York-Mason Posterior Transsphincteric Repair for Rectourethral Fistula
The York–Mason repair exposes a rectourethral fistula (RUF) through a posterior transsphincteric incision. It is an established option for selected, usually nonirradiated iatrogenic fistulas when direct exposure permits separate urinary and rectal closure. The operation deliberately divides and reconstructs the anal sphincter; published closure rates are encouraging, but fecal continence is not guaranteed. In a study using patient questionnaires, 2 of 10 respondents reported rare fecal incontinence despite a low mean symptom score.[2][3][4]
Route selection depends on fistula level, tissue quality, radiation injury, urinary outlet function, baseline bowel function and previous repairs. Compare Transperineal RUF Repair, Endorectal Advancement Flap and Transanal Minimally Invasive Repair.
Selection and Preparation
The posterior route can provide access to the anterior rectal fistula opening while avoiding some previously operated anterior tissues. It is most attractive when the urinary defect can be closed without extensive urethral reconstruction and the rectal and urinary tissues are suitable for healing. Radiation damage, active infection, major tissue loss, outlet stenosis and multiple previous repairs may require vascularized interposition, another route or, in a devastated urinary/intestinal system, definitive diversion. These are individualized decisions rather than a validated size-based algorithm.[2][8][11][15][16]
Before repair, define the urinary and rectal openings by directed endoscopy and appropriate imaging, assess continence and sphincter function, and establish drainage and control of infection. Discuss possible persistent urinary incontinence even after successful fistula closure. Fecal diversion varies among centers: the original Utah series included 11 of 24 patients treated without prior urinary or fecal diversion, whereas the 2025 Dutch cohort used colostomy before or during repair in all 12 patients. Neither establishes that every patient should, or should not, be diverted.[2][4][5]
Bowel preparation, antimicrobial prophylaxis and urinary drainage should follow the planned colorectal/urinary operation and local protocols. A fixed three-month trial of catheterization before all repairs is not established by comparative evidence; the prolonged catheterization pathway in the 2025 report was that institution's practice.[2]
Surgical Technique
The following outlines the shared operative principles. Published modifications differ in incision, closure and interposition; the 2025 technical description uses a right-sided U-shaped incision rather than a classic posterior midline incision.[2]
- Position and expose. Use a prone position with hip flexion and buttock retraction to expose the posterior anal region, with careful pressure protection and an agreed plan for urinary access.
- Identify and mark the divided layers. Enter through the posterior/paraposterior approach. As sphincter and rectal-wall layers are divided, tag corresponding edges so they can be matched during reconstruction. Accurate identification is central to sphincter repair.
- Expose the fistula on the anterior rectal wall. Define the communication and develop the plane between rectal and urinary tissues under direct vision. Excise the tract and mobilize suitable tissue while preserving enough vascularized wall for tension-free closure; avoid indiscriminate removal of scar that would enlarge the defect unnecessarily.
- Close the urinary defect and test it. Close the urinary side with absorbable suture and assess for leakage. Repair the rectal defect separately, minimizing tension and avoiding directly opposed closure lines where feasible. Selected modifications add an interposition graft or flap.
- Reconstruct the posterior access. Reapproximate the divided rectal and sphincter layers using the marking sutures to match the original anatomy, then close the superficial tissues. The quality of this reconstruction matters, but it does not eliminate the possibility of continence symptoms.[2][3][5][6]
Postoperative Management
Maintain urinary drainage and document healing before catheter removal. For example, the Dutch series used a Foley catheter and cystogram at three weeks, with selected proctoscopy; this is a reported protocol, not a universal catheter-duration rule. Persistent leakage warrants reassessment and continued drainage rather than automatic catheter removal.[2]
Stoma reversal requires confirmation of fistula healing and assessment of bowel function, urinary status and fitness for another operation. The Dutch protocol considered reversal at least three months after successful repair, but actual reversal timing varied and some patients retained their colostomy. Closure, stoma reversal and continence should be recorded as separate outcomes.[2][5][9]
Modifications and Their Evidence
- Free gluteal fat graft: McKibben et al. interposed buttock fat between the urinary and rectal closures. This is a free graft, not a vascularized pedicled flap. Fistula closure occurred in 16 of 17 patients; the additional harvest has its own wound, and this uncontrolled series does not establish superiority over closure alone.[3]
- Dartos flap: Dafnis reported vascularized scrotal dartos interposition combined with York–Mason repair in five patients, all with closure at median 70 months. All were diverted; only three had undergone reversal when bowel continence was assessed. This small technical series cannot establish comparative effectiveness or universal continence preservation.[9]
- Modified Montsouris technique: In a 30-patient nonirradiated series, closure was 80% after the first procedure, 97% after two and 100% after three. Repeat-repair success must not be presented as first-operation success.[6]
Outcomes by Series
These are heterogeneous retrospective reports. Recruitment periods, follow-up, first-repair success and eventual closure are different quantities; the Utah reports overlap and must not be pooled as independent patients.
