Male Fistula Repair
Male fistula repair covers rectourethral, bowel–bladder, urosymphyseal and urethrocutaneous fistulae. The organs involved, the cause, tissue quality, obstruction, and baseline urinary and bowel function determine the choice of 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.[1][2][3]
Identify the Communication
| Clinical clue | Evaluation focus |
|---|---|
| Pneumaturia, fecaluria or urine per rectum after prostate treatment | Evaluate for RUF with directed urinary and rectal endoscopy and urethrography; assess prior radiation, outlet stenosis and continence.[1] In a six-man series after combined brachytherapy and external-beam radiotherapy, RUF followed rectal biopsy or hemorrhoidectomy; the authors advised against rectal-ulcer biopsy and elective surgery on irradiated rectal tissue.[22] |
| Pneumaturia or recurrent UTI with bowel disease | Define the bowel source, abscess or obstruction and exclude malignancy.[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. A monitored drainage trial may suit a small uncomplicated fistula, while significant symptoms, infection or tissue damage change the urgency and the diversion plan. Fecaluria marks a more severe fistula and often prompts fecal diversion. It does not by itself mandate a colostomy followed by a three-to-six-month wait.[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 with or without extirpative surgery | May best match severe tissue destruction, poor organ function, prior unsuccessful reconstruction, operative fitness and patient preferences. |
| Anterior transanosphincteric (Gecelter) approach | Selected small traumatic or surgical fistulae when simultaneous posterior urethral reconstruction is needed, a normal anal sphincter is present and there is no prior anorectal disease; affords wide access to the proximal and posterior urethra but is not suited to large defects needing an interposition flap.[19] |
The route considerations above derive from reconstructive reviews and retrospective series. No randomized comparison exists.[1][6] Radiation raises the risk of failure and reported results differ widely between selected reconstructive series and cohorts with severe tissue destruction. The fecal-diversion page tabulates populations and denominators.
One route-selection heuristic measures fistula distance from the anal verge on examination: a fistula less than 6 cm from the verge can often be approached transanally, while one more than 6 cm away often requires an abdominal (laparoscopic, robotic or open) or transsacral approach.[20]
For a small traumatic or surgical fistula with a concomitant posterior urethral distraction defect requiring simultaneous reconstruction, one described anterior Gecelter transanosphincteric sequence catheterizes the fistula and uses an anterior midline incision from the scrotal base to the anal verge; the transverse perineal muscles, central tendon and sphincter complex are divided in the midline and tagged for restoration, and the rectum is separated to the peritoneum. Concurrent urethral stricture can be reconstructed before a two-layer rectal closure and paired reapproximation of the sphincter components, with gracilis interposition. This differs from the posterior sagittal York-Mason route. In an eight-patient post-traumatic experience, catheters were described as removed at 3-6 weeks after imaging, with possible stoma reversal at 3-6 months after reassessment; these are dated author-practice intervals, and no closure or functional outcome rate is reported for this eight-patient subset.[19]
Selected reported outcomes
| Series | Population and approach | Reported outcome |
|---|---|---|
| Vanni 2010 | 74 RUF repaired through a transperineal approach with a muscle interposition flap (68 gracilis) and selective buccal mucosa onlay; 35 nonradiated and 39 radiated or ablated | Closed with one procedure in 100% of nonradiated and 84% of radiated or ablated fistulae at mean follow-up of 20 months. Permanent fecal diversion was required in 31% of the radiated or ablated group.[8] |
| Harris 2017 | 201 men from four reconstructive centers; 97 after prostatectomy alone, 104 after energy ablation; interposition flap or graft in 91% to 92% | Ultimate closure 99% after prostatectomy and 87% after ablation (92% overall). Postoperative urinary incontinence was 16% and 35%, and complications 11% and 25%, respectively.[9] |
| Khouri 2024 | 23 men with posterior urethral stenosis or defect who had urethroplasty at the time of RUF repair (anastomotic in 18, buccal graft in 5; gracilis in 21) | Closure in 20/23 (87%) at median follow-up of 55.7 months. Urinary incontinence occurred in 14/23 (61%), and 7 (30%) had an artificial urinary sphincter placed. Posterior urethral stenosis did not by itself preclude restorative repair.[10] |
| Long Depaquit 2026 | 57 patients at four French centers (27 York–Mason, 30 transperineal gracilis); retrospective; median follow-up 27 versus 53 months | Twelve-month reintervention-free survival, the primary endpoint, was 68.2% with York–Mason versus 94.7% with gracilis. First-attempt success was 44% versus 77%, and overall success at last follow-up was 70% versus 94%. Complex morphology predicted York–Mason failure; the authors conclude it may remain suitable for selected simple, nonirradiated fistulae.[11] |
| Linder 2013 | 45 patients; 29 after radiation or ablation, 16 without | Primary repair was attempted in 6/29 (21%) radiation/ablation cases and 15/16 (94%) others; it succeeded in 1/6 and 13/15, respectively. Permanent colostomy occurred in 25/29 versus 0/16 and permanent urinary diversion in 27/29 versus 1/16. These are differently selected cohorts.[12] |
| Hechenbleikner 2013 | Systematic review of 416 patients in retrospective series | Among the 90% who underwent one of four reported repair categories, 65.9% had transperineal and 5.9% transanal repair. Fistula closure was 87.5%, and overall permanent fecal and urinary diversion rates were 10.6% and 8.3%, respectively.[13] |
Baseline function is documented and later continence treatment is discussed separately. See fistula principles and male SUI procedures.
