Rectovesical Fistula

A rectovesical fistula (RVF) is an epithelialized communication between the rectal lumen and the bladder. In contemporary practice the condition is rare but devastating, and is most often the consequence of prostate cancer treatment — radical prostatectomy (open, laparoscopic, or robotic), external-beam radiation, brachytherapy, or ablative salvage therapies (HIFU, cryotherapy). Less common etiologies include inflammatory bowel disease, pelvic trauma, rectal or pelvic malignancy with direct invasion, perirectal sepsis, and Fournier's gangrene sequelae.^[1][2][6]

A critical distinction separates RVF from its close anatomic cousin, the rectourethral fistula (RUF): the bladder neck is the anatomic landmark. A fistulous tract entering the urinary tract proximal to the bladder neck (typically at the vesicourethral anastomosis after radical prostatectomy) is an RVF. A tract entering distal to the bladder neck — through the membranous or prostatic urethra — is an RUF. The two lesions share most of their clinical and reconstructive landscape, but they differ in optimal approach: RVF is preferentially repaired transabdominally, with direct access to the posterior bladder, fistulous tract, and rectal wall; RUF is preferentially repaired transperineally. The distinction is routinely missed because RVFs after radical prostatectomy are frequently mislabeled as rectourethral.^{[1][2][10][15]}

Successful repair requires careful patient selection, an approach matched to etiology and complexity, vascularized tissue interposition in virtually every case, and almost always a period of temporary fecal and urinary diversion. Post-surgical (non-radiated) fistulas have excellent outcomes — 96–98% closure rate, 94% restoration of GI continuity, and return to near-normal function. Post-radiation fistulas are substantially more complex, with higher complication rates, a strong likelihood of permanent diversion, and the frequent need for salvage prostatectomy.^[1][16][19]

See also: Rectourethral Fistula, The Bladder, Gracilis Flap, Omental Flap, Buccal Mucosa Graft, Radiation Tissue Effects, Fistulas landing page.

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Epidemiology & Etiology

Prostate Cancer Treatment (Dominant)

Prostate cancer treatment accounts for the majority of contemporary RVFs.

Modality	Incidence
Radical prostatectomy (open, laparoscopic, robotic)	0.3–3%[1][4]
External-beam radiation therapy (EBRT)	0.19–0.26%[3][4]
Brachytherapy	Low individually; increased with combined-modality[3]
Combined-modality RT + brachytherapy	Higher than either alone[3][4]
Salvage HIFU, cryotherapy, salvage prostatectomy	Elevated; complex fistulas with cavitation[1][3]

Sequential energy treatments (e.g., EBRT → brachytherapy → salvage HIFU) create the most complex fistulas, typically with tissue cavitation, extensive ischemia, and associated bladder-neck contracture.^[1]

Iatrogenic Interventions Post-Treatment

A meaningful fraction of RVFs after prostate cancer therapy are provoked by subsequent interventions in irradiated tissue:^[3][5]

• TURP after radiation — performed in 5 of 12 fistula patients in one brachytherapy series vs 0 of 9 ulcer-only patients^[3]
• Bladder-neck-contracture (BNC) treatment — endoscopic incision or dilation in radiated patients is a well-documented precipitant^[1][5]
• Rectal biopsy after brachytherapy — 3 of 8 patients who underwent biopsy in one series developed a fistula^[3]
• Argon plasma coagulation for radiation proctitis bleeding^[3]

The teaching point: be cautious with any instrumentation — urinary or rectal — in an irradiated pelvis, and counsel patients that even "minor" endoscopic maneuvers can precipitate catastrophic complications.

