Transabdominal Repair for Rectourethral and Rectovesical Fistula
A transabdominal or combined abdominoperineal approach provides access to high urinary–rectal defects, the bladder and prostate, and abdominal tissue for interposition. It is useful when local exposure is inadequate or repair must accompany outlet reconstruction, bowel resection or urinary diversion. Radiation history alone does not dictate an abdominal operation, and available series do not establish robotic surgery as the preferred platform.[1][2][5]
RUF connects the rectum to the urethra; RVF on this page means rectovesical, not rectovaginal, fistula. Their separation and interposition principles overlap, but repairing a bladder defect differs from reconstructing the urethra or vesicourethral anastomosis. Define the actual urinary opening, bladder function, sphincter and associated stenosis before selecting a repair.[3][14]
Related approaches: transperineal repair, endorectal advancement flap, York-Mason, Turnbull-Cutait pull-through and transanal minimally invasive repair.
Choosing the Approach
Plan repair jointly with reconstructive urology and colorectal surgery. Evaluate fistula location and size, cavitation, prior radiation or ablation, necrotic tissue, rectal disease, bladder capacity, urethral continuity and stenosis, continence, previous attempts and cancer status. Control sepsis and ensure appropriate urinary drainage; fecal diversion is often part of complex repair but is not mandated for every fistula.[4][5][10]
Abdominal access may help when:
- The defect cannot be adequately exposed or closed using a local route.
- Bladder-neck or anastomotic reconstruction, salvage prostatectomy, cystectomy or colorectal resection is required.
- Cavitation, multiple defects or a failed repair require broader dissection and vascularized coverage.
- Omental interposition is desirable and can reach the repair with good perfusion.[3][4][9][14]
These are considerations, not a fixed escalation ladder. A viable prostate does not have to be removed solely because radiation preceded the fistula. Conversely, preservation should not leave uncontrolled infection or a nonfunctional reservoir. In a 30-patient multidisciplinary series, only two required an abdominal approach, for positive oncologic margins or a nonfunctioning bladder; other centers treat a different mix of referrals.[4][10]
Classification and evidence limits
Rivera's 2007 staging system, developed in 14 patients, distinguished low and high nonirradiated fistulas using 4 cm from the anal verge, small and large irradiated fistulas using 2 cm, and ischial-decubitus fistulas. These are historical descriptors, not validated limits of perineal reach or mandatory assignments to an abdominal operation.[8]
Mundy and Andrich emphasized cavitation, bladder-neck contracture and extensive ischemia. Of 17 postirradiation cases in their series, 14 had an abdominal or combined approach and three a perineal repair. Their experience should not be translated into a rule that all irradiated fistulas require abdominal repair.[4]
Mishra's seven-study meta-analysis (490 patients) associated radiation/ablation with worse outcomes, but its radiation-versus-no-radiation comparison was different from its Martini grade 1-versus-grade 0 analysis. Neither analysis proves which operative route is superior for an individual patient.[11]
Operative Framework
Published techniques vary with the location of the urinary defect and the quality of the bowel. The following sequence describes common components; port number, cystotomy direction, suture layers and diversion are not universal requirements.[3][7][9][12]
Exposure and identification
Position and prepare for abdominal and, when needed, perineal access. Enter the abdomen, perform necessary adhesiolysis and assess the available omentum. Mobilize colon or splenic flexure when required for the planned bowel reconstruction rather than routinely for every fistula.[4][9]
Cystoscopy and rectal assessment localize the openings and identify ureteral orifices and associated outlet disease. In selected published transvesical repairs, a catheter placed through the fistula guides dissection and ureteral catheters aid identification. Use guided instrumentation; neither fistula catheterization nor ureteral stents are obligatory if they add risk without useful information. Transvesical and extravesical exposure depend on anatomy.[7][9][12]
Separation and tissue assessment
Develop the plane between the anterior rectal wall and the involved bladder, anastomosis or urethra. Excise the tract and nonviable tissue while preserving enough viable tissue for closure. Radiation may obliterate planes; wider dissection or combined access may be required. If the rectum is irreparably damaged or severely diseased, local closure alone may be inadequate and colorectal resection or diversion should be considered.[4][5][6]
Urinary reconstruction
| Finding | Reconstructive consideration |
|---|---|
| Bladder defect with an otherwise useful reservoir | Close viable bladder tissue without tension and protect the ureters; do not assume urethral reconstruction is necessary |
| Urethral or anastomotic involvement | Repair or reconstruct the outlet according to tissue loss and stenosis; assess continence separately |
| Associated VUAS | Mobilization and reconstruction may require combined abdominal and perineal access to reach healthy margins and obtain a tension-free anastomosis |
| Unsuitable urethral outlet but salvageable bladder | Bladder-neck closure with an appropriate drainage or catheterizable strategy may be considered; evaluate catheterization capacity and reservoir function |
| Devastated or nonfunctional urinary tract | Discuss urinary diversion, with extirpation when needed for source control and symptom relief |
These endpoints were represented in small reconstructive series; healthy-looking distal urethra alone is insufficient to select VUA without considering reach, bladder and sphincter function.[3][6][14]
Selective salvage prostatectomy
Prostatectomy can remove a diseased prostate and facilitate separation when one remains in situ. Mundy and Andrich performed it in eight selected postirradiation cases, explicitly stating that its role required further definition. Medina reported two post-focal-treatment cases: one underwent VUA and the other bladder-neck closure with suprapubic drainage because the urethra was extensively destroyed. These examples support individualized endpoints, not mandatory prostatectomy after radiation or ablation.[3][4]
See salvage prostatectomy for USF for the distinct pubic-bone fistula setting; cancer-salvage and USF outcomes must not be treated as RUF estimates.
