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Robotic Transabdominal Repair for Rectourethral and Rectovesical Fistula

The robotic transabdominal approach is an emerging minimally invasive technique that achieves 100% fistula closure in the largest published series (15 patients, 12-month follow-up), though it remains supported only by small case series and accounts for ~12.5% of all RUF repairs.[1][2][3] It applies essentially the same operation to rectourethral fistula (RUF) and rectovesical fistula (RVF — bladder-rectum): deep pelvic dissection, fistula excision, separate rectal and urinary closures, and omental flap interposition, with vesicourethral anastomosis in RUF and direct cystotomy closure in RVF. It is best suited for complex fistulas — particularly those associated with energy ablation treatments (cryotherapy, HIFU) where the prostate is still in situ, those with a residual prostate requiring salvage prostatectomy, those with concomitant vesicourethral anastomotic stricture (VUAS), and rectovesical fistulas where the higher anatomic location favors an abdominal approach.[2][4][5][9]

For perineal alternatives see Transperineal Gracilis Interposition, York-Mason Repair, ERAF for RUF, Transanal Minimally Invasive Repair, and Conservative Management of RUF.

Historical Development​

The transabdominal approach for RUF / RVF repair was first described in the open era as a major operation involving laparotomy, deep pelvic dissection, and tissue interposition. The laparoscopic adaptation was pioneered by Sotelo 2007 (3 cases of laparoscopic RUF repair after prostate surgery — mean OR 247 min, LOS 2.6 d, 100% success at 12 mo).[6] The robotic platform was adopted shortly after — Sotelo 2008 reported the first robotic RVF repair after radical prostatectomy.[7] The technique has since been refined primarily by Sotelo and Medina across two international institutions over a 17-year period (2004–2021).[1][2]

Indications​

The robotic transabdominal approach is reserved for complex fistulas where perineal or transanal approaches are insufficient or contraindicated:[1][2][4][5][8][9]

  • RUF after energy ablation (cryotherapy, HIFU, brachytherapy, EBRT) — 53–73% of patients in transabdominal series; the prostate is still in situ
  • Residual prostate requiring salvage prostatectomy — when the fistula traverses damaged / necrotic prostate that must be removed to achieve closure[2][5][9]
  • Concomitant VUAS — uniquely allows simultaneous fistula repair and stricture revision in a single operation[4]
  • Rectovesical fistulas (rectum-bladder, above the urethral anastomosis) — higher location favors abdominal approach[4][7]
  • Large or complex fistulas with extensive tissue destruction not amenable to perineal repair[1][5]
  • Failed prior perineal repairs — transabdominal route provides access through virgin tissue planes[1][9]
  • Fistulas with cavitation — Mundy & Andrich identified cavitation (especially after salvage HIFU following EBRT + brachytherapy) as a marker of complexity requiring transabdominal or abdominoperineal repair with interposition flap[9]

Surgical Technique​

1. Preoperative preparation​

  • Mechanical bowel prep
  • Fecal diversion (colostomy or ileostomy) preoperatively, or synchronously during the robotic procedure[1][6]
  • Urinary drainage (suprapubic ± urethral catheter)
  • Broad-spectrum antibiotics

2. Positioning and port placement​

  • Supine with steep Trendelenburg (similar to robotic radical prostatectomy)
  • 5–6 ports (camera, 3 robotic arms, 1–2 assistant)[1][4][7]
  • Dock the da Vinci

3. Cystoscopy and fistula catheterization​

  • Initial cystoscopy identifies the urethral / bladder side of the fistula
  • A 5F ureteral catheter or guidewire passed through the tract from the urethral side facilitates identification during dissection[2][4]

4. Adhesiolysis and pelvic dissection​

  • Lyse adhesions; mobilize sigmoid and rectum
  • Develop the rectovesical / rectourethral plane — most technically demanding step, requiring careful dissection through scarred, previously operated tissue[1][4][5]

5. Fistula excision​

  • Identify the tract (aided by the catheter) and circumferentially excise all fibrotic and necrotic tissue
  • Completely separate rectum from bladder / urethra[1][2][4]

6. Salvage prostatectomy (RUF with residual prostate)​

Critical and unique to the transabdominal approach when the prostate is still in situ (after energy ablation rather than radical prostatectomy):[2][5][9]

  • Excise the damaged / necrotic prostate — the necrotic tissue serves as a nidus for persistent fistula and prevents healing (Gözen 2012)
  • Medina 2018 — performed in both initial robotic cases (post-cryo, post-HIFU); reconstruction strategy depends on the ability to reach the distal urethra after prostatectomy
  • Mundy & Andrich — performed in 8/14 post-irradiation transabdominal patients still having a discrete prostate

7. Urinary reconstruction​

Strategy depends on urethral / bladder status:[2][4]

ScenarioReconstruction
Healthy distal urethra (RUF after salvage prostatectomy)Vesicourethral anastomosis (VUA) robotically — analogous to RP anastomosis
Concomitant VUASExcise strictured anastomosis + new VUA; ± perineal urethral mobilization for tension-free anastomosis (Sayegh 2023)
Urethra destroyed / insufficientBladder-neck closure + permanent suprapubic tube
Rectovesical fistula (intact bladder, no urethral involvement)Direct 2-layer cystotomy closure

