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Rectourethral Fistula

A rectourethral fistula (RUF) is an epithelialized communication between the rectum and the urethra, prostatic fossa, or bladder neck. It is rare but operatively demanding, and almost always a complication of prostate cancer treatment — radical prostatectomy or energy-based therapy (radiation, brachytherapy, cryotherapy, HIFU). Modern reconstruction is dominated by the transperineal approach with gracilis muscle flap interposition, which closes 87–100% of non-irradiated and 84–87% of irradiated fistulas at high-volume centers.[1][2][3][4]

For the female-perineum equivalent and the broader interposition-flap framework, see Rectovaginal Fistula. For the operative steps and donor-site anatomy of the gracilis flap itself, see Gracilis Flap.

Epidemiology​

RUF incidence varies by inciting treatment.[4][5][6][7][8][9]

EtiologyIncidence
Radical prostatectomy0.34% (retropubic) – 1.04% (perineal)[5]
Brachytherapy monotherapy0.19–0.2%[6][7]
Brachytherapy + EBRT (combined)2.9%[4]
Salvage brachytherapy8.8%[4]
Primary whole-gland cryotherapy1.2% (~0.55% in modern era)[9]
HIFU — single session1.17%[8]
HIFU — repeat sessions13.6%[8]
Salvage HIFU4.5%[8]

In the largest multi-institutional series (201 patients), 48.2% of RUFs followed radical prostatectomy alone and 51.8% followed energy ablation.[4]

Etiology and Mechanism​

CauseNotes
Radical prostatectomyUnrecognized rectal injury during posterior dissection at Denonvilliers' fascia; ~54% of post-RP RUFs had a rectal lesion primarily closed at the index operation; perineal approach 3.06× the risk of retropubic[5]
Radiation / ablationIschemic necrosis of the rectourethral septum weeks–months after treatment. Post-treatment rectal biopsy, argon-plasma coagulation, and TURP all materially escalate fistula risk after brachytherapy[6][7]
TraumaPenetrating perineal / pelvic injury (blast, gunshot, stab); pelvic fracture[14][15]
Crohn's disease~0.3% of Crohn's patients; 6–11% of all GU fistulas in Crohn's[13]
Cryptoglandular / perirectal sepsisPerianal abscess eroding into urethra
Iatrogenic non-prostateRectal surgery, transanal excision

Classification​

Muñoz etiologic (1998)[11]​

  • Benign: Crohn's, trauma, perirectal sepsis, iatrogenic
  • Malignancy-related: neoplasm at fistula site, radiation-induced, surgery-induced, combined

Mundy & Andrich complexity (2011)[17]​

  • Simple — post-surgical (prostatectomy), no cavitation, no bladder neck contracture; amenable to primary repair
  • Complex — post-irradiation or post-ablation, cavitation (tissue loss creating a rectourethral cavity), bladder neck contracture, or extensive ischemia; requires interposition, often permanent diversion. Cavitation is most common after salvage HIFU following combined EBRT + brachytherapy

Clinical Presentation​

Symptoms develop days to weeks after surgery, weeks to months after radiation/ablation.[1][5][12][18]

SymptomFrequency
Pneumaturia — often the earliest finding~24%
Fecaluria — pathognomonic~10% as presenting symptom
Urine per rectum~48%
Recurrent UTI~21%
Dysuria~21%
Concurrent urethral stricture / BNC14% non-irradiated; 26% irradiated[4][19]

A small fistula without fecaluria has a meaningful chance of conservative closure; the presence of fecaluria mandates fecal diversion.[5]

Diagnostic Evaluation​

StepRole
CystourethroscopyMaps urethral / prostatic-fossa opening; identifies concurrent stricture or BNC[12]
Proctoscopy / sigmoidoscopyRectal opening; surrounding mucosa[12]
VCUGConfirms tract, demonstrates rectal extravasation[12]
CT with rectal contrastTract anatomy, abscess, periureteral pathology
MRI pelvisBest soft-tissue characterization; tissue quality and radiation-injury extent[12]
Examination under anesthesiaOften necessary to fully define anatomy and tissue quality[12]
Biopsy of fistula edgeMandatory in post-radiation patients to rule out cancer recurrence before reconstruction[12]

Management​

The algorithm is etiology-driven, with the dominant axis being non-irradiated vs irradiated/ablation-induced.[1][4][12][20]

1. Conservative management (selected non-irradiated patients)​

For small fistulas without fecaluria — urethral catheter ± suprapubic tube, bowel rest, antibiotics for sepsis. Spontaneous closure occurred in 3 of 13 (23%) post-prostatectomy RUFs (none of whom had fecaluria) in one series, and in 47% in an algorithm-based cohort (27% before diversion, 20% after).[5][16] Spontaneous closure is rare after radiation/ablation.[20]