Other Etiologies

• Trauma — penetrating pelvic injury, pelvic fracture, combat-related injury^[6]
• Inflammatory bowel disease — Crohn's disease
• Colorectal malignancy — up to 20% of advanced colon cancers with local invasion
• Perirectal sepsis
• Fournier's gangrene

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Classification

By Etiology^[2]

• Benign fistulas — Crohn's, trauma, perirectal sepsis, iatrogenic surgical injury
• Malignancy-related fistulas — neoplasm, radiation, surgery for cancer, or combined tumor/treatment effects

By Complexity — Mundy & Andrich^[1]

Simple fistulas:

• Post-surgical, non-irradiated
• Small, well-defined single tract
• No cavitation
• No associated bladder neck contracture

Complex fistulas (one or more):

• Post-irradiation (complex even without cavitation or BNC)
• Cavitation (tissue loss with cavity formation)
• Associated bladder neck contracture
• Extensive ischemia from serial energy applications
• Wide, tough scar tissue from multiple prior repair attempts^[7]

By Size and Repair History — Contemporary Refinement

A contemporary working classification used by the Sotelo group further subdivides complexity:^[15]

Simple: single tract, size <2 cm, no prior failed repair, no energy treatment.

Complex: multiple tracts, size ≥2 cm, prior failed repair, prior energy treatment, or associated bladder-neck stricture.

By Anatomic Location

The anatomic distinction between RVF and RUF is the bladder neck:^[2][10]

• Proximal to the bladder neck (typically at the vesicourethral anastomosis) → rectovesical fistula
• Distal to the bladder neck (membranous or prostatic urethra) → rectourethral fistula

In one series of 41 post-prostate-cancer fistulas, 54% (22/41) were rectovesical and 46% (19/41) rectourethral.^[2]

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Clinical Presentation

Symptoms

Recurrent polymicrobial urinary tract infection is the most frequent presenting feature — reported in up to 88% of patients at presentation.^[2] Additional symptoms:^[1][8][9]

• Urinary leakage per rectum — 48%
• Pneumaturia — 24%
• Fecaluria — 10%
• Recurrent UTIs — 21% (as a lead symptom; 88% across full presentation)
• Dysuria — 21%
• Suprapubic or groin pain (especially if pubovesical fistula coexists)^[5]

Time to Presentation

• Post-surgical fistulas — median 10 months (range 4–13) from prostatectomy to repair^[8]
• Post-radiation fistulas — 6 months to 20 years after last radiation treatment^[13]

Diagnosis

History, pelvic examination, and digital rectal examination establish the suspicion. Targeted workup:^{[6][10][11][12]}

• Cystourethroscopy — visualize the fistula orifice; characterize surrounding mucosa; catheterize the tract
• Urethroscopy with DRE under anesthesia — the most reliable single diagnostic maneuver in equivocal cases^[11]
• Colonoscopy / proctoscopy — identify rectal orifice; rule out malignancy or IBD
• Cystography / retrograde urethrography — delineate the tract and exclude distal obstruction
• CT urogram — assess size, cavitation, relation to surrounding structures, concurrent ureteral injury
• MRI — high-resolution tract characterization, especially in complex or multi-tract fistulas
• Biopsy — mandatory when pelvic malignancy is suspected or when history includes prior cancer

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Management Principles

Conservative Management — Limited Role

Spontaneous closure of a complex urorectal fistula is uncommon to nonexistent.^[14] In one series of 3 patients managed non-operatively, none required formal closure over follow-up but all required ongoing symptomatic and episodic care — a decision driven by quality-of-life considerations rather than curative intent.^[14] Conservative management is reasonable only for patients who decline surgery or are poor operative candidates.

A distinct finding: post-brachytherapy rectal ulcers (without fistulization) healed with conservative management in 8 of 15 patients (53%), but no established fistula closed without surgery in the same series.^[3] The distinction between pre-fistula rectal ulcer and established RVF is therefore prognostically meaningful.

Fecal and Urinary Diversion

Early double diversion — fecal (end sigmoid or loop colostomy) plus urinary (suprapubic cystostomy or urethral catheter) — is the standard initial maneuver.^[6][11] Rationale: decompress the inflamed field, allow edema and inflammation to resolve, and create the tissue-quality window within which definitive repair can proceed (typically 3–6 months).

• Performed in 96% of patients in a contemporary minimally invasive repair series^[15]
• In post-traumatic fistulas, double diversion alone produced healing in 46.5% of small, less-fibrous fistulas without any formal repair^[11]
• Reversal rates after successful definitive repair: non-radiated 94% vs radiated 65%^[16]; transperineal with gracilis 83% (10/12)^[9]

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Surgical Approaches

The choice of approach is driven by etiology, location, and complexity, and has a large effect on outcome.

