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Turnbull-Cutait Pull-Through for Rectourethral Fistula

The Turnbull-Cutait (TC) pull-through is a two-stage coloanal anastomosis that serves as a salvage operation for complex rectourethral fistulas (RUF) — particularly radiation-induced injury or failed prior repairs — offering an alternative to permanent fecal diversion.[1][2][3] The defining principle: proctectomy with exteriorization of the proximal colon through the anus, then a delayed hand-sewn coloanal anastomosis 6–10 days later, by which point pelvic adhesions have formed around the pulled-through colon to seal the anastomosis and reduce leak risk.[3]

For first-line transperineal repair see Transperineal Approach to RUF; for permanent dual diversion as the alternative endpoint see Conservative Management of RUF. For the analogous RVF transabdominal operation see Transabdominal RVF Repair.

Historical Background​

R. B. Turnbull Jr (Cleveland Clinic, 1952) described a transanal colonic pull-through with two-stage coloanal anastomosis for rectal cancer and Hirschsprung disease. D. E. Cutait (Brazil) independently described the same technique for acquired megacolon from Chagas disease.[3] The technique was largely superseded by stapled anastomosis and standard hand-sewn coloanal anastomosis with diverting ileostomy, then reintroduced as a salvage procedure for complex pelvic conditions — anastomotic dehiscence, pelvic-irradiation fistulae, chronic pelvic infection, and complex rectourethral / rectovaginal fistulae.[2][3]

Indications​

TC is an option of last resort before permanent diversion for RUF patients who are not candidates for or have failed standard transperineal repair:[1][2][4]

  • Radiation-induced RUF with extensive rectal injury or radiation proctitis — diseased rectum is the problem; simple fistula closure is insufficient
  • Failed prior RUF repairs (multiple previous unsuccessful procedures)
  • Large fistulas (≥ 20 mm) unlikely to close with primary repair
  • Concurrent severe radiation proctitis requiring proctectomy regardless of the fistula
  • Patients motivated to avoid permanent fecal diversion who understand the complexity and risks

Lane 2006 (Cleveland Clinic) specifically positioned proctectomy + staged coloanal pull-through + BMG urethroplasty as the preferred approach for radiation-induced RUF — 100% fistula closure in 9 patients who underwent urethral reconstruction and bowel integrity in all 8 candidates for rectal reconstruction.[4]

Surgical Technique​

Stage 1 — Proctectomy and colonic exteriorization​

  1. Position lithotomy or modified lithotomy; GA.
  2. Abdominal phase — mobilize left colon and splenic flexure for a tension-free pull-through; ligate the IMA; mobilize sigmoid / descending colon on its mesentery. Martín-Pérez 2021 — performed the proctectomy via transanal minimally invasive surgery (TAMIS) rather than traditional abdominal approach, reducing pelvic-dissection morbidity.[1]
  3. Proctectomy — resect the diseased rectum (containing the fistula). Carefully separate the rectum from the posterior urethra / prostate bed. Address the urethral defect simultaneously — primary closure or BMG urethroplasty.[4]
  4. Mucosectomy — strip the remaining rectal mucosa distal to the resection from the muscular cuff down to the dentate line (or leave the muscular cuff intact for the Soave variant).[5][6]
  5. Colonic pull-through — pull the mobilized proximal colon through the anal canal and exteriorize 5–7 cm beyond the anal verge. Held in place by tension-free mobilization, anal-sphincter resting pressure, and two fixation stitches to the perianal skin.[3]
  6. Fecal diversion — loop ileostomy to protect the repair, particularly in the contamination-prone RUF setting.[1]

Interval period (6–10 days)​

  • Daily inspection of the exteriorized colon for viability and perfusion at the anal margin
  • Adhesions and scarring form between the serosal surface of the pulled-through colon and the pelvic walls / anal canal — biological seal that reduces dehiscence risk[3]
  • If ischemia is detected at the proximal end of the exteriorized colon, perform stage 2 earlier than planned[3]