2. Fecal diversion​

Loop or end colostomy. Indicated for fecaluria, sepsis, large fistula, failed conservative trial, or as a prerequisite to reconstruction. Performed in 65–84% of patients before definitive repair.[4] Diversion alone closes ~33% of post-prostatectomy RUFs and ~46% of post-traumatic RUFs.[5][15]

Caveat at high-volume centers: the Lahey Clinic series demonstrated that 97% of non-irradiated patients had bowel undiverted with 100% success — diversion is not an absolute prerequisite when the fistula and tissue bed are favorable.[2]

3. Surgical repair — first repair is the best repair​

Subsequent repairs are progressively harder; success drops with each attempt.[21][27]

Surgical approach selection​

ApproachBest fitSuccess
Transperineal + gracilis flap ± BMGStandard of care; non-irradiated and irradiated84–100%[1][2][3][4]
Transsphincteric (York-Mason)Small, non-irradiated RUF as first surgical intervention88–100%[10][27][28][29][33]
Transanal (advancement flap, MITAR, robotic TAMIS)Small (< 1.5 cm), non-irradiated, no fecaluriaVariable 25–100%[25][35]
Transabdominal / roboticComplex irradiated; needs salvage prostatectomy, omental flap, proctectomy, or concurrent VUAS repairVariable[26][30][36]

A. Transperineal repair with gracilis flap (Lahey / Vanni–Zinman–Buckley)​

The reference operation for both non-irradiated and irradiated RUF.[1][3][12][23]

Steps:

  1. Exaggerated lithotomy
  2. Vertical or inverted-U perineal incision
  3. Dissection through the perineal body to the fistula tract
  4. Separation of rectum from urethra / prostatic fossa
  5. Excision of the tract
  6. Two-layer rectal closure
  7. Urethral closure — primary or with buccal mucosal graft (BMG) onlay when there is a concurrent urethral stricture or significant urethral tissue loss
  8. Gracilis harvest from the medial thigh on the medial circumflex femoral pedicle, tunneled subcutaneously to the perineum, interposed between rectal and urethral suture lines
  9. Suprapubic + urethral catheter
  10. Cystogram at 3–4 weeks before catheter removal

Outcomes:

SeriesNNon-irradiatedIrradiated
Vanni 201074100%84%[2]
Kaufman / Lahey 20169898%86%[32]
Harris multi-institutional 201720199%87%[4]
Sbizzera Eur Urol 202221—95% (mixed cohort)[22]
Muñoz-Duyos 20179100%—[31]

Concurrent urethral stricture (BMG patch onlay): present in 11% of non-irradiated and 28% of irradiated RUFs; in a series of 23 patients with concurrent posterior urethral stenosis, simultaneous urethroplasty + RUF repair achieved 87% fistula closure at median 56 months.[2][19]

B. York-Mason transsphincteric repair​

Technique:[10][12][28][29][33]

  1. Prone jackknife
  2. Parasacral incision from coccyx to anal verge
  3. Posterior-midline (6 o'clock) division of external and internal sphincter complex
  4. Direct exposure of the anterior rectal wall and fistula
  5. Tract excision; urethral closure; rectal closure
  6. Anatomic re-approximation of the divided sphincter complex in labeled layers
  7. Optional dartos / gluteal-fat interposition[24][28]

Outcomes:

SeriesNSuccessContinence
van der Graaf 2025 (post-RARP, non-irradiated)10100% as first surgical interventionIntact at 5.1 yr[10]
Dafnis 20182090%100% intact at 84.7 mo[29]
McKibben 20181794%Mean Wexner 1.4/20[28]
Falavolti 201339~90% first surgery; 50% redoPreserved[27]
Dal Moro 20-yr14100%Intact[33]

Where York-Mason fits: small to mid-sized non-irradiated RUF — particularly as first surgical intervention. Not recommended for irradiated fistulas — the bed is too poor to heal reliably without vascularized interposition.[10][34]

C. Minimally invasive approaches​

  • MITAR (minimally invasive transanal repair through Parks' retractor) — 100% success in a small series of selected, simple, non-irradiated RUF[25]
  • Robotic TAMIS — enhanced visualization for transanal repair; early data, not yet a standard option[35]
  • Robotic transabdominal — useful when salvage prostatectomy, omental interposition, or concurrent vesicourethral-anastomotic-stricture repair is needed; 100% success at 12 months in a 15-patient series; allows the simultaneous repair of RUF + VUAS[30][36]
  • Transanal endoscopic surgery (TES / TEM) — poor results (25% success); biological mesh interposition 0% success — not recommended as a primary technique[37]

4. Radiation/ablation-induced RUF — the difficult subset​

Radiation and ablation RUFs differ fundamentally and need a different mental model:[1][4][17][20][34][38]