Transperineal Approach

First-line for post-surgical, non-radiated fistulas.^[1][9][17]

Technique:

1. Vertical perineal incision
2. Fistula dissection, tract excision, and debridement of non-viable margins
3. Separate closure of bladder / urethral and rectal defects in non-overlapping suture lines
4. Gracilis muscle flap interposition between the two suture lines^[18][9]
5. Wide drain placement

Outcomes:

• Post-surgical fistulas: 98% (48/49) closed with one procedure^[16]
• Post-radiation fistulas: 86% (42/49) closed with one procedure^[16]
• 5-year recurrence-free survival: 96%^[8]
• Transperineal gracilis: 95% (20/21)^[9]

Functional outcomes (largely reflect underlying disease, not approach):^[8][9]

• Significant urinary incontinence: 61%
• Mild fecal incontinence (St Mark's 5/24)
• Patient satisfaction: high (mean 9/10)
• Voiding restored (median LUTS 4/9)

Transabdominal / Abdominoperineal Approach

Preferred for post-radiation fistulas, complex fistulas with cavitation, and fistulas requiring salvage prostatectomy.^[1][13][19] In one series, 90.6% of radiated fistulas were approached abdominally.^[19]

Technique for radiation-induced cases with salvage intent:^[13]

1. Proctectomy when rectal tissue is severely damaged
2. Salvage radical prostatectomy if a discrete prostate still exists^[1]
3. Buccal mucosa graft to reconstruct the urethral defect^[13][16]
4. Staged colo-anal pull-through for rectal reconstruction
5. Gracilis muscle interposition

Outcomes — radiated vs non-radiated (Beddy et al.):^[19]

Outcome	Non-radiated	Radiated	P
Successful primary repair	80.9%	0%	<0.05
Permanent colostomy	0%	83%	<0.05
Permanent urostomy	19%	100%	<0.05

In the Mundy series of 40 radiated fistulas, combined transabdominal proctectomy + salvage prostatectomy + gracilis interposition cured all fistulas — but at the cost of frequent permanent diversion.^[1]

York Mason Posterior Transsphincteric Approach

Posterior, transanal, transrectal sphincter-splitting approach with direct visualization of the fistula from the rectal side and a rectal-wall advancement closure.^[20]

Outcomes:^[20]

• Overall: >50% fistula-free at follow-up
• Single prior procedure: 90% fistula-free
• Multiple prior procedures: significantly lower success
• Diabetes and concurrent infection did not influence outcome
• Most common etiology in contemporary series: laparoscopic prostate procedures

Advantages: good visualization, minimal bleeding, less postoperative pain than transperineal or transabdominal.

Limitations: deliberate sphincter division (with careful reconstruction), not a preferred approach for radiated fistulas.

Robotic / Laparoscopic Transabdominal Repair

Minimally invasive transabdominal repair has matured into a reproducible technique — the contemporary workhorse for RVFs after radical prostatectomy at centers with robotic reconstructive expertise.^{[10][12][15][21]}

Outcomes (Medina et al., 24 patients robotic / laparoscopic):^[15]

• 100% fistula closure at 12-month follow-up
• Median operative time: 180 min (140–282)
• Median blood loss: 50 mL (40–125)
• Median hospital stay: 2 days (2–3)
• No intraoperative complications
• Clavien II: 2 patients; Clavien IIIb: 1 patient

Step-by-Step — Sotelo-Group Robotic Technique^[15]

Positioning. Low lithotomy and steep Trendelenburg.

Cystoscopy and tract cannulation. Cystourethroscopy is performed first. Both ureters are catheterized — this simultaneously facilitates later identification and provides protection during excision and closure at the trigone. The fistulous tract is cannulated with a different-color open-ended ureteral catheter, passed through the fistula into the rectum, and retrieved through the anus to serve as an intraoperative locator.

Omental harvesting. An intact omentum of sufficient length can be brought directly to the pelvis. If length is inadequate, an omental flap based on the right gastroepiploic artery is created, replicating the open omentoplasty technique. Coloepiploic detachment is followed by careful dissection along the gastrocolic ligament with an energy device (Harmonic ACE or robotic Vessel Sealer Extend). If length remains inadequate, a longitudinal perpendicular incision through the omentum — carefully avoiding vascular arcades — further lengthens the flap. The patient is then placed in Trendelenburg for the pelvic phase.

