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Transperineal Approach to Rectourethral Fistula

The transperineal approach is the most commonly used and best-studied technique for rectourethral fistula (RUF) repair — used in approximately 66% of all surgical repairs and preferred by virtually all high-volume referral centers.[1][2] A systematic review of 416 patients found an initial closure rate approaching 90%, and it is the standard against which all other techniques are compared.[1] The dominant variant is transperineal repair with gracilis muscle flap interposition; the page also covers concurrent posterior urethroplasty (anastomotic or BMG onlay), alternative interposition flaps (dartos, BSM, puborectalis), and operative variants for pelvic-fracture RUF and irradiated tissue.

For alternative approaches see York-Mason Repair, ERAF for RUF, Transanal MIS Repair, Transabdominal RUF / RVF Repair, and Conservative Management of RUF. For the gracilis flap atlas see Gracilis.

Indications​

Broadly applicable across nearly all RUF etiologies:

  • Post-radical prostatectomy — most common cause; 0.01–1.5% after RP; preferred for both simple and complex post-RP fistulas[2][3]
  • Radiation / ablation-induced (cryotherapy, HIFU, brachytherapy, EBRT) — most challenging subset; transperineal remains the standard despite lower success (84–86%) vs non-radiated (98–100%)[4][5]
  • Pelvic fracture urethral injury (PFUI) — allows simultaneous urethroplasty and fistula repair in one operation[6]
  • Recurrent / failed prior repairs — transperineal + tissue interposition is the preferred salvage; Serra-Aracil 2018: 6/6 patients failing TEO/TEM were successfully salvaged with transperineal gracilis[7]
  • Concurrent posterior urethral stenosis or BNC — present in 14–28% of RUF; the transperineal approach uniquely allows concurrent urethroplasty in a single operation[2][3][6]

Relative contraindications: devastated pelvic anatomy with non-functional urinary and fecal systems (where permanent diversion may be more appropriate), active uncontrolled pelvic sepsis, and very high fistulas that cannot be reached perineally (which may require a transabdominal or combined approach).[1][8]

Preoperative Preparation​

  1. Fecal diversion — 60–100% of patients depending on series. Defer definitive repair ≥ 12 weeks after bowel diversion (Gupta).[9] Keller 2015: selective diversion in 67%; 27% achieved spontaneous healing without diversion, additional 20% after diversion alone. Fecaluria mandates colostomy.[10][11]
  2. Urinary diversion — suprapubic catheter in 47–87% across series, typically 3–6 months preoperatively, to divert urine and allow urethral pathology to declare fully.[6][10]
  3. Preoperative imaging and endoscopy — VCUG, RUG, cystoscopy, EUA to characterize fistula size, location, and any concurrent urethral stenosis.[3][9]
  4. Nutritional optimization and infection control — particularly in irradiated patients.
  5. Biopsy — rule out cancer recurrence at the fistula site (post-RP, post-XRT, post-ablation).[3]

Surgical Technique — Step-by-Step​

Position​

Exaggerated dorsal lithotomy (most common) or prone jackknife. Lithotomy provides simultaneous access to the perineum and the medial thigh for gracilis harvest.[9][12]

1. Incision and exposure​

  • Midline vertical perineal incision from the base of the scrotum to ~2 cm anterior to the anal verge; some use an inverted-Y or lambda incision for wider exposure[13][14]
  • Divide the bulbospongiosus in the midline; identify the bulbar urethra

2. Dissection of the rectourethral space​

  • Proceed through the central tendon of the perineum into the plane between posterior urethra / prostate bed and anterior rectal wall
  • Continue through Denonvilliers' fascia until the tract is identified and circumferentially mobilized[14]
  • Dissect 1–2 cm above the fistula to ensure adequate mobilization for tension-free closure[12]
  • Post-RP: vesicourethral anastomosis is identified; post-XRT / post-ablation: prostate remnant or cavity is encountered

3. Fistula excision​

  • Completely excise the tract; debride fibrotic / devitalized / irradiated tissue back to healthy, well-vascularized margins[4][13]
  • Separate the urethral and rectal openings into distinct defects

4. Rectal closure​

  • Two-layer closure (mucosa + muscularis) with interrupted 3-0 or 4-0 polyglactin
  • Transverse / horizontal orientation to minimize luminal narrowing[13][14]