Stage 2 — Delayed coloanal anastomosis (6–10 days later)​

  1. Transect the exteriorized colon at the level of the anal margin, removing the redundant segment
  2. Hand-sewn coloanal anastomosis with interrupted absorbable suture — circumferential anastomosis between healthy colon and the anal canal at or just above the dentate line[3]
  3. Brief procedure; regional or general anesthesia

Variations​

Soave procedure (coloanal sleeve anastomosis)​

Closely related technique — rectal mucosa stripped, muscular cuff of the rectum preserved, colon pulled through this muscular sleeve. Chirica 2006 (salvage for n = 8 complex rectourinary fistulas — 5 bladder, 3 urethral): ileostomy reversal in 7/8 (88%); 5/8 had failed 1–3 prior repairs; morbidity 38%; one colonic necrosis required reoperation on POD 1.[5]

TAMIS-assisted TC​

Martín-Pérez 2021 — transanal minimally invasive proctectomy + staged TC pull-through: 100% fistula closure in 3 patients with radiation-induced RUF after prostate cancer treatment; all ileostomies subsequently reversed without recurrence.[1]

Combined TC + BMG urethroplasty​

Lane 2006 — 5 patients underwent proctectomy + staged coloanal pull-through + BMG repair of the urethral defect for radiation-induced RUF: 100% successful fistula closure with bowel integrity in all candidates.[4]

Outcomes in RUF​

Seriesn (RUF)EtiologyTechniqueFistula closureStoma reversal
Lane 20065Radiation-inducedProctectomy + staged pull-through + BMG100%100% (2 awaiting)[4]
Martín-Pérez 20213Post-prostate cancer Tx (all radiated)TAMIS-assisted TC + ileostomy100%100%[1]
Chirica 2006 (Soave)8 (3 urethral, 5 bladder)Post-RP, post-rectal cancer + RTSoave sleeve anastomosis75% (6/8)88% (7/8)[5]
Nyam & Pemberton 19993 (of 16 total)Post-RP ± radiationColoanal anastomosisVariable75% (12/16 overall) at 80 mo[7]

Outcomes of TC for All Complex Pelvic Conditions​

Context for expected outcomes from the largest TC series:

SeriesnIndicationsSuccessPermanent stomaKey complications
Lavryk 2022 Cleveland81Mixed (fistulas, leak, cancer)69% stoma-free31%Stricture, leak, prolapse[2]
Remzi 2009 Cleveland67Mixed complex anorectal75%25%Stricture 16%, fistula 7%, prolapse 7%, leak 3% at 5.6 yr[8]
Lavryk 2023 RVF subset26Rectovaginal fistula85%15%Recurrence at 6–12 mo[9]
Collard 2023 GRECCAR564Primary 66% + salvage 34% DCAA74% bowel continuity at 3 yr~25%Colon necrosis 10%, AL 15–23%[10]
Patsouras 201434Complex rectal conditions89% overall healing~11%Early 41%, late 29%[11]

Functional Outcomes​

  • LARS — GRECCAR 564 DCAA patients: 60% no LARS or minor LARS, 36% major LARS, 4% required definitive stoma due to poor bowel function. Neither radiation history nor salvage indication predicted worse function.[12]
  • Fecal continence — TURNBULL-BCN RCT (rectal cancer): 3-yr Wexner 13.0 (TC) vs 10.9 (P = 0.92); LARS 34.0 vs 32.0 (P = 0.76). Stoma-free survival 84.1% TC vs 80.2% standard CAA.[13]
  • Comparison with standard CAA — Remzi 2009: fecal incontinence (P = 0.121), urinary incontinence (P = 0.073), and sexual function (P = 0.063) all comparable between TC and matched CAA.[8]
  • Long-term bowel function — systematic review of DCAA: poor fecal continence in ~25%.[14]