Dissection of the fistulous tract. Technique depends on whether the prostate is present:

• Absent prostate (post-prostatectomy RVF — the most common scenario): localize and dissect the rectovesical space. Perform a downward vertically oriented posterior cystotomy (bladder bivalving), advancing the incision until it reaches the fistulous tract. If concurrent bladder-neck contracture is present, anterior dissection through the space of Retzius permits bladder-neck reconstruction and a new vesicourethral anastomosis.
• Prostate in situ (post-radiation with salvage intent): salvage prostatectomy is performed concurrently. A retrovesical incision is made; dissection advances distally with monopolar scissors until the fistulous tract's proximal border is encountered. Anterior dissection through the Retzius space exposes the prostatic anterior capsule. The prostatic apex is dissected, the bladder neck freed, and the prostatectomy completed. The posterior bladder-neck plane is then followed distally until it meets the distal end of the fistulous tract.

Further rectovesical dissection with a combination of hook cautery and robotic monopolar scissors ensures clean separation of the rectum from the bladder.

Rectal closure. The fistulous tract is debrided with cold scissors — approximately 2 mm of non-viable tissue is removed circumferentially. Rectal closure is two-layer with the initial knot placed on the outer surface of the rectum, outside the defect area:

• Laparoscopic: interrupted UR-6 3-0 poliglecaprone (Monocryl)
• Robotic: running 3-0 barbed absorbable (V-Loc)

Indocyanine green (ICG) fluorescence imaging confirms adequate rectal perfusion. Anorectoscopy with a bubble test confirms watertight closure and appropriate rectal caliber.

Tissue interposition. The harvested omental flap is advanced through the rectovesical space and anchored distal to the rectal suture line (3-0 V-Loc). If omentum is unavailable or too short, alternatives include gracilis muscle, rectus abdominis, or a peritoneal flap from the nearest anatomic location.

Bladder closure and vesicourethral anastomosis. Bladder-trigone reconstruction in two layers with 3-0 V-Loc, ensuring non-overlapping suture lines relative to the rectal closure and to the omental flap. A tension-free vesicourethral anastomosis is then performed — running single-knot technique.

Postoperative care. Catheter patency is closely monitored; acute urinary retention from clot is the commonest early complication. The urethral catheter and Blake drain are typically removed on postoperative day 3 if drain output is low and there is no concern for urine leak. The urethral catheter or SPT is removed at 3 weeks after a leak-free cystogram. Laparoscopic Hartmann reversal is performed approximately 4 months after confirmed successful repair.

Follow-up: clinic visits at 1, 3, and 6 months with symptom assessment and examination; cystoscopy and/or CT urogram at 12 months to confirm durable closure.

Transanal Endoscopic Microsurgery (TEM)

Minimally invasive transanal approach for simple fistulas without radiation or cavitation.^[7]

Technique: magnified 3D stereoscopic visualization; precise resection of the fistula and surrounding rectal mucosa; four-layer hand-sewn closure of the rectal defect and muscle.

Outcomes (10 patients): 7 of 10 (70%) success; 3 failures all had wide, tough scar tissue from prior radiation, HIFU, or multiple repairs.^[7]

Contraindications (clear from the failure pattern): prior radiation, prior HIFU / cryotherapy, multiple failed repairs, wide tough-scar tracts.

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Tissue Interposition

Vascularized tissue interposition between the repaired bladder / urethral and rectal suture lines is mandatory in virtually every RVF repair. The interposed tissue prevents recurrent fistulization by breaking the direct line of continuity between the two suture lines.