8. Rectal-defect closure​

  • Close in 2 layers with interrupted absorbable suture[2][4][7]
  • Offset suture lines from the urinary closure to prevent overlap[4]

9. Tissue interposition​

A vascularized flap between urinary and rectal suture lines — a universal component of the transabdominal approach:

  • Omental flap (most common) — pedicled flap from the greater omentum brought down to cover the repair; used in 100% of Sayegh 2023 and Medina 2022 cases[1][2][4][7]
  • Peritoneal flap — Gözen 2/4 patients[5]
  • Tunica vaginalis flap — Gözen 1 patient[5]
  • Perivesical fat rotational flap — Hwang 2023, novel alternative when omentum is unavailable (prior surgery, short omentum); wide-based pedicled flap rotated over anterior rectal wall[10]

10. Drain placement and closure​

  • Pelvic Jackson-Pratt drain (median removal day 6)[4]
  • Close ports

11. Synchronous fecal diversion (if not already performed)​

A unique advantage: a diverting colostomy / ileostomy can be created laparoscopically / robotically during the same procedure without repositioning or additional incisions.[6]

Postoperative Management​

  • Urethral catheter median 30 d (range 27–41)[4]
  • Double-J stents (if placed during VUA) — median removal day 38[4]
  • Pelvic JP drain — median removal day 6[4]
  • VCUG at 3–4 weeks to confirm closure before catheter removal[2][4]
  • Stoma reversal at 3–4 months after confirmed healing[1][4]

Outcomes​

SeriesnApproachEtiologySuccessOR timeEBLLOSFollow-upComplicationsNotes
Medina 2022 (largest)159 robotic / 6 lap27% post-surgery, 53% energy ablation, 20% combined100%264 min (median)175 mL4 d12 mo9 (60% mostly low-grade)Single surgeon, 2 institutions, 17-yr span[1]
Sayegh 2023 (RVF + VUAS)4RoboticPost-RP with VUAS100%370 min (median)255 mL2.5 d16.25 mo (median)0%Simultaneous fistula + stricture repair; omental flap in all[4]
Gözen 20124LapPost-TURP 2 / post-RP 1 / post-RT-chemo 175% (3/4)NSMinimal12–34 dVariable1 persistent leakSalvage prostatectomy in 2; various interposition[5]
Sotelo 2007 (first lap series)3LapPost-prostate surgery100%247 min (mean)NS2.6 d (mean)12 mo (mean)0%First published lap RUF series[6]
Medina 2018 (post-focal Tx)2RoboticPost-cryo 1 / post-HIFU + EBRT 1100%NSNSNS4–9 mo0%Both required salvage prostatectomy + omental[2]
Sotelo 2008 (first robotic)1RoboticPost-open RP100%180 minNS1 d5 mo0%First published robotic RVF[7]

Aggregate context: Hechenbleikner 2013 SR — transabdominal accounted for 12.5% of 416 RUF repairs (52 patients), the third most common after transperineal (65.9%) and transsphincteric (15.7%).[3] Mundy & Andrich 2011 — largest open transabdominal / abdominoperineal series: 14/17 post-irradiation patients underwent transabdominal or abdominoperineal repair (combined with salvage prostatectomy in 8); 100% cure in all 40 patients across the entire cohort.[9]

Technical Variants​

Transvesical approach​

A subset uses a transvesical route — the bladder is opened (cystotomy) to access the fistula from above:[5][6]

  • Sotelo — for fistulas involving the bladder: extend the cystotomy toward the tract, dissect, close rectum, interpose tissue, close bladder[6]
  • Gözen — transvesical lap in 1 patient, transperitoneal transvesical in another[5]
  • Particularly useful for rectovesical fistulas (higher location) rather than true rectourethral fistulas

Abdominoperineal combined approach​

For the most complex cases:[9]

  • Mundy & Andrich used in their post-irradiation cohort, combining transabdominal dissection with perineal access
  • Allows both deep pelvic dissection from above and direct fistula access from below
  • Particularly useful for fistulas with cavitation — common after salvage HIFU following EBRT + brachytherapy

Robotic transabdominal + perineal urethral mobilization​

Sayegh 2023 hybrid technique combining robotic transabdominal with perineal urethral mobilization to achieve tension-free VUA when the urethral gap is too large for primary anastomosis from above alone.[4]

Advantages​

  • Superior deep-pelvic visualization — 3D magnification + wristed instrumentation in scarred planes[1][2][4]
  • Salvage prostatectomy possible — uniquely allows removal of the damaged / necrotic prostate critical for energy-ablation RUF[2][5][9]
  • Simultaneous concomitant pathology — VUAS, bladder-neck contracture, ureteral reimplantation in the same operation[4]
  • Direct omental flap access — without additional incisions[1][2][4][7]
  • Synchronous diversion — colostomy / ileostomy during the same procedure without repositioning[6]
  • Virgin tissue planes — avoids scarred perineal tissue in patients with prior perineal surgery[1][9]
  • MIS benefits vs open transabdominal — reduced EBL (175–255 mL median), shorter LOS (2.5–4 d), faster recovery[1][4]
  • No sphincter division vs York-Mason[1]
  • No perineal wound vs transperineal — avoids perineal infection / dehiscence[1]