| Series | Population and closure result | Follow-up and interpretation |
|---|---|---|
| Renschler & Middleton 2003 | 24 patients; 22 closed with York–Mason, including one repeat procedure; another closed after perineal salvage | “30 years” describes the experience/recruitment period, not 30-year follow-up for every patient. No fecal incontinence or anal stenosis was reported.[4] |
| Hadley 2012 | Update to the Utah experience: 51 total, including 27 additional patients; 25 of the additional 27 closed with one York–Mason procedure | “40 years” is the center's experience period. The updated failures involved radiation. The earlier 24 patients overlap the preceding report.[7] |
| Falavolti 2013 | 39 iatrogenic fistulas; overall closure reported as over 50%, with approximately 90% in patients with only one previous operation | Previous-operation burden was associated with outcome. The abstract does not establish that every prior operation was a failed fistula repair or give a reliable universal “two prior repairs” cutoff.[1] |
| Bergerat 2018 | 30 nonirradiated patients; 80% first-procedure closure, 100% after up to three procedures | Median 76 months; no acquired urinary or durable fecal incontinence reported. These qualifiers should be retained.[6] |
| Dafnis 2018 | 18 of 20 closed | Median 84.7 months. All 20 had diversion before or during repair; 13 had stoma reversal and were reported continent.[5] |
| McKibben 2018 | 16 of 17 closed after modified repair with a free fat graft | Median 39.4 months; only 10 completed the fecal-continence questionnaire. Two reported rare fecal incontinence and two frequent flatal incontinence; mean Wexner score 1.4/20.[3] |
| Dal Moro 2011 | 14 initially closed; one patient with Crohn's disease developed recurrence 11 years later | “20 years” is the experience period. This illustrates why early closure is not a lifetime guarantee.[10] |
| van der Graaf 2025 | 12 total patients; 8 nonirradiated patients receiving York–Mason as their first fistula operation all closed | Median 5.1 years applies to that eight-patient subgroup. Only five underwent colostomy reversal; their LARS scores were 0–20. Other patients had prior failed repairs and/or radiation, with mixed results.[2] |
| Fengler & Abcarian 1997 | Eight patients, including five with radiation exposure; all closed | Small historical series; reported stool continence does not establish safety for every irradiated fistula.[14] |
| Dafnis 2024 | Five patients with dartos interposition; all closed | Median 70 months; all diverted, three reversed. No comparative group.[9] |
Continence and Other Harms
Older series often report no fecal incontinence, but outcome ascertainment varies and bowel function cannot be fully judged while a patient remains diverted. In McKibben's questionnaire study, the low average Wexner score coexisted with symptoms in individual respondents. None sought treatment or reported lifestyle impairment, which is different from reporting no symptoms.[3]
Counsel about recurrent fistula, wound complications, potential sphincter dysfunction, anal narrowing and persistent urinary incontinence. Classic York–Mason avoids a remote muscle-flap harvest, but added fat grafts or dartos flaps introduce donor-site considerations. Small series reporting no complication cannot establish a zero risk.[2][3][4][9][10]
Radiation, Previous Repairs and Route Selection
Radiation can impair tissue vascularity and complicate both urinary and rectal reconstruction. The Utah update and other series support particular caution, while small successful irradiated series show that radiation is not an absolute prohibition. In the 2025 study, one patient irradiated before prostatectomy healed and one irradiated afterward did not; two individual patients cannot establish a rule based on radiation timing.[2][7][14]
The 37-patient Hanna cohort illustrates treatment selection: irradiated patients more often needed tissue interposition or exenteration and had lower stoma-reversal rates than nonirradiated patients. It does not provide a randomized York–Mason-versus-gracilis comparison.[15] Likewise, Vanni's 74-patient transperineal muscle-interposition series reported one-operation closure in 100% of nonirradiated and 84% of irradiated/ablated patients; those outcomes apply to that selected cohort, not to a head-to-head trial.[12]