5. Urethral closure / concurrent urethroplasty​

Concurrent urethral pathology is present in 14–28% of RUF (26% in energy-ablation, 14% in post-RP; 28% in radiated and 11% in non-radiated per Vanni). The transperineal approach uniquely allows simultaneous repair.[2][3][6]

Urethral statusReconstruction
Small defect, no stenosisPrimary re-approximation over catheter (interrupted absorbable, longitudinal orientation)[15]
Concurrent posterior urethral stenosisAnastomotic urethroplasty — excise the stenotic segment, spatulated reanastomosis (78% of Khouri concurrent cases)[6]
Long defect or poor tissue qualityBMG onlay (22% of Khouri concurrent cases); favored in radiated patients[4][6]
Pelvic-fracture RUF with proximal disruptionProximal urethral transection (Wang 2024) — transect the proximal stump to directly expose the fistula orifice, allowing precise excision and reanastomosis in one step[5]
Major prostatic destructionPartial or total prostatectomy with urethrovesical reanastomosis[15]
Long stricture / failed prior repairInferior pubectomy ± combined transpubic-perineal approach for defects > 4 cm[24][12]

Khouri 2024 concurrent urethroplasty series (n = 23, 65% radiated): 87% fistula closure, 0% isolated stricture recurrence at 55.7 mo.[6]

6. Tissue interposition — the critical step​

The vascularized flap between urethral and rectal suture lines is the most important determinant of recurrence:

  • Park 2022 — recurrence 8% with gracilis vs 50% without (P = 0.009); radiation history (P = 0.04) and urinary incontinence (P = 0.015) were independent risk factors for recurrence in the no-flap group.[16]
  • Voelzke 2013 — omitting interposition in energy-ablative RUF reduced success from 100% (with flap) to 63% (without).[15]
  • Garoufalia 2023 meta-analysis (n = 658 gracilis interposition for complex perineal fistulas): weighted success 79.4% (95% CI 73.8–85%); recurrence 16.7%; short-term complication rate 25.7%.[20]
  • Non-radiated post-RP — some series achieve 100% without interposition, suggesting selective omission is reasonable in this favorable subgroup.[11][15]

Interposition flap options​

Gracilis muscle flap (workhorse; ~ 72% of all repairs)[1]​

  1. Separate longitudinal incision over the ipsilateral medial thigh
  2. Dissect the muscle from its fascia, preserving the dominant vascular pedicle (medial circumflex femoral artery, entering ~ 10 cm below the pubic tubercle)
  3. Divide the distal tendinous insertion
  4. Tunnel the pedicled muscle subcutaneously to the perineum
  5. Place between the urethral and rectal closures to fully cover both suture lines[13][17]

Dartos flap​

  • Mobilized from scrotal / perineal tissue; avoids a separate thigh incision
  • Voelzke 2/10 postoperative RUF repairs with 100% success[15]
  • Dafnis 2024 — modified York-Mason + dartos: 100% in 5 patients at 70 mo[11]

Bulbospongiosus muscle (BSM) flap​

  • Avoids thigh morbidity
  • Hou 2025 (n = 36, 19 USURF): 94.4% success; no difference in IIEF-5 vs non-interposition controls (3.0 vs 6.5, P = 0.183 — both poor)[26]

Puborectalis muscle flap​

  • Solomon 2014 — double-breasted rotational interposition: 100% in 4 patients[14]

7. Closure​

  • Closed-suction drain in the perineal wound
  • Layered perineal closure
  • 18–20 Fr urethral catheter

Postoperative Management​

  • Urethral catheter maintained for 3–6 weeks[17][18]
  • Cystography at 3–6 weeks to confirm closure before catheter removal[13]
  • Stoma reversal at 3–6 mo after confirmed closure — Kaufman: GI continuity restored in 94% non-radiated vs 65% radiated[5]
  • Long-term surveillance for delayed complications (urethral diverticulum, stricture, incontinence)[5]

Outcomes by Etiology​

SeriesnEtiologyFistula closurePermanent fecal diversionFollow-up
Kaufman 201649 / 49Non-radiated / Radiated98% / 86%6% / 35%14.5 mo[5]
Vanni 201035 / 39Non-radiated / Radiated100% / 84%3% / 31%20 mo[4]
Muñoz-Duyos 20179Post-RP non-radiated100%11%54 mo[17]
Sbizzera 202221Post-prostate-cancer Tx95%17%27 mo[13]
Wagner 202629Post-RP96% at 5 yrNR50 mo[18]
Voelzke 201310 / 13Postop / Energy ablation100% / 62%NRNR[15]
Wexner 200836Mixed78% initial / 97% overallNRNR
Garoufalia 2023 meta-analysis658Gracilis interposition all-comers79.4% (weighted)NRNR[20]