Gracilis Muscle Flap — the Workhorse

The gracilis muscle flap is the most commonly used interposition for RVF and RUF repair.^{[9][17][18][22]}

Outcomes:

• Rectourethral fistulas: 78% initial success, 97% overall after secondary procedures (Wexner series, 53 patients)^[18]
• Transperineal repair with gracilis: 95% (20/21)^[9]
• Colorectal-surgeon-performed: 83.4%^[22]
• Postoperative complications: 16.7%^[22]
• Flap failure: 16.6% (3/18)^[22]
• Lower-extremity dysfunction: minimal (mean score 2/20)^[9]
• Donor-site scarring: acceptable (POSAS 19/70)^[9]

Omental Flap

The omental pedicle flap is highly effective for transabdominal repairs and for fistulas with cavitation that require dead-space obliteration.^[23][24]

Outcomes: 7 of 8 (87.5%) successful closure in one series.^[24]

Limitations: requires laparotomy or transabdominal access, not available in patients with prior omentectomy or short mesentery, adds operative complexity.

VRAM Flap

The vertical rectus abdominis myocutaneous (VRAM) flap has been used for complex urogenital fistulas including recalcitrant post-radiation RUF / RVF.^[25]

Outcomes (12 patients, mixed urogenital fistulas):^[25]

• 100% fistula eradication
• Mean operative time 5 h 31 min
• Continence preserved in all gracilis patients; VRAM patients showed slight residual incontinence
• Quality of life restored in both groups

Trade-off: gracilis achieves better continence outcomes; VRAM provides greater bulk for large defects.

Perivesical Fat Rotational Flap

A novel alternative described when omentum is unavailable:^[26] a wide-based pedicled flap of perivesical fat overlying the bladder dome is rotated and positioned over the defect in a tension-free manner, then anchored. Described applications include salvage prostatectomy after HIFU, RUF, and colovesical fistula. Small series (3 patients, 1 month to 3 years follow-up) with no complications or recurrence.

Buccal Mucosa Graft

Buccal mucosa graft is used to reconstruct large urethral defects that cannot be primarily closed, particularly after debridement in radiation-induced RUF and RVF with cavitation.^[13][16] The BMG is inlaid on the bladder-side defect and supported by muscle interposition (gracilis) on its ventral surface.

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Outcomes by Etiology

Post-Surgical (Non-Radiated) — Excellent Prognosis

^[1][16][19]

• Fistula closure: 98% with one procedure
• Approach: transperineal in 80%
• GI continuity restored: 94%
• Permanent fecal diversion: 0%; permanent urinary diversion: 19%
• Expectation: return to near-normal function

Post-Radiation — Complex, Uncertain

^{[1][13][16][19]}

• Fistula closure: 86% with one procedure
• Approach: transabdominal in 90.6%
• GI continuity restored: 65%
• Permanent colostomy: 83%
• Permanent urostomy: up to 100%
• 90-day complications: 24% (vs 2% in non-radiated)
• Salvage prostatectomy performed in 8/17 post-radiation patients in the Mundy series, with all fistulas cured^[1]

Benign vs Malignancy-Related^[2]

Outcome	Benign	Malignancy-related
Resolution after initial surgery	44%	21%
Resolution after reoperation	100%	88%
Mean surgeries per patient	1.8	2.1
Permanent diversion avoided	56%	25%

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Complications

Short- and Medium-Term^[16]

Time point	Non-radiated	Radiated
30-day complications	29%	29%
90-day complications	2%	24%

Delayed complications requiring surgery: urethral diverticula, urinary incontinence requiring artificial urinary sphincter, urethral stricture, bowel dysfunction.^[16]

Functional Outcomes

• Urinary: moderate incontinence persists in 61%, largely reflecting underlying disease and prior prostate-cancer treatment rather than RVF repair technique; median LUTS 4/9; a subset (8 patients in the Mundy series) require artificial urinary sphincter.^[1][8][9]
• Bowel: mild fecal incontinence (mean Wexner 3, St Mark's 5/24); continence largely preserved.^[8][9]
• Quality of life: high patient satisfaction (mean 9/10); median Decision Regret Scale 0.^[8][9]

Long-Term Recurrence^[8]

In an open-repair series of 29 patients (median follow-up 50–58 months):

• 5-year recurrence-free survival: 96%
• 5-year re-intervention-free survival: 75%

Predictors of Severe Complications^[27]

Patients with prostatic fistula (fistula tract extending outside the urinary tract into the prostatic bed) compared with localized radiation injury:

• Longer operative time (516 vs 414 min, P=0.017)
• Higher Clavien-Dindo ≥3 complications (44.8% vs 20%, P=0.027)
• Higher re-operation for pelvic abscess (37.9% vs 5%)

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Related Entity — Pubovesical Fistula

A distinct but overlapping entity in post-prostate-cancer-treatment patients: the pubovesical fistula — a communication between the bladder and the pubic bone, often with associated osteitis pubis or pubic osteomyelitis.^[5]

Classic setting: radiation for prostate cancer → bladder-neck contracture → endoscopic incision / dilation → pubovesical fistula.

