Transperineal Approach to Rectourethral Fistula
Transperineal repair provides access to the urinary–rectal defect while preserving the anal sphincter complex, and permits simultaneous urethral reconstruction and vascularized interposition. It is commonly used at specialist centers, including for selected radiation-associated and recurrent rectourethral fistulas (RUFs). A 2013 review reported 65.9% perineal repairs in its categorized series; contemporary reviews continue to describe frequent use of perineal repair with gracilis. These observations do not establish a universally superior approach or a current population-wide utilization rate.[1][2][3]
This page covers the perineal framework and outcomes. For flap anatomy and harvest see gracilis. Other options include York-Mason, endorectal advancement, transanal MIS, abdominal/combined repair and conservative management.
Selection and Preparation
Perineal repair is an option for postsurgical, radiation/ablation-associated, traumatic and recurrent RUF when the defect can be exposed and viable urinary and rectal reconstruction is possible. Associated posterior stenosis or tissue loss can often be addressed concurrently. This capacity is useful, but not exclusive to a perineal-only operation: combined approaches may also reconstruct the outlet.[4][5][6]
Evaluate fistula location and size, cavitation, bladder and urethral function, continence, rectal disease, radiation injury and previous repairs. Use cystoscopy, urethrography/cystography and rectal examination/endoscopy to define anatomy; MRI can assist in complex irradiated disease. Investigate or biopsy suspicious tissue when recurrent malignancy is a concern. Assess urinary drainage, infection, nutritional status, functional reserve and the patient's goals before definitive repair.[3][7]
Diversion and timing are individualized. Severe fecal contamination, sepsis, damaged tissue or major colorectal reconstruction often favor fecal diversion. Thomas' small series associated fecaluria with failure without diversion, but it does not establish a universal colostomy rule. Keller used selective diversion; its 8/30 closures without fecal diversion and 6/30 after diversion are proportions of the whole cohort, not comparative treatment-success rates.[8][9]
Allow inflammation to settle and optimize tissues, with planned reassessment rather than a mandatory three-to-six-month wait for every patient. Gupta's minimum 12-week interval and other centers' longer catheter/diversion intervals are institutional protocols in selected cohorts. Do not prolong observation through uncontrolled sepsis or inadequate drainage.[3][10][7]
For a very high or inaccessible defect, severe cavitation, nonfunctional bladder/rectum or extensive tissue loss, discuss combined abdominal access, resection or permanent diversion. Radiation alone does not preclude repair, and a failed repair does not automatically mandate extirpation.[4][11][6]
Operative Framework
Exposure and separation
Lithotomy facilitates perineal exposure and gracilis harvest; some centers use prone positioning or change position after flap harvest. Positioning and incision should suit the fistula and planned reconstruction. A midline perineal incision is commonly described, but its exact length and configuration are not standardized.[12][7]
Expose the bulbar/posterior urethral region and develop the plane along the anterior rectal wall, preserving the anal sphincter. Mobilize enough healthy tissue above and around the fistula to permit separate tension-free closures. Fibrosis can obscure normal planes; avoid treating a fixed dissection distance or a named fascial plane as a substitute for direct identification.[13][7][14]
Excise the tract and nonviable margins, preserving usable tissue. Radiation exposure does not mean all irradiated tissue should be removed. Assess the separate rectal and urinary defects before committing to the closure method.[4][7]
Rectal closure
Close viable rectal tissue without tension or luminal narrowing. Transverse closure, sometimes in two layers, is described in perineal series; orientation and layers depend on the actual defect. Large defects, poor rectal function or diseased bowel may require a different colorectal reconstruction or diversion rather than forced primary closure.[13][7][14]
