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York-Mason Posterior Transsphincteric Repair for Rectourethral Fistula

The York-Mason repair is a posterior transsphincteric approach for rectourethral fistula (RUF) that delivers excellent direct visualization through unscarred posterior tissue planes, achieving primary closure of 80–100% in non-radiated patients and 0% fecal incontinence across virtually all published series.[1][2][3][4][5][6][7] It is the second most commonly used approach for RUF repair (15.7% of repairs), after the transperineal approach (65.9%).[8]

For the gold-standard transperineal alternative see Transperineal Gracilis Interposition for RUF; for the simplest sphincter-preserving option see ERAF for RUF; for incisionless transanal alternatives see Transanal Minimally Invasive Repair.

Historical Background​

Originally described by P.R. Mason in 1970 as a posterior transsphincteric approach to the rectum for excision of rectal tumors, then adapted for rectourinary fistula repair. The longest continuous experience is from the University of Utah spanning 40 years and 51 patients (Middleton, Renschler, Hadley).[4][7] Multiple modifications are collectively referred to as modified York-Mason (MYM).

Surgical Technique​

1. Preoperative preparation​

  • Mechanical bowel prep
  • Fecal diversion practice varies — the Utah series performed single-stage repair without prior diversion in 11 of 24 initial patients; Dafnis used synchronous diverting stoma in 40%; van der Graaf 2025 used diverting ileostomy in all[2][4][5][7]
  • Suprapubic and/or urethral catheter
  • Broad-spectrum perioperative antibiotics

2. Positioning​

Prone jackknife with buttocks taped apart for optimal posterior-perineal exposure — distinct from the lithotomy of transperineal and transanal approaches.[1][4][6]

3. Posterior midline incision​

Incision from coccyx to anal verge through skin, subcutaneous tissue, and perianal fat; deepened through the posterior rectal wall in the midline.

4. Sphincter division​

  • Divide the external anal sphincter complex (subcutaneous, superficial, deep) and the internal anal sphincter in the posterior midline
  • Tag each layer with marking sutures (different colors per layer) to ensure precise anatomic re-approximation[2][5][6][9]
  • "Book-like" opening of the rectum

5. Fistula exposure and excision​

  • Anterior rectal wall now directly visualized
  • Circumferential excision / curettage of the tract — remove all granulation and fibrotic margins
  • Separate rectum and urethra / bladder into distinct planes

6. Layered closure​

  • Urethral / bladder defect first with interrupted absorbable suture (3-0 or 4-0 polyglactin)
  • Rectal-wall defect closed separately in layers with non-overlapping (offset) suture lines
  • Modifications: tissue interposition between suture lines (see below)

7. Sphincter reconstruction​

  • Close the posterior rectal wall
  • Meticulous layer-by-layer re-approximation of the sphincter complex using the marking sutures — internal sphincter, deep external sphincter, superficial external sphincter, subcutaneous external sphincter[2][5][6][9]
  • Skin closure

8. Postoperative management​

  • Urethral catheter 2–4 weeks
  • VCUG at 3–4 weeks to confirm closure before catheter removal
  • Diverting stoma reversed at 3–4 months after confirmed healing[2][5][10]

Key Modifications​

MYM + gluteal free fat graft (McKibben 2018)​

Free fat graft harvested from the buttock and interposed between urethral and rectal suture lines as a tissue barrier. 94% primary success (16/17), mean Wexner FI score 1.4/20 at 39 mo.[3]

MYM + dartos muscle flap interposition (Dafnis 2024)​

Dartos flap harvested from the scrotum through a separate scrotal incision and tunneled to the perineum, interposed between urethral and rectal closures via the York-Mason approach — combines posterior visualization with vascularized interposition. 5/5 successful closure, 0% recurrence at median 70 mo.[9]

Modified Montsouris (Bergerat 2018)​

Specific technical refinements over a 20-year experience (n = 30): 80% primary, 97% after 2 procedures, 100% after 3 procedures, no acquired urinary or durable fecal incontinence.[6]