Concurrent Urethroplasty Outcomes​

SeriesnEtiologyApproachUrethroplastyFistula successStricture recurrenceFollow-up
Khouri 202423Mixed (65% radiated)PerinealAnastomotic 78% / BMG 22%87%0%55.7 mo[6]
Guo 201732Pelvic fracturePerinealAnastomotic91%6%33 mo[25]
Wang 202440Pelvic fracturePerineal (proximal transection)Anastomotic90%NR45 mo[5]
Hou 202536 (19 USURF)TraumaticPerineal + BSMAnastomotic94.4%NR31 mo[26]
Xu 201031TraumaticPerineal ± pubectomy ± abdominalAnastomotic87%6.5%NR[24]

Functional Outcomes​

  • Urinary incontinence — the dominant long-term sequela: 37–80% of patients. Sbizzera 61% significant incontinence; Hampson 80% with some leakage (mostly mild). 30–73% of incontinent patients ultimately undergo AUS placement (Khouri 30%, Sbizzera).[6][10][13][23]
  • Fecal continence — generally preserved with the sphincter-sparing transperineal approach; Sbizzera mean St. Mark's 5/24; Wagner median Wexner 3.[13][18]
  • Erectile dysfunction — high rates, largely attributable to prior prostate cancer treatment rather than the fistula repair. Wang 2024 PFUI: 75% postoperative ED, median IIEF-5 9.[5]
  • Perineal pain at long-term follow-up: 53% of patients; gracilis-flap-related complaints (thigh numbness, weakness) in 43%.[23]
  • Patient satisfaction — Sbizzera 9/10; Wagner median Decision Regret Scale 0/100; 80% (Hampson) report surgery positively impacted their life; none would have opted for complete urinary diversion.[13][18][23]

Radiation-Induced RUF — Special Considerations​

The most challenging subset:

  • Lower success — 84–86% single-stage closure vs 98–100% non-radiated[4][5]
  • Higher complications — 90-d complication rate 24% (radiated) vs 2% (non-radiated)[5]
  • Higher permanent diversion — 31–35% permanent fecal; up to 93% permanent urinary in the Mayo Linder series[4][8]
  • Longer time to healing — significantly longer time to ostomy reversal[24]
  • Mayo (Linder) vs Lahey (Vanni / Kaufman) discordance — Mayo reported 86% permanent colostomy / 93% permanent urinary diversion in radiated cases, recommending early consideration of permanent diversion. Lahey closed 84–86% with single-stage transperineal repair. Likely reflects differences in patient selection, tissue quality, and surgical technique.[4][5][8]

Comparison with Other Approaches​

ApproachFrequencyKey advantageKey limitationBest indication
Transperineal66%Sphincter-sparing; allows concurrent urethroplasty; accommodates tissue interpositionCannot reach very high fistulas; separate thigh incision for gracilisComplex, radiated, recurrent RUF; concurrent urethral pathology[1][4]
Transsphincteric (York-Mason)16%Excellent direct visualization; layer-by-layer closure; short ORSphincter division (theoretical FI risk); limited interpositionSimple, non-radiated, post-RP RUF as first-line[21][22]
Transanal (TEO / TEM / MITAR)6%Minimally invasive; no external incisionLow success (25% in one series); poor for radiated tissueSmall, low, non-radiated fistulas[7]
Transabdominal (open / robotic)13%Access to high fistulas; omental flap; salvage prostatectomy possibleMajor abdominal surgery; higher morbidityHigh fistulas; concurrent cystectomy or proctectomy[1]

The York-Mason has reported 100% success in non-radiated post-RARP patients (van der Graaf 2025, n = 8, median 5.1 yr) and Dal Moro 2011 (100% in 14 over 20 yr). The transperineal advantage over York-Mason is the ability to perform tissue interposition and concurrent urethroplasty — critical in complex, radiated, or recurrent cases.[21][22]