| Operative consideration | York–Mason | Transperineal reconstruction with interposition |
|---|---|---|
| Access | Direct posterior transsphincteric exposure of the anterior rectal defect | Perineal access to urinary and rectal tissues |
| Anal sphincter | Deliberately divided and reconstructed | Usually avoids deliberate division of the anal sphincter |
| Interposition | Classic repair may omit it; graft/flap modifications exist | Facilitates vascularized tissue interposition and selected urinary reconstruction |
| Main decision | Suitability of the defect and tissues for closure through this exposure | Need for broader reconstruction, tissue support or management of compromised tissue |
| Outcomes | Closure and bowel function require separate assessment | Closure, bowel function and urinary continence likewise require separate assessment |
The 2022 transperineal gracilis series achieved closure in 20 of 21 patients, but 11 of 18 questionnaire respondents reported significant urinary incontinence. Its mean St Mark's bowel score of 5 out of 24 points is a symptom score—not “zero fecal incontinence” or five affected patients among 24. This is another reason to avoid cross-series claims that one approach guarantees better function.[13]
The frequently quoted 15.7% transsphincteric and 65.9% transperineal proportions describe the 416 patients in a 2013 systematic review, not current worldwide practice. More recent reviews continue to find heterogeneous, largely retrospective evidence and no single operation appropriate for every fistula. The 2026 post-prostatectomy review included 455 patients and reported surgical closure ranging from 41% to 100%; its proposed management pathway is a synthesis of that literature, not a prospectively validated algorithm.[8][11][16]
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References
1. Falavolti C, Sergi F, Shehu E, Buscarini M. "York Mason procedure to repair iatrogenic rectourinary fistula: our experience." World J Surg. 2013;37(12):2950–2955. doi:10.1007/s00268-013-2199-y
2. van der Graaf SH, Wit EMK, Beets GL, et al. "Management in robot-assisted radical prostatectomy patients with recto-urethral fistulas: the York-Mason technique." World J Urol. 2025;43(1):604. doi:10.1007/s00345-025-05996-5
3. McKibben MJ, Fuchs JS, Rozanski AT, et al. "Modified transanosphincteric (York Mason) repair of nonradiated rectourinary fistulae: patient-reported fecal continence outcomes." Urology. 2018;118:220–226. doi:10.1016/j.urology.2018.05.010
4. Renschler TD, Middleton RG. "30 years of experience with York-Mason repair of recto-urinary fistulas." J Urol. 2003;170(4 Pt 1):1222–1225. doi:10.1097/01.ju.0000082013.58783.17
5. Dafnis G. "Transsphincteric repair of rectourethral fistulas: 15 years of experience with the York Mason approach." Int J Urol. 2018;25(3):290–296. doi:10.1111/iju.13518
6. Bergerat S, Rozet F, Barret E, et al. "Modified York Mason technique for repair of iatrogenic recto-urinary fistula: 20 years of the Montsouris experience." World J Urol. 2018;36(6):947–954. doi:10.1007/s00345-018-2212-z
7. Hadley DA, Southwick A, Middleton RG. "York-Mason procedure for repair of recto-urinary fistulae: a 40-year experience." BJU Int. 2012;109(7):1095–1098. doi:10.1111/j.1464-410X.2011.10472.x
8. 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
9. 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
10. Dal Moro F, Secco S, Valotto C, et al. "Twenty-year experience with surgical management of recto-urinary fistulas by posterior sagittal transrectal approach (York-Mason)." Surgery. 2011;150(5):975–979. doi:10.1016/j.surg.2011.04.004
11. 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
12. 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
13. 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
14. Fengler SA, Abcarian H. "The York Mason approach to repair of iatrogenic rectourinary fistulae." Am J Surg. 1997;173(3):213–217. doi:10.1016/s0002-9610(96)00015-3
15. 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
16. 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