Turnbull–Cutait Pull-Through for Rectourinary Fistula
A Turnbull–Cutait pull-through combines rectal resection with a delayed hand-sewn coloanal anastomosis. It is an option for selected complex rectourinary fistulas when the diseased rectum needs resection and preservation of bowel continuity remains realistic. Its evidence in rectourethral fistula (RUF) consists mainly of small, selected series; the randomized trials concern low rectal cancer, not fistula repair.[1][3][4]
Use this page alongside Transperineal RUF Repair, Transabdominal RUF/RVF Repair, and Conservative RUF Management and Durable Diversion.
Selection and counseling
This operation is most relevant when local fistula closure would leave severely damaged rectum, such as selected radiation injuries, extensive scarring or recurrent complex fistulas. The decision incorporates rectal disease, urinary outlet and bladder function, sphincter function, prior reconstruction, operative fitness and the patient's priorities. A diameter threshold alone does not establish an indication, and prior failure of every perineal technique is not a prerequisite.[4][5][10]
Plan jointly with colorectal and reconstructive urological surgeons. Establish whether the urinary side can be repaired, needs urethral reconstruction, or requires diversion. Bowel continuity, fistula closure, urinary continence and satisfactory bowel function are separate goals. A successful urinary closure does not guarantee reversal of a fecal stoma.[4][10]
The ASCRS 2022 recommendation allowing completion proctectomy with or without a colonic pull-through applies specifically to radiation-related or recurrent complex rectovaginal fistula, with a weak recommendation based on low-quality evidence. It is not an RUF-specific recommendation or a mandate for pull-through in all radiation fistulas.[11]
Operative framework
The reconstruction varies with the remaining rectum, urinary defect and prior operations. The following describes the main stages; details of the urinary repair and any interposition flap require a separate operative plan.[1][3][4]
- Define and separate the diseased segment. Mobilize the rectum and fistula under direct exposure. Determine the extent of rectal resection and the viable urinary margins. Proctectomy is not interchangeable with simply oversewing a tract.
- Prepare a viable colonic conduit. Mobilization must permit a well-perfused colon to reach the anus without tension or mesenteric twist. Vascular division depends on the reconstruction; routine high inferior mesenteric artery ligation is not a defining requirement of this fistula operation.
- Complete the planned urinary reconstruction. Primary closure, graft reconstruction or another urinary strategy is selected according to the defect. Pull-through alone does not solve a urethral stricture, destroyed bladder outlet or poorly functioning bladder.
- Exteriorize the colon. Bring the viable distal colon through the anal canal and secure it according to the chosen technique. Protect the exteriorized segment and monitor its perfusion. Preserve sphincter structures appropriate to the intended reconstruction.
- Perform the delayed coloanal anastomosis. After an interval allowing adhesion of the pulled-through colon, resect the exteriorized segment and construct the anastomosis. In the low-rectal-cancer trial this was planned for 6–10 days; fistula-series protocols and patient circumstances vary.[3]
A Soave-type sleeve pull-through, which retains a rectal muscular cuff after mucosal dissection, is a related but distinct operation. Do not assume every Turnbull–Cutait repair requires a Soave cuff or routine anal mucosectomy. Transanal minimally invasive proctectomy has been described in a three-patient radiation-RUF series; this establishes feasibility in those cases, not reduced morbidity compared with other approaches.[1][5]
Diversion and perfusion
Some delayed coloanal reconstructions avoid a protective stoma, whereas complex fistula repairs often use temporary fecal diversion. The three-patient TAMIS RUF series used a loop ileostomy in each case. Stoma decisions should follow tissue quality, contamination, reconstruction and patient risk; avoiding a stoma is not assured.[1][3]
A dusky or necrotic pull-through requires urgent surgical assessment. Limited ischemia of the exteriorized segment and ischemia extending proximally are different problems. Do not proceed automatically to an earlier anastomosis through compromised bowel. The randomized cancer trial included severe colonic ischemia requiring colectomy or an end colostomy.[3]
Evidence specific to fistula reconstruction
| Source | Population and reported outcome | Interpretation |
|---|---|---|
| Lane 2006 | Twenty-two radiation-related RUFs received different strategies; five patients underwent proctectomy, staged coloanal pull-through and buccal mucosal graft urethral reconstruction. | The abstract's nine successful urethral reconstructions and eight restored bowel anatomies concern broader selected groups, not exclusively those five pull-through patients; two patients still awaited stoma closure.[4] |
