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Transabdominal Repair for Rectourethral and Rectovesical Fistula

The transabdominal approach to rectourethral fistula (RUF) and rectovesical fistula (RVF) repair accounts for ~12.5% of all RUF repairs[1] and is primarily reserved for complex, radiation / ablation-induced fistulas, high fistulas inaccessible perineally, cases requiring concurrent extirpative surgery (salvage prostatectomy, cystectomy, proctectomy), or failed prior perineal repairs. It can be performed via open, laparoscopic, or robotic-assisted technique — the robotic platform is increasingly favored for enhanced visualization and precision in the deep pelvis.[2][3] The operation applied to RUF (with urethral closure / vesicourethral anastomosis) and to RVF (with cystotomy closure) is essentially the same procedure; this page covers both.

For first-line perineal options see Transperineal Approach to RUF; for the simpler sphincter-preserving option see ERAF for RUF; for the posterior approach see York-Mason Repair; for the salvage proctectomy + delayed coloanal anastomosis option in radiation-damaged rectum see Turnbull-Cutait Pull-Through; for incisionless alternatives see Transanal Minimally Invasive Repair.

Indications​

Indicated when perineal approaches are insufficient or inappropriate:[4][5][6]

  • Post-radiation / ablation fistulas with cavitation — Mundy & Andrich identified a specific category, particularly common after salvage HIFU following EBRT + brachytherapy, requiring abdominoperineal repair with interposition flap; 14 of 17 post-irradiation patients required transabdominal or abdominoperineal repair.[4]
  • Fistulas requiring salvage prostatectomy — when a discrete prostate still exists (post-radiation, post-cryotherapy, post-HIFU), the diseased prostate is the fistula source and must be removed; best accomplished transabdominally.[3][7]
  • High fistulas (> 4 cm from anal verge) not reachable perineally.[8]
  • Concurrent need for cystectomy or proctectomy — devastated pelvic anatomy requiring extirpative surgery.[6]
  • Failed prior perineal or transsphincteric repairs.[9]
  • Positive oncologic margins or non-functioning bladder — Keller 2015: 7% required abdominal approach for these reasons.[10]
  • Need for omental flap interposition when gracilis or other perineal flaps are unavailable / have failed.[11]

Classification Systems Guiding Approach Selection​

Rivera staging (2007)[8]​

StageDescriptionRecommended approach
ILow (< 4 cm from anal verge), non-irradiatedTransperineal or transsphincteric
IIHigh (> 4 cm from anal verge), non-irradiatedTransperineal with gracilis or transabdominal
IIISmall (< 2 cm), irradiatedTransperineal with gracilis + colostomy
IVLarge (> 2 cm), irradiatedTransabdominal or abdominoperineal + gracilis
VLarge, ischial decubitusSpecialized perineal approach

Mundy-Andrich complexity (2011)[4]​

  • Simple URF — post-surgical without cavitation or bladder-neck contracture (BNC) → transperineal
  • Complex URF — post-irradiation, cavitation, BNC, or extensive ischemia from serial energy sources → transabdominal or abdominoperineal with interposition flap and possible salvage prostatectomy

Martini staging — meta-analysis validation​

Mishra 2021 meta-analysis (n = 490) — Grade I (radiation / ablation) fistulas vs Grade 0 (non-radiated): permanent bowel diversion 11.1×, fistula recurrence 9.1×, postoperative urinary incontinence 2.6×.[12]

Surgical Technique — Open Transabdominal​

Position: supine with modified lithotomy (Lloyd-Davies) to allow simultaneous perineal access.

Step 1 — Abdominal access and exploration​

  • Midline laparotomy or transperitoneal laparoscopic / robotic port placement (5-port configuration is standard for MIS).[9][13]
  • Adhesiolysis and mobilization of the sigmoid colon and splenic flexure as needed.

Step 2 — Omental flap mobilization​

The omentum is mobilized early — pedicled flap on the left or right gastroepiploic artery. The defining advantage of the transabdominal approach: the omentum provides a large, well-vascularized interposition not available through perineal approaches.[11][13]

Alternatives when omentum is insufficient (prior omentectomy, adhesions):

  • Perivesical fat rotational flap — Hwang 2023 novel technique using a wide-based pedicle of perivesical fat overlying the bladder dome, rotated to cover the anterior rectal wall; successful in RUF, VVF, and colovesical fistula repair at up to 3 yr follow-up[14]
  • Peritoneal flap — Gözen 2012 (lap URF when omentum unavailable)[7]
  • Tunica vaginalis flap — harvested from the scrotum and tunneled to the pelvis[7]

Step 3 — Cystotomy and fistula identification​

  • Posterior cystotomy extending toward the fistula tract — direct visualization of the vesicourethral anastomosis (post-RP) or the bladder neck / prostatic urethra (intact prostate).[9][13]
  • A ureteral catheter placed cystoscopically preoperatively through the tract guides dissection.[13]

Step 4 — Dissection of the rectovesical / rectourethral plane​

  • Develop the rectovesical space; separate posterior bladder / urethra from the anterior rectal wall.
  • In post-radiation cases this plane is often obliterated by fibrosis — the most technically demanding portion of the operation.[4]
  • Excise the tract; debride all fibrotic / necrotic tissue.