Rectal closure and interposition
Close the rectal defect in viable tissue, or perform the planned colorectal reconstruction, with secure separation from the urinary closure. An omental pedicle can be interposed between the suture lines; select its orientation according to perfusion and tension-free reach. Combined abdominal/perineal repairs can also use omentum, so its use is not exclusive to a purely abdominal repair.[4][9][12]
Peritoneal and other vascularized flaps are alternatives when suitable omentum is unavailable. Gözen's four heterogeneous laparoscopic cases included peritoneal and tunica vaginalis interposition. A 2023 report described a perivesical-fat rotational flap in several different reconstructive settings; it is a technical option, not evidence of equivalence to omentum or proven prevention of radiation-related fistulas.[7][13]
Plan urinary drainage and pelvic drains around the repair. Fecal diversion depends on contamination, tissue condition, rectal reconstruction and prior diversion. The high diversion proportion in a referral series describes its patients; it is not a universal requirement.[2][10]
Outcomes and Counseling
Evidence is predominantly retrospective and selected. A 2013 systematic review reported an abdominal approach in 12.5% of its categorized repairs; this is a historical study mix, not a current population-wide utilization rate. The 2026 review of 455 postprostatectomy rectourinary fistulas found marked variation in treatment and reported success. Its presenting-symptom percentages apply to that combined population, not specifically to rectovesical fistulas.[1][15]
| Series | Actual population and result | Interpretation |
|---|---|---|
| Medina 2023 | 24 rectovesical fistulas: 22 men and two women; 19 robotic and five laparoscopic. All met imaging-plus-symptom closure criteria at 12 months | Twenty were postsurgical, three after surgery plus radiation and one after combined energy treatment. Twenty-three had previous fecal diversion. Two grade II and one grade IIIb complications—not 60% morbidity. No route comparator |
| Sayegh 2023 | Four post-RP fistulas with concurrent VUAS; omentum in all and perineal mobilization in one. No recurrence at median 16.25 months | No reported perioperative complications; four cases cannot establish a complication-free standard or durable continence |
| Medina 2018 | Two focal-treatment RUFs repaired with salvage prostatectomy and different urinary endpoints | Imaging/symptom success at nine and four months; limited follow-up |
| Mundy and Andrich 2011 | 40 rectourinary fistulas: 23 postsurgical and 17 postirradiation; all ultimately cured in their reported follow-up | Mixed routes; 14 postirradiation cases had abdominal or combined repair. Eight AUS placements and two bladder-neck contractures were whole-cohort events |
Sources: Medina, Sayegh and Mundy.[2][3][4][14]
In the larger Harris multicenter series of 201 prostate-treatment RUF repairs, ultimate closure was 87% after energy ablation and 99% after prostatectomy alone, with higher postoperative incontinence and complications in the ablation group. These are treatment-history groups, not a randomized abdominal-versus-perineal comparison.[17]
Martins' 23-patient series illustrates a more severe referral population: five of ten radiation/ablation patients required permanent dual diversion, compared with none of 13 surgery-only patients. Not all ten irradiated patients had an abdominoperineal repair. Case severity, referral selection and definitions of success explain why these outcomes should not be ranked against another center's results as technique effectiveness.[6]
Open, laparoscopic or robotic?
Choose the platform that permits adequate exposure, source control and durable reconstruction in the treating team's hands. Small minimally invasive series show feasibility and short hospital stays; they do not establish lower morbidity or better fistula closure than open or perineal surgery. Concurrent bowel resection, extensive fibrosis or outlet loss may change the planned access or require conversion.[1][2][7][14]
Follow-up and investigational adjuncts
Assess healing before catheter changes or restoration of bowel continuity, using symptoms and imaging/endoscopy appropriate to the reconstruction. Report anatomic closure, urinary continence, bowel function, catheter dependence, diversion reversal and reinterventions separately; an imaging-confirmed closure does not guarantee restoration of normal function.[2][4][10]
A 2025 report describes successful transanal autologous mesenchymal-cell treatment of one postprostatectomy rectovesical fistula. This remains investigational. Crohn-related anorectal-fistula trial results or recommendations do not establish efficacy for postoperative urinary–rectal fistulas.[16]
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References
1. 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
2. Medina LG, Riva A, Perez LC, et al. "Minimally invasive management of post-treatment rectovesical fistulae." J Endourol. 2023;37(2):185–190. doi:10.1089/end.2022.0266
3. 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
4. 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
5. 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
6. 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
7. 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
8. Rivera R, Barboglio PG, Hellinger M, Gousse AE. "Staging rectourinary fistulas to guide surgical treatment." J Urol. 2007;177(2):586–588. doi:10.1016/j.juro.2006.09.058
9. 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
10. 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
11. Mishra K, Mahran A, Abboud B, et al. "Validating the Martini staging system for rectourethral fistula: a meta-analysis of postoperative outcomes." Urology. 2021;147:299–305. doi:10.1016/j.urology.2020.08.047
12. Sotelo R, Garcia A, Yaime H, et al. "Laparoscopic rectovesical fistula repair." J Endourol. 2005;19(6):603–607. doi:10.1089/end.2005.19.603
13. 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
14. 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
15. de Angelis M, Scilipoti P, Leni R, et al. "Clinical and surgical management of recto-urinary fistula after radical prostatectomy: a systematic review on current evidence." Prostate Cancer Prostatic Dis. 2026. doi:10.1038/s41391-026-01114-7
16. Eberspacher C, Lauro A, Salomone B, et al. "Curbing communication — transanal infiltration of autologous mesenchymal stem cells facilitating rectovesical fistula repair after radical prostatectomy." Dig Dis Sci. 2025. doi:10.1007/s10620-025-09145-1
17. 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