For selected patients with refractory fistula leakage, poor operative fitness or limited life expectancy whose leakage persists despite nephrostomy drainage alone, distal ureteral embolization through a nephrostomy tract has been described as a palliative option. Nephrostomy drainage then continues long term unless definitive reconstruction is performed. In a 12-year, 29-patient series (23 women, 6 men; 52 ureters), technical occlusion was achieved in all cases with complete or near-complete dryness within 3 days; 23 patients later died of cancer at a mean of 8.1 months after embolization.[18]
Enterovesical / Colovesical Fistula
The underlying bowel disease and any associated sepsis are treated first. The ASCRS 2026 guideline recommends elective colectomy for left-sided diverticulitis complicated by fistula or symptomatic stricture , updating its 2020 recommendation ; timing, anastomosis and diversion depend on clinical circumstances.[4][21] Bladder treatment depends on the actual defect. In Ferguson's 74-patient cohort of benign bowel disease without prior abdominal cancer or pelvic radiation, the bladder was managed by Foley catheter alone in 68% after bowel resection and by surgical repair in 32%.[3] Formal repair was reserved for overt bladder defects, and the series excluded cancer and radiation injury.[3]
Crohn's entero-urinary disease is planned jointly by gastroenterology and surgery. Recurrent symptomatic urinary tract infection, especially with pyelonephritis, is an indication for surgery in enterovesical or colovesical fistula.[23] Selected patients respond to anti-TNF treatment, but abscess, obstruction or sepsis changes the sequence. In Taxonera's 97-patient retrospective cohort, 45% of the 33 anti-TNF-treated patients achieved sustained remission without surgery, and 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 management failed in 96% of irradiated cases and 72% of radiation-naive cases. Among 214 reported post-radiation operations, 184 (86%) involved cystectomy with diversion and 30 (14%) bladder-sparing surgery.[2] These selected reports support early multidisciplinary reconstructive assessment.[2]
Infection control and urinary drainage, debridement with bladder or outlet preservation, and extirpative surgery with diversion are the options. The choice follows the remaining organ function, bone and soft-tissue damage, and patient fitness. When pubic bone is debrided for suspected osteomyelitis, consider intraoperative bone cultures to inform antimicrobial treatment; in Andrews's 25-patient irradiated surgical series, preoperative urine and intraoperative bone cultures differed in 21/22 patients with paired results.[15] Pubic, thigh and cutaneous extensions can overlap.[2] In a single-center series of 57 operated USF patients, 26/57 (46%) required major intervention for a complication occurring after 90 days at a median of 11 months, and 14/57 (25%) developed new or worsening sacral insufficiency fractures; follow-up beyond 90 days is warranted.[24]
| Series | Population | Reported outcome |
|---|---|---|
| Bugeja 2016 | 16 patients treated for USF after prostate cancer treatment; conservative management succeeded in 1 | 7/15 operated patients had reconstruction with salvage prostatectomy and substitution or augmentation cystoplasty and 8 had cystectomy with ileal conduit. Symptoms resolved in all, with pain resolving almost immediately.[14] |
| Andrews 2021 | 25 irradiated patients treated with pubectomy and urinary reconstruction | Pain resolved in 24/25 (96%), median ECOG performance status improved from 3 to 0, and 8/25 (32%) had major 90-day complications. Bone cultures showed active infection in 80%.[15] |
| Osterberg 2017 (TURNS) | 31 men with anterior urinary fistula after prostate radiotherapy (pubic symphysis in 19, thigh in 12) | 19 had cystectomy and 12 had fistula repair. Pain had resolved in 26/31 (84%) at the reported assessment (three months in Results, six months in the abstract); there was one fistula recurrence.[16] |
In a retrospective cohort of 58 patients who had decompression, pubic bone resection and reconstruction, 27 had repair within the study-defined 100-day cutoff and 31 later, with reported follow-up of 32.8 and 25.43 months, respectively; earlier repair was associated with less recurrent pain (11.1% versus 46.7%), recurrent osteomyelitis (0% versus 20%) and fistula recurrence (3.7% versus 23.3%).[17] The 100-day cutoff defined groups in this analysis.[17] Ninety-day complication rates were similar.[17]
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.[5] Associated stricture and poor tissue may make a larger reconstruction necessary.[5] If that reconstruction includes penile urethroplasty after failed hypospadias repair, the EAU strongly recommends against penile skin grafts or flaps when lichen sclerosus or scarred penile skin is present.[5]
The database below lists the options and links to their technique pages.