Step 5 — Salvage prostatectomy (when indicated)​

In patients with an intact prostate (post-radiation, post-cryo, post-HIFU), the diseased prostate is the epicenter of the fistula. Salvage prostatectomy removes the diseased tissue and facilitates separation of urinary and rectal systems.[3][4][7]

  • Mundy & Andrich — salvage prostatectomy in 8 of 17 post-irradiation patients with a discrete remaining prostate; 100% fistula closure.[4]
  • Medina 2018 — robotic salvage prostatectomy + RUF repair in 2 post-focal-therapy patients (cryotherapy and salvage HIFU) with omental flap; successful closure in both.[3]
  • Gözen 2012 — laparoscopic salvage prostatectomy in 2 of 4 complex URF patients; "valuable operative option" requiring advanced laparoscopic experience.[7]

Step 6 — Urinary tract reconstruction​

Strategy depends on the status of the distal urethra:[3]

Urethral / bladder statusReconstruction
Healthy urethra presentVesicourethral reanastomosis (primary or with BMG augmentation)
Urethra destroyedBladder-neck closure + permanent suprapubic catheter or continent catheterizable channel
Bladder non-functionalCystectomy with ileal conduit or continent diversion
Concurrent VUAS (Sayegh 2023)Excise stricture; new VUA ± perineal urethral mobilization for tension-free anastomosis
Rectovesical fistula (intact bladder, no urethral involvement)Direct 2-layer cystotomy closure

Step 7 — Rectal closure​

Two-layer closure with interrupted absorbable suture; offset from the urinary suture line.[9][13]

Step 8 — Omental interposition​

Mobilized omental pedicle is brought into the pelvis and interposed between the rectal and urinary suture lines; secured with absorbable suture.[9][13]

Step 9 — Closure​

  • Close cystotomy in two layers
  • Closed-suction pelvic drain
  • Diverting colostomy if not already present (96% in Medina RVF series)[2]

Minimally Invasive Variants​

Robotic-assisted repair​

The robotic platform offers enhanced 3D visualization, wristed instrumentation, and tremor filtration in the deep pelvis.

Medina 2023 — largest MIS series (n = 24 RVF, single surgeon, 3 institutions):[2]

  • 79% robotic / 21% laparoscopic
  • 83% post-surgical / 12.5% post-surgery + radiation / 4.1% post-energy treatment
  • 96% had prior fecal diversion
  • Median OR 180 min (IQR 140–282); median EBL 50 mL (IQR 40–125); median LOS 2 d (IQR 2–3)
  • No intraoperative complications
  • 100% fistula closure at 12-mo follow-up
  • 2 Grade II and 1 Grade IIIb postoperative complications

Sayegh 2023 — robotic RVF + concurrent VUAS (n = 4 post-RP):[15]

  • Median OR 370 min; median EBL 255 mL; LOS 2.5 d
  • Foley removal median 30 d; DJ stent removal median 38 d
  • 100% closure at median 16.25 mo, no postoperative complications
  • All used omental interposition

Medina 2018 — robotic RUF + salvage prostatectomy (n = 2 post-focal-therapy):[3]

  • Both received salvage prostatectomy + rectal closure + omental flap
  • One had vesicourethral reanastomosis; the other had bladder-neck closure due to extensive urethral destruction
  • Both achieved successful closure

Laparoscopic repair​

Sotelo 2005 — first published laparoscopic RVF repair: 5-port transperitoneal, cystotomy, fistula excision, rectal closure, omental interposition, colostomy creation. OR 240 min; LOS 3 d; fistula closed at follow-up.[13]

RVF-Specific Considerations​

Rectovesical fistula differs from RUF in that the communication is with the bladder rather than the urethra:[16][17]

  • Higher anatomic location — typically higher in the pelvis; less accessible perineally, more amenable to transabdominal repair
  • Etiology — most commonly post-radical prostatectomy (rectal injury at the base of the bladder / vesicourethral anastomosis); also post-radiation, post-TURP, post-rectal surgery
  • Presentation — similar to RUF: urine per rectum (60.7%), fecaluria (44.1%), pneumaturia (50%), recurrent UTI[18]
  • Approach selection — transabdominal is more commonly used than for RUF because of higher anatomic location. York-Mason has also been used: Renschler & Middleton 22/24 successful repairs over 30 yr including 11 bladder fistulas[16]
  • TEM for RVF — Kanehira reported 7/10 (70%) closure after RP; the 3 failures were associated with wide, tough scar from prior irradiation, HIFU, or repeated surgical attempts[19]

