Rectourethral fistula (RUF) is a challenging problem encountered by urologic and colorectal surgeons and may result from radiation to the pelvis, prostate cryotherapy, prior surgery, inflammatory conditions, trauma, or congenital defects.

Although transanal or transanosphincteric (York Mason) repair may be considered for small fistulas following surgery alone, perineal repair with gracilis interposition is favored for complex RUFs. This category includes fistulas that develop in the setting of prior radiation therapy or ablative procedures, such as cryotherapy or high-intensity focused ultrasound, and defects that are large or have failed prior reconstruction.

Prior to repair of complex RUF, it is critical to perform fecal diversion (loop colostomy or ileostomy) and selective urinary diversion (suprapubic catheter) for 3-6 months to decrease inflammation in the perineum and surrounding tissues before surgery.

Careful endoscopic evaluation (Fig. 15-1A-C) and examination under anesthesia should be performed following a period of diversion to assess the external urethral and anal sphincters, size and
location of the fistula, quality of the rectum and tissues surrounding the fistula, the urethra for evidence of stricture, and the approximate capacity and quality of the bladder. Consideration of these factors will aid in generating the ultimate surgical plan.

If future urinary and bowel function are likely to be adequate based on the above evaluation, repair the urethral defect, with selective use of a buccal mucosa graft. Restore bowel function via primary rectal repair and then interpose a gracilis muscle flap. In rare situations when the anal sphincter is intact and the rectum cannot be closed primarily, proctectomy with coloanal pull-through may be considered.

If future bowel function is not likely to be adequate or the anal sphincter is clearly compromised, repair the urethral defect, with selective use of a buccal mucosa graft, with transfer of a gracilis muscle flap to buttress the repair. Continue with the current fecal diversion if a colostomy or convert the ileostomy to a colostomy. Proctectomy or rectal closure will also be needed depending on patient anatomy.

If future bowel function is likely to be adequate, but urinary function not restorable due to contracted bladder, extensive radiation cystitis, or devastated bladder outlet, perform a cystoprostatectomy with ileal conduit urinary diversion. Bowel function can then be restored via primary rectal repair or proctectomy with coloanal pull-through and later reversal of the diverting colostomy or ileostomy. Omental pedicle flap to the pelvis should be considered when feasible.

Finally, if neither bowel nor urinary function is likely to be adequate, perform a pelvic exenteration with ileal conduit and colostomy.