Key data (Matsushita et al.):^[5]

• All patients had prior radiation therapy and a BNC requiring endoscopic treatment
• Median interval from BNC treatment to pubovesical fistula: 35.9 months (range 0.6–97)
• 10 of 12 patients required cystectomy with urinary diversion
• Presenting feature most suggestive of pubovesical (vs simple RVF): suprapubic or groin pain with imaging evidence of pubic-bone involvement

Prevention: exercise restraint with endoscopic BNC intervention in radiated patients; counsel before any endoscopic manipulation in this population; and consider pubovesical fistula in the differential for any radiated prostate-cancer survivor with BNC and pubic pain.

See also: Urethropubic Fistula — the urethra-side cousin.

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Clinical Recommendations

Diagnostic Workup

1. Establish the diagnosis — cystoscopy + urethroscopy + DRE under anesthesia^[11]
2. Classify by etiology and complexity — post-surgical vs post-radiation; Mundy-Andrich simple vs complex^[1]
3. Confirm the anatomic level — proximal or distal to the bladder neck (RVF vs RUF)^[2][10]
4. Screen for malignancy when the history or imaging suggests it — biopsy as indicated

Initial Management

• Early fecal and urinary diversion — especially for complex or post-radiation cases^[6][11]
• Allow 3–6 months for tissue healing before definitive repair in most cases

Approach Selection

Scenario	Preferred Approach	Interposition
Post-surgical (non-radiated), simple	Transperineal	Gracilis
Post-surgical RVF after RALP (at VUA)	Robotic / laparoscopic transabdominal	Omentum (preferred), gracilis if unavailable
Post-radiation, any complexity	Transabdominal ± perineal; consider salvage prostatectomy	Gracilis + omentum; BMG for urethral defect
Simple fistula in previously operated field	TEM (selected cases)	None (with limitations)
Complex with cavitation or BNC	Transabdominal with concurrent BNC reconstruction	Omentum first-line

Patient Counseling

Post-surgical fistulas: excellent prognosis (98% closure, 94% stoma reversal, return to near-normal function).

Post-radiation fistulas: 86% closure with one procedure, but high likelihood of permanent diversion (colostomy 83%, urostomy up to 100%), moderate urinary incontinence common (61%), mild fecal incontinence expected. Despite this, patient satisfaction is high (9/10) when expectations are set appropriately.

Surveillance

• Clinic visits at 1, 3, and 6 months postoperatively — symptom and physical exam
• Cystoscopy and/or CT urogram at 12 months to confirm durable closure^[15]
• Long-term follow-up recommended — delayed complications (urethral stricture, diverticulum, incontinence) may arise and require additional surgery^[8][16]

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References

1. Mundy AR, Andrich DE. Urorectal Fistulae Following the Treatment of Prostate Cancer. BJU International. 2011;107(8):1298–1303. doi:10.1111/j.1464-410X.2010.09686.x

2. Muñoz M, Nelson H, Harrington J, et al. Management of Acquired Rectourinary Fistulas: Outcome According to Cause. Diseases of the Colon and Rectum. 1998;41(10):1230–1238. doi:10.1007/BF02258219

3. Leong N, Pai HH, Morris WJ, et al. Rectal Ulcers and Rectoprostatic Fistulas After 125-I Low-Dose-Rate Prostate Brachytherapy. Journal of Urology. 2016;195(6):1811–1816. doi:10.1016/j.juro.2015.12.095

4. Sadighian M, Hakam N, Amend G, et al. Radiation-Induced Fistulas in Patients With Prior Pelvic Radiotherapy for Prostate Cancer: A Systematic Review and Meta-Analysis. Urology. 2023;176:121–126. doi:10.1016/j.urology.2023.03.015