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 prerequisites. |
| 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; assess pubic bone debridement and infection control alongside diversion. |
| 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. Hall J, Hardiman K, Lee S, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis. Dis Colon Rectum. 2020;63(6):728–747. doi:10.1097/DCR.0000000000001679.
5. European Association of Urology. Urethral Strictures: Disease Management in Males. 2026, section 6.3.1.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.
8. 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.
9. 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.
10. Khouri RK Jr, 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.
11. 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.
12. Linder BJ, Umbreit EC, Larson D, Dozois EJ, Thapa P, Elliott DS. 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.
13. 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.
14. Bugeja S, Andrich DE, Mundy AR. Fistulation into the pubic symphysis after treatment of prostate cancer: an important and surgically correctable complication. J Urol. 2016;195(2):391–398. doi:10.1016/j.juro.2015.08.074.
15. Andrews JR, Hebert KJ, Boswell TC, et al. Pubectomy and urinary reconstruction provides definitive treatment of urosymphyseal fistula following prostate cancer treatment. BJU Int. 2021;128(4):460–467. doi:10.1111/bju.15333.
16. Osterberg EC, Vanni AJ, Gaither TW, et al. Radiation-induced complex anterior urinary fistulation for prostate cancer: a retrospective multicenter study from the Trauma and Urologic Reconstruction Network of Surgeons (TURNS). World J Urol. 2017;35(7):1037–1043. doi:10.1007/s00345-016-1983-3.
17. Escandón JM, Kreutz-Rodrigues L, Fadel AE, et al. Timing for repair of urosymphyseal fistula after diagnosis determines the incidence postoperative outcomes. J Surg Oncol. 2026;133(2):217–225. doi:10.1002/jso.70133.
18. Shindel AW, Zhu H, Hovsepian DM, Brandes SB. Ureteric embolization with stainless-steel coils for managing refractory lower urinary tract fistula: a 12-year experience. BJU Int. 2007;99(2):364-368. doi:10.1111/j.1464-410X.2006.06569.x.
19. Zinman LN. Contemporary Management of Rectourethral Fistula. In: Montague DK, Gill IS, Angermeier KW, Ross JH, eds. Textbook of Reconstructive Urologic Surgery. Informa Healthcare; 2008:502-509.
20. Kerr PK, Brandes SB. Treatment Decision. In: Sotelo R, Polotti CF, Arriaga J, eds. Urinary Fistula. Springer; 2022:15-29. doi:10.1007/978-3-031-15317-4_2
21. Hawkins AT, et al. "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Left-Sided Colonic Diverticulitis." Dis Colon Rectum. 2026;69(10):2431–2450. doi:10.1097/DCR.0000000000004382
22. Marguet C, Raj GV, Brashears JH, et al. "Rectourethral fistula after combination radiotherapy for prostate cancer." Urology. 2007;69(5):898–901. doi:10.1016/j.urology.2007.01.044
23. Lichtenstein GR, Loftus EV, Afzali A, et al. "ACG Clinical Guideline: Management of Crohn's Disease in Adults." Am J Gastroenterol. 2025;120(6):1225–1264. doi:10.14309/ajg.0000000000003465
24. Pinkhasov A, Kemble J, Fadel A, et al. "Delayed Morbidity Associated With Surgical Management of Urosymphyseal Fistula." Urology. 2025;197:180–184. doi:10.1016/j.urology.2024.11.062