Urinary reconstruction
| Finding | Option and qualification |
|---|---|
| Small defect without important stenosis | Primary closure in viable tissue, maintaining urethral caliber |
| Short posterior stenosis or obliteration | Excision and anastomotic urethroplasty when healthy ends can meet without tension |
| Larger defect or stenosis suitable for augmentation | Selective buccal-mucosal graft reconstruction with an adequate vascular bed/support; a graft does not compensate for nonviable tissue |
| PFUI with urethrorectal fistula | Trauma-specific posterior reconstruction; corporal separation or inferior pubectomy may be needed for exposure and a tension-free repair |
| Major cavitation or prostatic/outlet destruction | Consider more extensive reconstruction, combined access, selective prostatectomy or diversion according to the remaining bladder and outlet |
Published choices vary with tissue integrity, defect extent and previous treatment. Neither BMG nor pubectomy is mandatory for every irradiated or long defect. See the urethral reconstruction atlas for urethroplasty techniques.[4][5][7][15][16]
Vascularized interposition
Strongly consider healthy tissue between urinary and rectal closures for radiation/ablation injury, recurrent repairs, dead space and tenuous tissue. Gracilis is a common option, not the sole acceptable flap. Its use does not substitute for source control, viable margins and a tension-free repair.[4][12][7]
Protect the dominant pedicle during harvest and bring the muscle through a tunnel that avoids compression, twisting or excessive tension. Position it to separate and cover the repair. Exact pedicle anatomy and flap reach must be identified in the patient; see the gracilis atlas rather than relying on a fixed distance from a bony landmark.[12][17]
The comparative evidence is limited:
- Park 2022: recurrence was 8% in 24 gracilis cases versus 50% in 12 controls. This was retrospective, and risk factors were examined using single-variable, not multivariable, regression. It supports an association, not proof that gracilis is the single most important determinant of success.[18]
- Voelzke 2013: among 13 energy-ablative cases, success was 3/5 with a flap and 5/8 without on the reported intent-to-treat analysis. Two flap patients died early and were counted as failures; the three surviving flap patients succeeded. This cannot support an uncomplicated causal “100% versus 63%” benefit or prove equivalence. The authors still strongly favored considering interposition in damaged tissue.[7]
- Garoufalia 2023: pooled weighted success was 79.4% across 658 complex perineal fistulas, only 33.7% of which were rectourethral; heterogeneity was substantial. This is not an RUF-specific expected cure rate.[19]
Selected nonirradiated postoperative fistulas have healed without a flap, but omission should follow the actual tissue and suture-line assessment. The 72% interposition figure in the older review included all flap types, predominantly gracilis, rather than 72% gracilis use alone.[1][7]
Other flaps
Dartos, bulbospongiosus, rectus and local options can be considered according to available vascularized tissue. Small reports cannot establish interchangeable outcomes. Solomon's bilateral puborectalis technique involved four patients, with three bowel-diversion reversals and one permanent ileostomy; this limited experience does not remove the need to assess sphincter function.[13][7]
Hou's 2025 BSM series included 19 traumatic fistulas and 17 cases of anterior rectal-wall weakness. Its 94.4% overall reconstructive success is not a 36-patient fistula-closure rate. Nonsignificant functional comparisons against selected non-BSM urethroplasty controls do not prove equivalent erectile or ejaculatory safety.[20]
Dartos can also be used with a transsphincteric York-Mason repair: Dafnis reported five such cases. Thus, the presence of interposition alone does not distinguish a perineal repair from every alternative route.[21]
Outcomes in the Relevant Population
| Cohort | Result | Qualification |
|---|---|---|