Algorithm​

  1. Diagnosis confirmed → biopsy to rule out cancer recurrence → urinary diversion (SPC) ± fecal diversion
  2. Conservative trial (catheter ± colostomy) × 3–6 mo — spontaneous closure in 33–47% of post-RP without radiation (Thomas, Keller)[10][11]
  3. Persistent → definitive transperineal repair with tissue interposition
  4. Non-radiated, simple — transperineal ± gracilis (York-Mason alternative first-line)
  5. Radiated / ablation / recurrent — transperineal with mandatory gracilis and selective BMG urethroplasty
  6. Devastated pelvis with non-functional systems — permanent urinary + fecal diversion

Key Takeaways​

  • The transperineal approach is the dominant technique (~ 66% of all RUF repairs) and the only approach that allows simultaneous concurrent urethroplasty, tissue interposition, and management of complex radiation-induced fistulas in one operation.
  • Tissue interposition (gracilis preferred) is the single most important determinant of success — Park 2022 reduced recurrence 50% → 8%.
  • Concurrent urethroplasty (anastomotic 78% / BMG 22%) achieves 87% fistula closure and 0% isolated stricture recurrence at nearly 5 years (Khouri 2024).
  • Radiation is the dominant negative prognostic factor — Mayo / Lahey discordance reflects selection / technique variability; counsel re: up to 93% permanent urinary diversion in the most severe series.
  • Functional morbidity is substantial — 37–80% urinary incontinence, 30–73% of those will need AUS — but patient satisfaction remains high (9/10) and 80% report positive life impact; none would opt for complete urinary diversion.

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. 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

3. 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

4. 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

5. 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

6. Khouri RK, Accioly JPE, DeWitt-Foy ME, Wood HM, Angermeier KW. "Posterior urethral reconstruction at the time of rectourethral fistula repair: technique and outcomes." Urology. 2024;186:36–40. doi:10.1016/j.urology.2024.02.026

7. 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

8. Linder BJ, Umbreit EC, Larson D, et al. "Effect of prior radiotherapy and ablative therapy on surgical outcomes for the treatment of rectourethral fistulas." J Urol. 2013;190(4):1287–1291. doi:10.1016/j.juro.2013.03.077

9. Gupta G, Kumar S, Kekre NS, Gopalakrishnan G. "Surgical management of rectourethral fistula." Urology. 2008;71(2):267–271. doi:10.1016/j.urology.2007.10.042

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. 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

12. 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

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. Solomon MJ, Tan KK, Bromilow RG, Wong JC. "Bilateral puborectalis interposition repair of rectourethral fistula." Dis Colon Rectum. 2014;57(1):133–139. doi:10.1097/01.dcr.0000437789.54759.c9

15. Voelzke BB, McAninch JW, Breyer BN, Glass AS, Garcia-Aguilar J. "Transperineal management for postoperative and radiation rectourethral fistulas." J Urol. 2013;189(3):966–971. doi:10.1016/j.juro.2012.08.238

16. Park KM, Rosli YY, Simms A, et al. "Preventing rectourethral fistula recurrence with gracilis flap." Ann Plast Surg. 2022;88(4 Suppl 4):S316–S319. doi:10.1097/SAP.0000000000003085

17. 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

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

20. Garoufalia Z, Gefen R, Emile SH, et al. "Gracilis muscle interposition for complex perineal fistulas: a systematic review and meta-analysis of the literature." Colorectal Dis. 2023;25(4):549–561. doi:10.1111/codi.16427

21. 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

22. 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

23. Hampson LA, Muncey W, Sinanan MN, Voelzke BB. "Outcomes and quality of life among men after anal sphincter-sparing transperineal rectourethral fistula repair." Urology. 2018;121:175–181. doi:10.1016/j.urology.2018.06.052

24. Xu YM, Sa YL, Fu Q, Zhang J, Jin SB. "Surgical treatment of 31 complex traumatic posterior urethral strictures associated with urethrorectal fistulas." Eur Urol. 2010;57(3):514–520. doi:10.1016/j.eururo.2009.02.035

25. Guo H, Sa Y, Fu Q, Jin C, Wang L. "Experience with 32 pelvic fracture urethral defects associated with urethrorectal fistulas: transperineal urethroplasty with gracilis muscle interposition." J Urol. 2017;198(1):141–147. doi:10.1016/j.juro.2017.01.071

26. Hou C, Huang J, Zhu W, et al. "Use of bulbospongiosus muscle for repair of traumatic posterior urethral stenosis combined with urethrorectal fistulas." BJU Int. 2025;135(6):1049–1057. doi:10.1111/bju.16709