  • Higher concurrent urethral stricture / BNC (26% vs 14%)
  • Higher post-repair urinary incontinence (35% vs 16%)
  • Higher permanent fecal diversion (31–86% vs 0–3%)
  • Higher permanent urinary diversion (up to 93% vs 6% in one series)
  • Tissue interposition is mandatory — without it, primary repair has only a 17% success rate vs 87% with interposition[20]
  • Salvage prostatectomy may be required when a discrete prostate remains[17][26]
  • Proctectomy with coloanal pull-through (Turnbull–Cutait) for severe rectal injury[39][40]
  • Permanent dual diversion (fecal + urinary) should be discussed early as a legitimate primary option — required in ~50% of radiation/ablation patients in one multi-institutional series[38]

Concurrent Posterior Urethral Reconstruction​

Posterior urethral stenosis is present in ~18% of RUF patients and complicates repair. In a Cleveland Clinic series of 23 patients, simultaneous posterior urethroplasty + RUF repair achieved 87% fistula closure; 78% of urethroplasty was anastomotic and 22% used BMG. Postoperative urinary incontinence in 61%, with 30% ultimately needing artificial urinary sphincter — but no isolated stricture recurrences requiring instrumentation.[19]

The bottom line: patients with concurrent posterior urethral stenosis should not be excluded from restorative surgery.[19]

Long-Term Functional Outcomes​

Even after successful closure, functional sequelae are common and must be discussed preoperatively.[4][18][19][20][28]

OutcomeRate
Post-repair urinary incontinence16% (non-irradiated) → 61% (in concurrent urethroplasty cohorts)
Eventual AUS placement~30% in concurrent-urethroplasty series
Permanent fecal diversion0–3% (non-irradiated); 31–86% (irradiated)
Permanent urinary diversion6–20% (non-irradiated); up to 93% (irradiated, severe)
Fecal incontinence after York-MasonMinimal (mean Wexner 1.4–5/24)
Patient satisfactionHigh (mean 9/10) despite incontinence
Decision regretNegligible (median 0/100)

A 2026 long-term outcomes study (median follow-up 50 months) reported 96% 5-year recurrence-free survival after open RUF repair, with restored voiding function, mild fecal incontinence, high patient satisfaction, and negligible decisional regret — though moderate urinary incontinence persisted in some.[18]

Algorithm Summary​

  1. Confirm diagnosis — cystoscopy, proctoscopy, VCUG, MRI; biopsy to rule out cancer recurrence in post-radiation patients
  2. Characterize — size, location, etiology, concurrent stricture / BNC, tissue quality, cavitation
  3. Conservative trial for small fistula without fecaluria (catheter ± SP tube, bowel rest)
  4. Fecal diversion for fecaluria, sepsis, or failed conservative management — and standard before any complex / irradiated repair
  5. Definitive repair
    • Non-irradiated, small/simple → York-Mason (or MITAR in selected cases)
    • Non-irradiated, larger or complex → Transperineal + gracilis ± BMG
    • Irradiated / ablation-induced → Transperineal + gracilis + BMG; concurrent salvage prostatectomy if discrete prostate remains; discuss permanent dual diversion early
  6. Failed repair / devastated pelvis → permanent fecal and/or urinary diversion; pelvic exenteration as last resort[11][38]

Operative Principles​

  • The first repair is the best repair[21][27]
  • Etiology dictates complexity — non-irradiated and irradiated/ablation RUFs are different operations with different expectations
  • Vascularized tissue interposition (gracilis, omentum, dartos) is essential for irradiated fistulas; the "interposition by default" reflex is appropriate in any complex non-irradiated case as well
  • Multidisciplinary planning with colorectal surgery is the rule
  • Treat concurrent urethral pathology simultaneously when feasible[19]
  • Counsel about post-repair incontinence and possible AUS as part of the preoperative conversation
  • Permanent diversion is not failure — it is the right operation for the right radiation/ablation patient[20][38]

Surgical Video Resources​

References​

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2. 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

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. 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

5. 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

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18. 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

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31. 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

32. 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

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34. 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

35. Hebert KJ, Naik N, Allawi A, et al. "Rectourethral fistula repair using robotic transanal minimally invasive surgery (TAMIS) approach." Urology. 2021;154:338. doi:10.1016/j.urology.2021.05.027

36. 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

37. Serra-Aracil X, Labró-Ciurans M, Mora-López L, et al. "The place of transanal endoscopic surgery in the treatment of rectourethral fistula." Urology. 2018;111:139–144. doi:10.1016/j.urology.2017.08.049

38. 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

39. Lane BR, Stein DE, Remzi FH, et al. "Management of radiotherapy induced rectourethral fistula." J Urol. 2006;175(4):1382–1387. doi:10.1016/S0022-5347(05)00687-7

40. Martín-Pérez B, Dar R, Bislenghi G, et al. "Transanal minimally invasive proctectomy with two-stage Turnbull-Cutait pull-through coloanal anastomosis for iatrogenic rectourethral fistulas." Dis Colon Rectum. 2021;64(2):e26–e29. doi:10.1097/DCR.0000000000001850