| Vanni 2010, 74 patients | One-procedure closure: 35/35 nonirradiated and 84% of 39 radiation/ablation-associated cases | All had muscle interposition, with BMG used selectively; 31% of the radiation/ablation group required permanent fecal diversion |
| Kaufman 2016, 98 patients | One-procedure closure: 48/49 nonirradiated and 42/49 radiation/ablation-associated cases | Bowel continuity restored in 45/48 and 30/46, respectively. These are separate denominators from all repaired patients |
| Sbizzera 2022, 21 patients | Fistula closure in 20/21; digestive stoma closure in 10/12 diverted patients | Two grade ≥IIIb complications; 18 completed questionnaires, including 11/18 with significant urinary incontinence |
| Wexner 2008, 36 male RUF cases within 53 perineal fistulas | Initial male RUF success 78%, overall clinical healing 97% after further procedures | Seventeen men had postoperative complications; initial versus final healing must remain distinct |
Sources: original reports.[4][22][12][23]
Vanni and Kaufman share an institution and overlapping recruitment periods; do not combine them as independent cohorts. Their selected reconstructive results also differ from Linder's severe radiation/ablation referral population, in which 25/29 needed permanent colostomy and 27/29 permanent urinary diversion. These differences do not prove superiority of one center's technique or define every irradiated patient's prognosis.[4][22][11]
Concurrent posterior urethroplasty
Khouri reported 23 concurrent reconstructions within 130 RUF repairs: 22 used a perineal approach and one a prone Kraske approach; 18 had anastomotic urethroplasty and five BMG. At median 55.7 months, 20/23 had successful fistula closure, and no isolated stricture recurrence requiring instrumentation was reported. This endpoint does not mean every patient was free of fistula recurrence or all possible stenosis. Fourteen reported incontinence and 7/23 received an AUS—30% of the full cohort, or half of the 14 incontinent men.[5]
For PFUI, Guo reported 29/32 overall successful reconstructions with gracilis; two developed isolated recurrent strictures and one a recurrent fistula with stricture. Wang's separate 2024 proximal-transection series reported 36/40 success at median 45 months, with postoperative ED in 75%. Its definition combined urethral patency, absence of leakage and no further intervention; it was not a comparison with distal transection and does not quantify new ED caused by repair.[16][24]
Function, Follow-up and Patient Expectations
Plan urinary drainage and assessment of healing according to the repair. Reported catheter protocols vary, including three-week assessment and four-to-six-week cystography. Persistent leakage may require continued drainage and reassessment; bowel continuity should be restored only after healing and function have been evaluated, rather than automatically at a fixed postoperative month.[7][25][14]
Anatomic closure and functional recovery are different outcomes. Counsel about urinary incontinence, bowel dysfunction, erectile dysfunction, perineal or donor-site symptoms, recurrent stenosis, catheter needs and later procedures. Prior cancer treatment or trauma may already have impaired function; studies without baseline measures cannot attribute all postoperative impairment to the fistula operation.[5][12][25][14]
In Hampson's 21-patient series, 15 had postoperative urinary incontinence and 11 of those 15 received an AUS. Fifteen of the 21 were contacted for the long-term survey: 12/15 reported some urinary leakage, 8/15 perineal pain and 12/15 a positive life change. None of those respondents would have chosen complete urinary diversion instead, but responder selection and the absence of a standardized preoperative quality-of-life comparison limit generalization. Do not present these as the preferences or outcomes of every repair candidate.[14]
Wagner 2026 adds long-term follow-up with validated questionnaires: 29 open repairs included 26 perineal and three abdominal operations. Six patients were lost to follow-up; among the 23 included in survival analysis, estimated five-year freedom from fistula recurrence was 96%, while freedom from any disease-related reintervention was 75%. Seventeen completed PROMs, reporting high satisfaction but residual urinary and bowel symptoms. These data support assessing both closure and subsequent treatment burden; they are not a 29-patient, pure-gracilis or pure-perineal cure rate.[25]