| Chirica 2006 | Eight complex rectourinary fistulas treated with a Soave sleeve procedure; two fistula recurrences, seven ileostomy reversals and one early colonic necrosis requiring conversion to an ileal pouch. | Seven reversals do not mean seven fistula cures. This is a small series of a related sleeve technique.[5] |
| Martín-Pérez 2021 | Three radiation-associated RUFs treated with TAMIS proctectomy, staged Turnbull–Cutait reconstruction and loop ileostomy; all three fistulas closed and ileostomies were reversed. | Promising feasibility; no comparative trial or reliable general success estimate.[1] |
| Lavryk 2023 | Twenty-six women with complex rectovaginal fistulas; four recurrences, yielding 85% reported healing. | This is RVF evidence, not an RUF result or an 85% stoma-reversal rate. The patients came from the institution's larger 81-patient pull-through cohort.[6] |
The larger Cleveland Clinic report included 81 patients undergoing pull-through for mixed indications: 69% were stoma-free at a median 1.4 years. Its immediate-coloanal-anastomosis comparator had different selection and longer follow-up. These retrospective data cannot establish superiority or equivalence for an individual radiation RUF.[2]
What the rectal-cancer trials do and do not show
The 2020 randomized trial allocated 92 patients with low rectal cancer to delayed Turnbull–Cutait or immediate coloanal anastomosis with diverting ileostomy. Composite postoperative complications were 34.8% versus 45.7% (P = .40), and leaks were 6/46 versus 11/46 (P = .28). Thus, neither superiority nor a universal 2–3% leak rate was demonstrated.[3]
At three years, the same trial found no statistically significant difference in cumulative morbidity or reported bowel-function scores. Median LARS scores were 34 and 32, respectively, demonstrating that important bowel dysfunction can remain with either reconstruction. The trial does not establish equivalent outcomes, normal continence or effectiveness in previously operated radiation-fistula patients.[9]
Longer-term function and complications
Discuss anastomotic leak, pelvic sepsis, colonic ischemia or necrosis, stricture, recurrent fistula, evacuation difficulty, urgency, incontinence and the possibility of permanent diversion. The 564-patient GRECCAR cohort reported leaks in 15% of primary and 23% of salvage reconstructions and intra-abdominal colonic necrosis in 10%. Three-year bowel continuity was 74% overall. These are heterogeneous colorectal reconstructions, not RUF-specific probabilities.[7]
The later GRECCAR functional study assessed 243 of 385 eligible patients from a 552-patient cohort. Of those assessed, 146/243 had no or minor LARS, 88 had major LARS and nine had a stoma for poor function; most had rectal cancer. Selection, nonresponse and exclusion of patients without bowel continuity limit extrapolation. “Bowel continuity” is not synonymous with good function.[8]
Before reversing a temporary stoma, assess healing of both organs and whether bowel continuity is likely to provide useful function. Continue surveillance for urinary obstruction or leakage as well as bowel symptoms. Permanent diversion may provide a better functional outcome for some patients despite technically feasible reconstruction.[4][10]
References
1. 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
2. Lavryk OA, Bandi B, Shawki SF, et al. "Turnbull-Cutait abdominoperineal pull-through operation: the Cleveland Clinic experience in the 21st century." Colorectal Dis. 2022;24(10):1184–1191. doi:10.1111/codi.16163
3. Biondo S, Trenti L, Espin E, et al. "Two-stage Turnbull-Cutait pull-through coloanal anastomosis for low rectal cancer: a randomized clinical trial." JAMA Surg. 2020;155(8):e201625. doi:10.1001/jamasurg.2020.1625
4. 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
5. Chirica M, Parc Y, Tiret E, et al. "Coloanal sleeve anastomosis (Soave procedure): the ultimate treatment option for complex rectourinary fistulas." Dis Colon Rectum. 2006;49(9):1379–1383. doi:10.1007/s10350-006-0636-9
6. Lavryk OA, Justiniano CF, Bandi B, et al. "Turnbull-Cutait pull-through procedure is an alternative to permanent ostomy in patients with complex pelvic fistulas." Dis Colon Rectum. 2023;66(12):1539–1546. doi:10.1097/DCR.0000000000002920
7. Collard MK, Rullier E, Tuech JJ, et al. "Is delaying a coloanal anastomosis the ideal solution for rectal surgery? Analysis of a multicentric cohort of 564 patients from the GRECCAR." Ann Surg. 2023;278(5):781–789. doi:10.1097/SLA.0000000000006025
8. Collard MK, Tuech JJ, Sabbagh C, et al. "Long-term bowel function following delayed coloanal anastomosis: analysis of a multicentric cohort study (GRECCAR)." Colorectal Dis. 2025;27(2):e70013. doi:10.1111/codi.70013
9. Biondo S, Barrios O, Trenti L, et al. "Long-term results of 2-stage Turnbull-Cutait pull-through coloanal anastomosis for low rectal cancer: a randomized clinical trial." JAMA Surg. 2024;159(9):990–996. doi:10.1001/jamasurg.2024.2262
10. 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
11. 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