5. Matsushita K, Ginsburg L, Mian BM, et al. Pubovesical Fistula: A Rare Complication After Treatment of Prostate Cancer. Urology. 2012;80(2):446–451. doi:10.1016/j.urology.2012.04.036

6. Kucera WB, Jezior JR, Duncan JE. Management of Post-Traumatic Rectovesical / Rectourethral Fistulas: Case Series of Complicated Injuries in Wounded Warriors and Review of the Literature. Military Medicine. 2017;182(3):e1835–e1839. doi:10.7205/MILMED-D-16-00148

7. Kanehira E, Tanida T, Kamei A, et al. Transanal Endoscopic Microsurgery for Surgical Repair of Rectovesical Fistula Following Radical Prostatectomy. Surgical Endoscopy. 2015;29(4):851–855. doi:10.1007/s00464-014-3737-x

8. Wagner MC, Klemm J, Roessler N, et al. Long-Term Patient-Reported Outcomes of Open Urorectal Fistula Repair After Prostate Cancer Treatment. BJU International. 2026. doi:10.1111/bju.70233

9. 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. European Urology. 2022;81(3):305–312. doi:10.1016/j.eururo.2021.09.017

10. Sotelo R, Garcia A, Yaime H, et al. Laparoscopic Rectovesical Fistula Repair. Journal of Endourology. 2005;19(6):603–607. doi:10.1089/end.2005.19.603

11. al-Ali M, Kashmoula D, Saoud IJ. Experience With 30 Posttraumatic Rectourethral Fistulas: Presentation of Posterior Transsphincteric Anterior Rectal Wall Advancement. Journal of Urology. 1997;158(2):421–424. doi:10.1016/s0022-5347(01)64493-8

12. 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

13. Lane BR, Stein DE, Remzi FH, et al. Management of Radiotherapy-Induced Rectourethral Fistula. Journal of Urology. 2006;175(4):1382–1387. doi:10.1016/S0022-5347(05)00687-7

14. Venkatesan K, Zacharakis E, Andrich DE, Mundy AR. Conservative Management of Urorectal Fistulae. Urology. 2013;81(6):1352–1356. doi:10.1016/j.urology.2012.10.040

15. Medina LG, Riva A, Perez LC, et al. Minimally Invasive Management of Post-Treatment Rectovesical Fistulae. Journal of Endourology. 2023;37(2):185–190. doi:10.1089/end.2022.0266

16. 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

17. Lo Re M, Pezzoli M, Garcia Rojo E, et al. A Systematic Review on the Surgical Management of Acquired Rectourethral Fistula. International Journal of Impotence Research. 2026;38(3):214–225. doi:10.1038/s41443-025-01100-y

18. 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. Annals of Surgery. 2008;248(1):39–43. doi:10.1097/SLA.0b013e31817d077d

19. Beddy D, Poskus T, Umbreit E, et al. Impact of Radiotherapy on Surgical Repair and Outcome in Patients With Rectourethral Fistula. Colorectal Disease. 2013;15(12):1515–1520. doi:10.1111/codi.12350

20. Falavolti C, Sergi F, Shehu E, Buscarini M. York Mason Procedure to Repair Iatrogenic Rectourinary Fistula: Our Experience. World Journal of Surgery. 2013;37(12):2950–2955. doi:10.1007/s00268-013-2199-y

21. Gözen AS, Malkoc E, Al-Sudani I, Rassweiler J. Laparoscopic Urorectal Fistula Repair: Value of the Salvage Prostatectomy and Review of Current Approaches. Journal of Endourology. 2012;26(9):1171–1176. doi:10.1089/end.2012.0024

22. Oner M, Tsay AT, Abbas MA. The Use of the Gracilis Flap in Colorectal Surgery: Surgical Technique, Results, and Review of the Literature. International Journal of Colorectal Disease. 2025;40(1):133. doi:10.1007/s00384-025-04928-4

23. O'Leary DP. Use of the Greater Omentum in Colorectal Surgery. Diseases of the Colon and Rectum. 1999;42(4):533–539. doi:10.1007/BF02234183

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