Complications​

  • Colonic necrosis (most feared) — 10% in GRECCAR; risk factors: male sex (OR 2.67), BMI > 25 (OR 2.78), peripheral artery disease (OR 4.68). Requires urgent reoperation and may necessitate permanent diversion.[10]
  • Anastomotic stricture — 16% (Remzi); often managed with dilation[8]
  • Colonic prolapse — 7%; exteriorized colon may prolapse further through the anus before stage 2[8]
  • Anastomotic leak — 2–3% in most series — the primary theoretical advantage of the delayed anastomosis; adhesions formed during the interval provide a biological seal[8][14]
  • Pelvic abscess / sepsis — 0–25%[14]
  • Overall morbidity — 57% in GRECCAR (30% major), reflecting patient complexity[10]

Rationale: Why TC for RUF?​

  1. Removes the diseased rectum — radiation proctitis often coexists; simple fistula closure leaves the diseased rectum in situ with ongoing bleeding, tenesmus, discharge, and a high recurrence rate. Proctectomy addresses both pathology and fistula.[4][6]
  2. Brings healthy, well-vascularized tissue — the pulled-through colon is non-irradiated tissue with intact perfusion, providing the best substrate for healing in a hostile irradiated pelvis.[1][3]
  3. Soave variant avoids deep pelvic dissection — preserves the rectal muscular cuff, avoiding dissection of the rectum off the urethra / prostate bed (the most dangerous part of the operation in a radiated fibrotic pelvis).[5][6]
  4. Delayed anastomosis reduces leak risk — the 6–10 day interval allows adhesions to form, sealing the anastomosis biologically.[3][14]

Place in the RUF Algorithm​

  1. First-line for most RUF — Transperineal repair with gracilis ± BMG urethroplasty (87–100% success)[15][16]
  2. Alternative first-line for simple non-radiated RUF — York-Mason
  3. Failed transperineal repair or radiation-induced RUF with severe proctitis — Turnbull-Cutait pull-through (or Soave sleeve) with concurrent urethral reconstruction — last option before permanent diversion[1][4][5]
  4. Devastated pelvis with non-functional systems — permanent urinary + fecal diversion[15][17]

ASCRS 2022 acknowledges the role of proctectomy with primary or staged (TC) coloanal anastomosis for radiation-related or recurrent complex pelvic fistulas — weak recommendation, low-quality evidence (Grade 2C).[18]

Key Takeaways​

  • TC achieves fistula closure 75–100% and stoma reversal 85–100% in RUF series — remarkable given that these patients would otherwise face permanent diversion.[1][4][5]
  • Technically demanding — requires multidisciplinary collaboration (colorectal + urology); significant morbidity (colonic necrosis ~10%, overall ~57%).[10]
  • Acceptable function — 60% achieve no or minor LARS; continence comparable to standard coloanal anastomosis.[12][13]
  • Evidence in RUF is limited to case series of 3–8 patients; no comparative studies vs other approaches for RUF.

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. Gazet JC. "Parks' coloanal pull-through anastomosis for severe, complicated radiation proctitis." Dis Colon Rectum. 1985;28(2):110–114. doi:10.1007/BF02552659

7. Nyam DC, Pemberton JH. "Management of iatrogenic rectourethral fistula." Dis Colon Rectum. 1999;42(8):994–997. doi:10.1007/BF02236689

8. Remzi FH, El Gazzaz G, Kiran RP, Kirat HT, Fazio VW. "Outcomes following Turnbull-Cutait abdominoperineal pull-through compared with coloanal anastomosis." Br J Surg. 2009;96(4):424–429. doi:10.1002/bjs.6458

9. 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

10. 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

11. Patsouras D, Yassin NA, Phillips RK. "Clinical outcomes of colo-anal pull-through procedure for complex rectal conditions." Colorectal Dis. 2014;16(4):253–258. doi:10.1111/codi.12532

12. 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

13. 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

14. Portale G, Popesc GO, Parotto M, Cavallin F. "Delayed colo-anal anastomosis for rectal cancer: pelvic morbidity, functional results and oncological outcomes: a systematic review." World J Surg. 2019;43(5):1360–1369. doi:10.1007/s00268-019-04918-y

15. 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

16. 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

17. 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

18. 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