Endorectal Advancement Flap (ERAF) for Rectourethral Fistula
ERAF covers the rectal side of a rectourethral fistula (RUF) with mobilized viable rectal tissue. A purely transanal approach avoids deliberate external anal-sphincter division and a distant muscle donor site. It can be useful for an accessible defect with healthy local tissue, but the evidence consists mainly of small series. Anatomical closure, urinary continence, bowel function and reversal of diversion are distinct outcomes.[1][2]
Compare Transperineal RUF Repair, York-Mason Repair, Transanal Minimally Invasive Repair, and the separate ERAF for RVF page.
Selection and preoperative planning
Assess rectal access, fistula level and size, urethral stricture, residual continence mechanisms, infection and tissue damage from radiation or ablation. Active infection needs control before elective closure. Local flap repair is less attractive with severe proctitis, ischemia, a large tissue deficit or a urethra requiring substantial reconstruction.[3][4]
There is no validated universal 1.5-cm ERAF cutoff. That threshold was an exclusion criterion in Nicita's 12-patient MITAR series, a distinct transanal repair using laparoscopic instruments and separate urinary/rectal suturing. It should not be transferred to every advancement-flap technique.[5]
Fecal diversion is individualized according to contamination, symptoms, tissue and planned repair. Two of Dreznik's three patients underwent a purely transanal flap without urinary or fecal diversion; the third underwent a posterior transsphincteric repair after both diversions. This experience establishes feasibility in selected patients, not that diversion is generally unnecessary.[6] In Joshi's five-patient series, diversion was less likely with localized than severe intra-abdominal sepsis; this was not a randomized comparison.[2]
The 2022 ASCRS recommendation for advancement flaps, its statement that diversion usually adds no benefit, its failure predictors and its reported incontinence rates concern fistula-in-ano. The guideline has a separate RVF section. These are not validated RUF-specific recommendations or complication probabilities.[7]
Operative concept and its limits
Expose the anterior rectal-wall opening and establish its relationship to the urethra. The conventional advancement-flap concept is to prepare the tract/opening, mobilize a broad viable rectal flap, close the underlying opening as appropriate and advance the flap without tension over that closure. Mucosa, submucosa and variable muscle may be incorporated. The exact flap thickness and urinary-side repair depend on anatomy and exposure; descriptions of anal-fistula flap construction are technical background rather than RUF comparative evidence.[1][6][7]
Avoid tension, thermal injury and a poorly perfused distal flap. Preserve the anal sphincter and avoid enlarging an already tissue-deficient defect. There is no evidence that the rectum is invariably the “high-pressure side” or that the urinary defect can always be left to heal without attention. If safe exposure or urinary reconstruction cannot be achieved transanally, select another approach.[3][4]
Purely transanal ERAF and posterior transsphincteric advancement are different operations. The latter divides and repairs the posterior sphincter/rectal complex to expose the anterior wall, as in al-Ali's traumatic-fistula series. Eleven patients treated with that method had fistula closure, but three developed urethral stricture. These are not outcomes of a sphincter-avoiding transanal flap.[8]
What the primary RUF series show
| Study | Patients and approach | Closure and follow-up |
|---|---|---|
| Garofalo 2003 | 12 advancement-flap repairs within a 23-patient RUF series | 8/12 primary, then 10/12 after repeat repair; average follow-up 31 months. One reported complication. Quality-of-life data were collected, but the small cohort cannot establish a general low-risk guarantee.[1] |
| Joshi 2011 | Five patients receiving six transanal flaps; four had laparoscopic prostatectomy without radiation | 4/5 primary, all five after a second procedure in one patient; mean follow-up 11 months.[2] |
| Dreznik 2003 | Two purely transanal repairs and one posterior transsphincteric repair | All three healed with reported normal urinary/fecal continence; route-specific denominators are only two and one.[6] |
These are separate, selected cohorts. Pooling them into a 67–100% personal success estimate obscures the influence of selection, technique, repeat operations and follow-up.
Comparison with transperineal interposition
A transperineal approach permits wider urethral exposure, concomitant urethral reconstruction and vascularized interposition; these features often favor it in complex or irradiated defects. An advancement flap avoids a distant donor incision but may provide limited exposure and does not itself place a distant vascularized barrier between urinary and bowel repairs.[3][4]
Park's retrospective comparison found recurrence in 2/24 gracilis repairs versus 6/12 controls (reported 8% versus 50%, P = 0.009). It did not randomize ERAF against gracilis, and the abstract does not establish that all controls had ERAF. It supports further study of interposition rather than a proven comparative ERAF failure rate.[9]
The 2013 systematic review described 416 patients in retrospective studies, with transperineal repair commonly used in high-volume centers. The 2025 review likewise found transperineal gracilis common and more difficult outcomes after radiation. Practice frequency and between-series success rates cannot establish superiority for every simple fistula.[3][10]
After recurrence, reassess the cause, perfusion, infection and urinary defect. A repeat flap succeeded in two Garofalo patients; others need a different route or interposition. Neither automatic repeat ERAF nor automatic conversion to gracilis is supported for every recurrence.[1]
Postoperative assessment
Plan urinary drainage and catheter removal according to the actual repair and confirmation of healing. Joshi used postoperative cystography to document closure. A fixed two-to-four-week catheter prescription for all ERAF repairs is not established by comparative trials.[2]
Before reversing fecal diversion, confirm closure and assess bowel and urinary function. Persistent leakage needs localization; SUI, obstruction and another fistula can remain despite successful repair. Discuss recurrence, urinary/anal continence problems and the possibility of later procedures without borrowing the ASCRS “up to 35%” anal-fistula incontinence estimate as an RUF-specific risk.[3][7]
References
1. Garofalo TE, Delaney CP, Jones SM, Remzi FH, Fazio VW. "Rectal advancement flap repair of rectourethral fistula: a 20-year experience." Dis Colon Rectum. 2003;46(6):762–769. doi:10.1007/s10350-004-6654-6
2. Joshi HM, Vimalachandran D, Heath RM, Rooney PS. "Management of iatrogenic recto-urethral fistula by transanal rectal flap advancement." Colorectal Dis. 2011;13(8):918–920. doi:10.1111/j.1463-1318.2010.02278.x
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. 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
5. 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
6. Dreznik Z, Alper D, Vishne TH, Ramadan E. "Rectal flap advancement — a simple and effective approach for the treatment of rectourethral fistula." Colorectal Dis. 2003;5(1):53–55. doi:10.1046/j.1463-1318.2003.00400.x
7. Gaertner WB, Burgess PL, Davids JS, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula." Dis Colon Rectum. 2022;65(8):964–985. doi:10.1097/DCR.0000000000002473
8. 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
9. Park KM, Rosli YY, Simms A, et al. "Preventing rectourethral fistula recurrence with gracilis flap." Ann Plast Surg. 2022;88(4 Suppl 4):S316–S319. doi:10.1097/SAP.0000000000003085
10. 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