient fitness. Pubic, thigh and cutaneous extensions can overlap; their location alone does not determine the operation.[2]
Urethrocutaneous Fistula
Separate an isolated tract from broader complications of hypospadias repair or urethral reconstruction. Inspect the urethral plate, distal outlet, skin and available vascularized tissue. A fistula does not automatically require staged urethroplasty; associated stricture and poor tissue may make a larger reconstruction necessary.[5]
Evidence about preventing fistula during primary pediatric hypospadias surgery cannot directly rank treatments for an established adult recurrent fistula. The database below describes options and links to their technique pages; it does not rank them by unadjusted success percentages.
Treatment Database
| Technique | Fistula Type | Best for / indication |
|---|---|---|
| Conservative Management | Rectourethral Fistula | Selected small, uncomplicated RUF with planned reassessment; diversion and timing are individualized. |
| Transperineal Approach to RUF | Rectourethral Fistula | Access for complex RUF, tissue interposition and simultaneous outlet reconstruction when needed. |
| York-Mason Repair | Rectourethral Fistula | Selected accessible RUF with suitable tissue; anal-sphincter division requires careful repair and counseling. |
| Endorectal Advancement Flap | Rectourethral Fistula | Selected accessible rectal defects with viable tissue and a suitable outlet. |
| Transanal Minimally Invasive Repair | Rectourethral Fistula | Limited-access transanal techniques for selected RUF; feasibility reports do not establish a universal size cutoff. |
| Transabdominal Repair | Rectourethral Fistula | High or complex communication, abdominal pathology or need for urinary/bowel reconstruction. |
| Turnbull-Cutait Pull-Through | Rectourethral Fistula | Selected complex salvage requiring colorectal reconstruction; compare with permanent diversion. |
| Permanent Dual Diversion | Rectourethral Fistula | Consider when tissue destruction, bladder/outlet function or patient goals favor definitive diversion. |
| Fecal Diversion | Rectourethral Fistula | Temporary adjunct or definitive symptom control; assess fecal contamination and reversal feasibility. |
| Rectovesical Fistula Repair | Rectovesical Fistula | Route depends on rectal and bladder defect location, tissue quality and required reconstruction. |
| Enterovesical / Colovesical Fistula Repair | Enterovesical / Colovesical Fistula | Treat underlying bowel disease; bladder repair depends on the actual defect and tissue condition. |
| Salvage Prostatectomy for USF | Urosymphyseal / Puboprostatic Fistula | Selected USF with prostate in situ; extent of infection and remaining bladder/outlet determine feasibility. |
| Organ-Sparing Repair with Interposition Flap | Urosymphyseal / Puboprostatic Fistula | Selected USF with salvageable urinary tract; infection control, debridement and viable tissue are essential. |
| Primary Repair (No Flap) | Urosymphyseal / Puboprostatic Fistula | Highly selected repair; suitability depends on viable tissue and ability to achieve durable separation. |
| Cystectomy + Ileal Conduit | Urosymphyseal / Puboprostatic Fistula | Destructive USF or unusable bladder/outlet when restoration is unsuitable. |
| Simple Closure + Skin Advancement Flap | Urethrocutaneous Fistula | Isolated UCF with viable local tissue; assess distal obstruction and associated urethral disease. |
| Double Dartos Flap | Urethrocutaneous Fistula | Vascularized coverage option; evidence from prevention in primary hypospadias differs from recurrent UCF repair. |
| Tunica Vaginalis Flap | Urethrocutaneous Fistula | Vascularized coverage option for selected recurrent UCF when pedicle reach and prior surgery permit. |
| PATIO Repair | Urethrocutaneous Fistula | Tract-inversion technique described for selected UCF; selection and drainage vary across series. |
| Scrotal Flaps | Urethrocutaneous Fistula | Coverage option according to local tissue, prior operations and pedicle availability. |
| Urethroperineal Fistula Repair | Urethroperineal Fistula | Congenital or acquired tract requiring anatomical definition and individualized reconstruction. |
References
1. Chen S, Gao R, Li H, Wang K. Management of acquired rectourethral fistulas in adults. Asian J Urol. 2018;5:149–154. doi:10.1016/j.ajur.2018.01.003.
2. Patel N, Mehawed G, Dunglison N, et al. Uro-symphyseal Fistula: A Systematic Review to Inform a Contemporary, Evidence-based Management Framework. Urology. 2023;178:1–8. doi:10.1016/j.urology.2023.05.002.
3. Ferguson GG, Lee EW, Hunt SR, Ridley CH, Brandes SB. Management of the bladder during surgical treatment of enterovesical fistulas from benign bowel disease. J Am Coll Surg. 2008;207:569–572. doi:10.1016/j.jamcollsurg.2008.05.006.
4. American Society of Colon and Rectal Surgeons. Treatment of Left-Sided Colonic Diverticulitis. 2020 guideline, elective colectomy recommendation2. Official guideline.
5. European Association of Urology. Urethral Strictures: Disease Management in Males. 2026, section6.3.1.d. Guideline chapter.
6. 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;38:214–225. doi:10.1038/s41443-025-01100-y.
7. Taxonera C, Barreiro-de-Acosta M, Bastida G, et al. Outcomes of Medical and Surgical Therapy for Entero-urinary Fistulas in Crohn's Disease. J Crohns Colitis. 2016;10:657–662. doi:10.1093/ecco-jcc/jjw016.