Outcomes by Series​

SeriesnEtiologyPrimaryFinalFollow-upFecal incontinenceAnal stenosisNotes
Hadley 2012 — Utah 40-yr51Post-prostatic surgery~92% (47/51)~98%40 yr0%0%Largest single-center; failures were radiation-induced[7]
Falavolti 2013 — USC/UCBM39Iatrogenic (prostate cancer)~90% (1 prior) / ~50% (≥ 2 prior)NSNS0%0%Success independent of etiology; prior-surgery count matters[1]
Bergerat 2018 — Montsouris30Iatrogenic80%100% after ≤ 376 mo (median)0%0%No acquired urinary or fecal incontinence[6]
Renschler & Middleton 2003 — Utah 30-yr24Post-prostatic surgery (75%)92%96%30 yr0%0%11 without preoperative diversion; OR 2 h[4]
Dafnis 2018 — 15-yr20Mixed90%90%84.7 mo (median)0%0%Diabetes, smoking, radiation more frequent in failures[5]
McKibben 2018 — MYM + fat graft17Prostatectomy 65%, cryo 12%94%94%39.4 mo (median)Wexner 1.4/200%18% had failed prior perineal repairs[3]
Dal Moro 2011 — 20-yr14Post-RRP (71%)100%93% (1 late at 11 yr)20 yr0%0%1 wound infection; 1 Crohn's recurrence at 11 yr[10]
van der Graaf 2025 — post-RARP12Post-RARP100% non-radiated, first surgery100%5.1 yr (median)0%0%100% when used as first surgical intervention[2]
Fengler & Abcarian 19978Prostate cancer (5 radiated)100%100%NS0%0%Included 3 radiation-only and 2 surgery + radiation[20]
Dafnis 2024 — MYM + dartos5Post-RP100%100%70 mo (median)0%0%Novel combination with dartos interposition[9]

Aggregate Outcomes​

  • Primary closure (non-radiated): 80–100%; lower for radiated, with failures concentrated in irradiated patients[1][5][6][7]
  • Final closure (incl. repeat procedures): 96–100%[4][6][7]
  • Fecal incontinence: essentially 0% across all series — the most remarkable and consistent finding. Despite deliberate division of the entire sphincter complex, meticulous layer-by-layer re-approximation preserves continence in virtually all patients[1][2][3][4][5][6][7][9][10]
  • Anal stenosis: 0% across all series[4][5][7][10]
  • OR time: typically ~ 2 h[3][4]
  • Blood loss: minimal (50–400 mL); no transfusions in most series[4]
  • LOS: median 2 days (1–13)[3]

Impact of Radiation​

Radiation history is the dominant predictor of failure:

  • Utah 40-yr — all failures in the updated cohort were radiation-induced.[7]
  • Dafnis — diabetes, smoking, and preoperative irradiation more frequent in failed group (NS due to small sample).[5]
  • Hanna 2014 (Duke) — non-irradiated patients most commonly underwent York-Mason (50%); irradiated patients required gracilis interposition (38%) or pelvic exenteration (19%); irradiated had higher wound infection and lower stomal reversal (55% vs 91%).[21]
  • van der Graaf 2025 — York-Mason effective when radiotherapy preceded RARP but not when salvage radiotherapy followed RARP.[2]
  • Fengler & Abcarian — 100% in 8 patients including 5 with radiation history, but small.[20]

Consensus: York-Mason is best for non-radiated RUF; in irradiated patients transperineal gracilis is preferred.[8][11][21]

Impact of Prior Failed Repairs​

  • Falavolti — ~90% with 1 prior procedure / ~50% with ≥ 2 prior surgeries.[1]
  • McKibben — 18% had failed prior perineal repairs; overall success still 94%.[3]
  • van der Graaf — most effective when used as the first surgical intervention.[2]