Outcomes Summary​

SeriesnFistula typePlatformFistula closureOR timeLOSFollow-up
Medina 202324RVFRobotic 79% / Lap 21%100%180 min2 d12 mo[2]
Sayegh 20234RVF + VUASRobotic100%370 min2.5 d16.25 mo[15]
Mundy & Andrich 201114URF (post-RT)Open abdominoperineal100%NRNR> 12 mo[4]
Medina 20182RUF (post-focal Tx)Robotic100%NRNR4–9 mo[3]
Gözen 20124URF (mixed)Laparoscopic75% (3/4)NR12–34 dNR[7]
Sotelo 20081RVF (post-RP)Robotic100%180 min1 d1 mo[9]
Sotelo 20051RVF (post-RP)Laparoscopic100%240 min3 d1 mo[13]
Oderda 20141RVF (post-RP)Robotic100%70 min3 dNR[20]
Trippitelli 19858RUF (mixed)Open abdominoperineal100%NRNRNR[11]
Martins 202110 (G1)RUF (post-RT / ablation)Abdominoperineal50%NRNR54 mo[6]

Transabdominal vs Transperineal Approach​

FeatureTransabdominalTransperineal
Frequency of use~12.5%~66%[1]
Primary indicationComplex / radiated, high fistulas, need for extirpative surgeryMost RUF, including many radiated[1][2]
Tissue interpositionOmentum (primary); peritoneal flap; perivesical fatGracilis (primary); dartos; BSM
Concurrent proceduresSalvage prostatectomy, cystectomy, proctectomyUrethroplasty (anastomotic or BMG)
Fistula closure75–100%84–100%
OR time70–370 min (robotic)Variable
LOS1–3 d (robotic) / longer (open)Variable
Key advantageAccess to omentum; can address high fistulas + extirpative surgerySphincter-sparing; familiar to urologists; gracilis interposition
Key disadvantageMajor abdominal surgery; higher morbidity (open); requires advanced MIS skillsCannot reach very high fistulas; no access to omentum

Salvage Prostatectomy as Part of Transabdominal Repair​

Mundy & Andrich rationale: in post-irradiation patients with an intact prostate, the prostate is the diseased tissue harboring the fistula, and its removal is often necessary for definitive closure.[4]

  • Performed in patients with a discrete prostate still present (post-radiation, post-cryo, post-HIFU — not post-RP)
  • Can be performed open, laparoscopically, or robotically[3][7]
  • Allows complete excision of the tract and all necrotic / irradiated prostatic tissue
  • Urinary reconstruction after prostatectomy depends on distal-urethral status (VUA if healthy urethra; bladder-neck closure if destroyed)[3]
  • Martins 2021 — radiation / energy-ablation group: abdominoperineal approach with flap interposition 60% vs 7.7% (P = 0.019); permanent dual diversion 50% vs 0% (P < 0.001)[6]

Emerging: Mesenchymal Stem Cells​

Eberspacher 2025 — case report of iatrogenic RVF after RP successfully treated with transanal infiltration of autologous MSCs around the rectal orifice of the fistula, avoiding major surgery.[21] ASCRS gives a weak recommendation (2B) for MSC use in refractory Crohn's-associated fistulas based on phase III trial data showing 50–83% efficacy[22]; application to post-prostatectomy RVF remains limited to case reports. Tripathi 2024 umbrella review of 19 SRs: stem cell therapy improved clinical remission (RR 1.299) and short-term (RR 1.481) and long-term (RR 1.422) fistula closure with no significant increase in adverse events.[23]

Algorithm — Where the Transabdominal Approach Fits​

  1. Simple, non-radiated RUF / RVF → transperineal (or York-Mason) → 98–100% success
  2. Radiated / ablation-induced RUF → transperineal + gracilis + BMG → 84–86% success
  3. Complex radiated RUF with cavitation, intact prostate, or high fistula → transabdominal (robotic preferred) + salvage prostatectomy + omental interposition → 75–100% success
  4. Failed prior repairs or concurrent VUAS → transabdominal repair with omental interposition ± vesicourethral reanastomosis
  5. Severe radiation proctitis with diseased rectum → Turnbull-Cutait pull-through ± BMG urethroplasty
  6. Devastated pelvis → permanent dual diversion ± extirpative surgery (cystectomy, proctectomy)