Limitations​

  • Limited evidence — small case series (1–15) from few centers; no comparative studies vs transperineal or transsphincteric[1][2][4][5][6]
  • Long OR times — median 264–370 min vs transperineal 2–4 h or York-Mason ~ 2 h[1][4]
  • Higher complication rate — Medina 9/15 (60%) postoperative complications, mostly low-grade; vs 0–8% for York-Mason or ERAF[1]
  • Technical complexity — advanced robotic skills, especially pelvic dissection and intracorporeal suturing in scarred planes[5]
  • Intraperitoneal risks — bowel injury, ileus, adhesion formation[1][5]
  • Not appropriate for simple RUF — complexity / morbidity not justified for small non-radiated post-surgical fistulas amenable to perineal or transanal repair[3][8]
  • Limited distal-urethral access — may require bladder-neck closure + permanent SP tube when the urethra is too destroyed for anastomosis[2]
  • Cost — robotic instruments and longer OR times raise procedural cost[1]
  • Steep learning curve — few surgeons have experience with the technique[1][5]
  • Variable LOS — Sotelo 1–3 d vs Gözen 12–34 d, suggesting significant variability in perioperative management[5][6]

Robotic Transabdominal vs Other Approaches​

FeatureRobotic transabdominalTransperineal gracilisYork-MasonERAF
Proportion of all RUF repairs12.5%65.9%15.7%5.9%[3]
Primary success75–100%84–100%80–100%67–100%
Tissue interpositionYes (omental)Yes (gracilis)Not standardNone
Salvage prostatectomy possibleYesLimitedNoNo
Simultaneous VUAS repairYesNoNoNo
OR time264–370 min2–4 h~ 2 h~ 1 h
LOS2.5–4 d5–7 d2 d1.5–4.5 d
Sphincter preservationYesYesDivided / re-approximatedYes
Suitable for radiated RUFYesYes (84%)VariableNo
Suitable for energy-ablation RUFIdealYesVariableNo
Donor-site morbidityNoneMild (thigh)NoneNone
Complication rate60% (mostly low-grade)9% (≥ 3b)0–8%0–8%
Evidence levelCase series (n = 1–15)Case series (n = 9–74)Case series (n = 5–51)Case series (n = 3–12)

Place in the Algorithm​

The robotic transabdominal approach occupies a specific niche:[1][3][8][9][18]

  • Not first-line for simple non-radiated post-surgical RUF — best managed transperineally or transanally
  • Preferred for energy-ablation RUF with residual prostate — where salvage prostatectomy is required
  • Preferred for concomitant RUF + VUAS — only approach allowing simultaneous repair of both
  • Preferred for rectovesical fistula — higher anatomic location favors the abdominal route
  • Considered for complex / recurrent RUF after failed perineal repair — virgin tissue planes
  • Considered for fistulas with cavitation — particularly after sequential energy treatments (EBRT + brachytherapy + salvage HIFU)[9]

Keller 2015 — only 2/30 (7%) required an abdominal approach (positive oncologic margins or non-functioning bladder), confirming the route is reserved for a small subset of complex cases.[18]

Summary​

The robotic transabdominal approach is technically demanding but is the single approach that can simultaneously address fistula closure, salvage prostatectomy, VUAS revision, omental interposition, and synchronous fecal diversion in one operation. 100% closure in the largest series with the benefits of 3D magnification and direct omental access.[1][2][4] Long OR times (264–370 min), 60% complication rate (mostly low-grade), and need for advanced robotic expertise restrict it to ~ 12.5% of all RUF repairs and to a specific subset of complex cases — energy-ablation RUF, RUF + VUAS, rectovesical fistula, and recurrent / cavitated fistulas.[3][5] The transperineal approach with gracilis muscle interposition remains the dominant technique at high-volume centers for the majority of RUF.[3][19]

References​

1. 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

2. 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

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. 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

5. Gözen AS, Malkoc E, Al-Sudani I, Rassweiler J. "Laparoscopic urorectal fistula repair: value of the salvage prostatectomy and review of current approaches." J Endourol. 2012;26(9):1171–1176. doi:10.1089/end.2012.0024

6. Sotelo R, Mirandolino M, Trujillo G, et al. "Laparoscopic repair of rectourethral fistulas after prostate surgery." Urology. 2007;70(3):515–518. doi:10.1016/j.urology.2007.04.029

7. Sotelo R, de Andrade R, Carmona O, et al. "Robotic repair of rectovesical fistula resulting from open radical prostatectomy." Urology. 2008;72(6):1344–1346. doi:10.1016/j.urology.2008.06.017

8. 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

9. 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

10. Hwang A, Watson M, Talluri S, Okafor H, Singh A. "A novel perivesical fat rotational flap as an alternative to omental interposition in challenging urological reconstruction." Urology. 2023;182:e262–e263. doi:10.1016/j.urology.2023.08.023

18. 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

19. 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