Videos
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. 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
3. 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
4. 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
5. Khouri RK, 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
6. 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
7. Voelzke BB, McAninch JW, Breyer BN, Glass AS, Garcia-Aguilar J. "Transperineal management for postoperative and radiation rectourethral fistulas." J Urol. 2013;189(3):966–971. doi:10.1016/j.juro.2012.08.238
8. 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
9. Thomas C, Jones J, Jäger W, et al. "Incidence, clinical symptoms and management of rectourethral fistulas after radical prostatectomy." J Urol. 2010;183(2):608–612. doi:10.1016/j.juro.2009.10.020
10. Gupta G, Kumar S, Kekre NS, Gopalakrishnan G. "Surgical management of rectourethral fistula." Urology. 2008;71(2):267–271. doi:10.1016/j.urology.2007.10.042
11. Linder BJ, Umbreit EC, Larson D, et al. "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
12. Sbizzera M, Morel-Journel N, Ruffion A, et al. "Rectourethral fistula induced by localised prostate cancer treatment: surgical and functional outcomes of transperineal repair with gracilis muscle flap interposition." Eur Urol. 2022;81(3):305–312. doi:10.1016/j.eururo.2021.09.017
13. Solomon MJ, Tan KK, Bromilow RG, Wong JC. "Bilateral puborectalis interposition repair of rectourethral fistula." Dis Colon Rectum. 2014;57(1):133–139. doi:10.1097/01.dcr.0000437789.54759.c9
14. Hampson LA, Muncey W, Sinanan MN, Voelzke BB. "Outcomes and quality of life among men after anal sphincter-sparing transperineal rectourethral fistula repair." Urology. 2018;121:175–181. doi:10.1016/j.urology.2018.06.052
15. Xu YM, Sa YL, Fu Q, Zhang J, Jin SB. "Surgical treatment of 31 complex traumatic posterior urethral strictures associated with urethrorectal fistulas." Eur Urol. 2010;57(3):514–520. doi:10.1016/j.eururo.2009.02.035
16. Guo H, Sa Y, Fu Q, Jin C, Wang L. "Experience with 32 pelvic fracture urethral defects associated with urethrorectal fistulas: transperineal urethroplasty with gracilis muscle interposition." J Urol. 2017;198(1):141–147. doi:10.1016/j.juro.2017.01.071
17. Muñoz-Duyos A, Navarro-Luna A, Pardo-Aranda F, et al. "Gracilis muscle interposition for rectourethral fistula after laparoscopic prostatectomy: a prospective evaluation and long-term follow-up." Dis Colon Rectum. 2017;60(4):393–398. doi:10.1097/DCR.0000000000000763
18. 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
19. Garoufalia Z, Gefen R, Emile SH, et al. "Gracilis muscle interposition for complex perineal fistulas: a systematic review and meta-analysis of the literature." Colorectal Dis. 2023;25(4):549–561. doi:10.1111/codi.16427
20. Hou C, Huang J, Zhu W, et al. "Use of bulbospongiosus muscle for repair of traumatic posterior urethral stenosis combined with urethrorectal fistulas." BJU Int. 2025;135(6):1049–1057. doi:10.1111/bju.16709
21. Dafnis G. "Transsphincteric Repair of Rectourethral Fistulas in Combination With Dartos Muscle Flap Interposition Following Radical Prostatectomy." Urology. 2024;191:130–135. doi:10.1016/j.urology.2024.05.041. PMID:38834146.
22. Kaufman DA, Zinman LN, Buckley JC, et al. "Short- and long-term complications and outcomes of radiation and surgically induced rectourethral fistula repair with buccal mucosa graft and muscle interposition flap." Urology. 2016;98:170–175. doi:10.1016/j.urology.2016.06.065
23. Wexner SD, Ruiz DE, Genua J, et al. "Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients." Ann Surg. 2008;248(1):39–43. doi:10.1097/SLA.0b013e31817d077d
24. Wang L, Song W, Lv R, et al. "Precise treatment of pelvic fracture urethral injury associated with urethrorectal fistula." BJU Int. 2024;134(4):589–595. doi:10.1111/bju.16401
25. Wagner MC, Klemm J, Roessler N, et al. "Long-term patient-reported outcomes of open urorectal fistula repair after prostate cancer treatment." BJU Int. 2026. doi:10.1111/bju.70233