Advantages​

  • Superior visualization through healthy, unscarred posterior tissue planes — considered the best of any RUF approach[1][4][6][10]
  • Excellent fecal continence preservation despite sphincter division — 0% across virtually all series[1][2][3][4][5][6][7][10]
  • No anal stenosis consistently[4][5][7][10]
  • Short OR time (~ 2 h)[4]
  • Low blood loss (50–400 mL); no transfusions[4]
  • Short LOS (median 2 d)[3]
  • No donor-site morbidity (unless combined with dartos flap)[1][4]
  • Diversion may be avoided in selected patients[4][7]
  • Repeatable with good results[6]
  • Access through unscarred planes — avoids the scarred anterior planes from prior prostate surgery, a major advantage over transperineal approach[4][10]

Limitations​

  • Sphincter division — primary theoretical concern; clinical FI essentially unreported, but McKibben found 20% reported rare incontinence on detailed PROMs[3]
  • Not ideal for radiated fistulas — failures concentrated in irradiated patients; the standard technique provides no vascularized interposition (modifications address this)[5][7][21]
  • No tissue interposition in the classic technique — addressed by gluteal-fat-graft and dartos-flap modifications[3][9]
  • Diminished success with multiple prior repairs — drops to ~ 50% with ≥ 2 prior surgeries[1]
  • Prone jackknife positioning — challenging in obese patients; limits simultaneous urologic access (e.g., cystoscopy)[1][4]
  • Less commonly performed — only 15.7% of all RUF repairs vs 65.9% transperineal; high-volume centers (≥ 25 patients) almost exclusively use transperineal[8]

York-Mason vs Transperineal Gracilis Interposition​

FeatureYork-MasonTransperineal Gracilis
Primary success (non-radiated)80–100%97–100%[1][2][3]
Primary success (radiated)Variable; most failures here84–86%[12][17]
Tissue interpositionNot standard (modifications available)Vascularized gracilis muscle
Fecal incontinence0%0% (St. Mark's 5/24)[1][17]
Anal stenosis0%N/A
Urinary incontinence0% (new onset)61% (mostly pre-existing)[17]
OR time~ 2 hLonger (includes flap harvest)[4][17]
LOS2 d5–7 d[3][17]
Donor-site morbidityNoneMild (thigh numbness)[17]
Sphincter preservationDivided and re-approximatedPreserved
VisualizationExcellent (direct posterior)Excellent (perineal)
Proportion of all RUF repairs15.7%65.9% (transperineal total)[8]
Best indicationSmall, non-radiated, first-time repairAll complexities including radiated

Place in the Algorithm​

  • de Angelis 2026 SR (n = 455 post-RP RUF): transperineal and transsphincteric approaches were the most commonly employed, with success 41–100%; flowchart positions conservative management first, then surgical repair tailored to fistula complexity and radiation history.[22]
  • Hanna 2014 (Duke) etiology-based algorithm:
    • Non-irradiated RUF → York-Mason (50% of non-irradiated cohort)
    • Irradiated RUF → gracilis interposition (38%) or pelvic exenteration (19%) for the most complex cases[21]

Summary​

The York-Mason posterior transsphincteric approach is a well-established, highly effective technique providing unparalleled direct visualization of the fistula through unscarred posterior planes. Its hallmark is the preservation of fecal continence (0%) despite deliberate sphincter division, achieved by meticulous layer-by-layer re-approximation. With primary closure of 80–100% in non-radiated patients, short OR times, minimal blood loss, and rapid recovery, it is an excellent option for small-to-moderate, non-radiated, iatrogenic RUF, particularly when used as the first surgical intervention. Recent modifications (dartos flap, gluteal fat graft) address the absent-tissue-interposition limitation. For radiation-induced or complex RUF, transperineal gracilis interposition remains the preferred approach at most high-volume centers.

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

17. 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

20. 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

21. 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

22. 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