Decision should be made in a multidisciplinary setting involving reconstructive urology and colorectal surgery; approach tailored to fistula complexity, radiation history, urethral / bladder status, and patient goals.[5][24]

Key Takeaways​

  • ~ 12.5% of all RUF repairs; the only approach that allows simultaneous salvage prostatectomy, VUAS revision, cystectomy / proctectomy, and omental interposition in one operation.
  • Robotic platform is increasingly preferred — Medina 2023 RVF series: 100% closure at 12 mo with LOS 2 d.
  • Salvage prostatectomy is the critical maneuver for post-radiation / post-energy-ablation fistulas with an intact prostate.
  • Higher morbidity than perineal approaches (~ 60% in Medina, mostly low-grade); long OR times (180–370 min for robotic).
  • Reserve for complex, radiated, recurrent, high, or extirpation-required cases — not appropriate for simple non-radiated RUF.

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. Medina LG, Riva A, Perez LC, et al. "Minimally invasive management of post-treatment rectovesical fistulae." J Endourol. 2023;37(2):185–190. doi:10.1089/end.2022.0266

3. Medina LG, Cacciamani GE, Hernandez A, et al. "Robotic management of rectourethral fistulas after focal treatment for prostate cancer." Urology. 2018;118:241. doi:10.1016/j.urology.2018.05.012

4. Mundy AR, Andrich DE. "Urorectal fistulae following the treatment of prostate cancer." BJU Int. 2011;107(8):1298–1303. doi:10.1111/j.1464-410X.2010.09686.x

5. Campbell JG, Vanni AJ. "Complex lower genitourinary fistula repair: rectourethral fistula and puboprostatic fistula." Urol Clin North Am. 2022;49(3):553–565. doi:10.1016/j.ucl.2022.04.012

6. 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

7. Gözen AS, Malkoc E, Al-Sudani I, Rassweiler J. "Laparoscopic urorectal fistula repair: value of the salvage prostatectomy and review of current approaches." J Endourol. 2012;26(9):1171–1176. doi:10.1089/end.2012.0024

8. Rivera R, Barboglio PG, Hellinger M, Gousse AE. "Staging rectourinary fistulas to guide surgical treatment." J Urol. 2007;177(2):586–588. doi:10.1016/j.juro.2006.09.058

9. 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

10. 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

11. Trippitelli A, Barbagli G, Lenzi R, Fiorelli C, Masini GC. "Surgical treatment of rectourethral fistulae." Eur Urol. 1985;11(6):388–391. doi:10.1159/000472547

12. Mishra K, Mahran A, Abboud B, et al. "Validating the Martini staging system for rectourethral fistula: a meta-analysis of postoperative outcomes." Urology. 2021;147:299–305. doi:10.1016/j.urology.2020.08.047

13. Sotelo R, Garcia A, Yaime H, et al. "Laparoscopic rectovesical fistula repair." J Endourol. 2005;19(6):603–607. doi:10.1089/end.2005.19.603

14. Hwang A, Watson M, Talluri S, Okafor H, Singh A. "A novel perivesical fat rotational flap as an alternative to omental interposition in challenging urological reconstruction." Urology. 2023;182:e262–e263. doi:10.1016/j.urology.2023.08.023

15. 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

16. 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

17. Muñoz M, Nelson H, Harrington J, et al. "Management of acquired rectourinary fistulas: outcome according to cause." Dis Colon Rectum. 1998;41(10):1230–1238. doi:10.1007/BF02258219

18. 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

19. Kanehira E, Tanida T, Kamei A, et al. "Transanal endoscopic microsurgery for surgical repair of rectovesical fistula following radical prostatectomy." Surg Endosc. 2015;29(4):851–855. doi:10.1007/s00464-014-3737-x

20. Oderda M, Bonet X, Campobasso D, Gaston R. "Robotic rectovesical fistula repair: a successful approach." J Laparoendosc Adv Surg Tech A. 2014;24(8):567–570. doi:10.1089/lap.2014.0002

21. Eberspacher C, Lauro A, Salomone B, et al. "Curbing communication — transanal infiltration of autologous mesenchymal stem cells facilitating rectovesical fistula repair after radical prostatectomy." Dig Dis Sci. 2025. doi:10.1007/s10620-025-09145-1

22. Gaertner WB, Burgess PL, Davids JS, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula." Dis Colon Rectum. 2022;65(8):964–985. doi:10.1097/DCR.0000000000002473

23. Tripathi T, Mohan S, Alfaifi HA, et al. "Efficacy and safety of stem cell therapy for fistula management: an overview of existing systematic reviews." Int J Surg. 2024;110(12):7573–7584. doi:10.1097/JS9.0000000000002125

24. 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