Local tissue interposition flaps in the management of post-traumatic rectouretheral fistulae: a case series

Document Type : Case Report


1 Department of Urology and Renal Transplant All India Institute of Medical sciences, Bhubaneswar, India

2 Department of Urology and Renal Transplant, All India Institute of Medical Sciences, Bhubaneswar, India


Recto urethral fistula is relatively rare condition with worldwide incidence rates of less than 3%, and have a wide range of clinical presentations. Treatment involves surgical correction with various techniques described in literature. Here we look at a case series of complex recto urethral fistulae and their management involving local tissue flaps.

Three patients with complex recto urethral fistulae underwent surgical repair with a pedicled gracilis muscle flap. All patients underwent a pelvic magnetic resonance scan and a flexible antegrade and retrograde cystoscopy prior to their repair. For two patients, the gracilis muscle flap was harvested from the left thigh and the right thigh for the third patient.

Trauma and radiation are the two most common causes of recto urethral fistulae. Most of these patients have a poor quality of life and require surgical repair with some form tissue interposition. The failure of a prior RUF repair results in worsening of the patient’s quality of life and makes the subsequent surgery more challenging. Diversion of both the urine and faeces as the initial treatment results in better outcomes of the final repair, and hence should always be included in the management protocol of this rare entity.


  1. Choi JH, Jeon BG, Choi SG, Han EC, Ha HK, Oh HK, et al. Rectourethral fistula: systemic review of and
    experiences with various surgical treatment methods. Annals of coloproctology. 2014;30(1):35-41.
  2. Keller DS, Aboseif SR, Lesser T, Abbass MA, Tsay AT, Abbas MA. Algorithm-based multidisciplinary treatment approach for rectourethral fistula. International journal of colorectal disease. 2015;30(5):631-8.
  3. Thomas C, Jones J, Jäger W, Hampel C, Thüroff JW, Gillitzer R. Incidence, clinical symptoms and management
    of rectourethral fistulas after radical prostatectomy. The Journal of urology. 2010;183(2):608-12.
  4. Hanna JM, Turley R, Castleberry A, Hopkins T, Peterson AC, Mantyh C, et al. Surgical management of complex
    rectourethral fistulas in irradiated and nonirradiated patients. Diseases of the colon and rectum. 2014;57(9):1105-12.
  5. Beddy D, Poskus T, Umbreit E, Larson DW, Elliott DS, Dozois EJ. Impact of radiotherapy on surgical repair and
    outcome in patients with rectourethral fistula. Colorectal disease : the official journal of the Association of
    Coloproctology of Great Britain and Ireland. 2013;15(12):1515-20.
  6. Chrouser KL, Leibovich BC, Sweat SD, Larson DW, Davis BJ, Tran NV, et al. Urinary fistulas following external radiation or permanent brachytherapy for the treatment of prostate cancer. The Journal of urology. 2005;173(6):1953-7.
  7. Hechenbleikner EM, Buckley JC, Wick EC. Acquired rectourethral fistulas in adults: a systematic review
    of surgical repair techniques and outcomes. Diseases of the colon and rectum. 2013;56(3):374-83.
  8. Thompson IM, Marx AC. Conservative therapy of rectourethral fistula: five-year follow-up. Urology. 1990;35(6):533-6.
  9. Tran H, Flannigan R, Rapoport D. Transperineal approach to complex rectourinary fistulae. Canadian
    Urological Association journal = Journal de l’Association des urologues du Canada. 2015;9(11-12):E916-20.
  10. Sotelo R, Mirandolino M, Trujillo G, Garcia A, de Andrade R, Carmona O, et al. Laparoscopic repair of rectourethral fistulas after prostate surgery. Urology. 2007;70(3):515-8.
  11. Bislenghi G, Verstraeten L, Verlinden I, Castiglione F, Debaets K, Van der Aa F, et al. Surgical management
    of acquired rectourethral fistula: a retrospective analysis of 52 consecutive patients. Techniques in
    coloproctology. 2020;24(9):927-33.
  12. Samplaski MK, Wood HM, Lane BR, Remzi FH, Lucas A, Angermeier KW. Functional and quality-of-life
    outcomes in patients undergoing transperineal repair with gracilis muscle interposition for complex
    rectourethral fistula. Urology. 2011;77(3):736-41.
  13. Voelzke BB, McAninch JW, Breyer BN, Glass AS, Garcia-Aguilar J. Transperineal management
    for postoperative and radiation rectourethral fistulas. The Journal of urology. 2013;189(3):966-71.
  14. 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.                                                    The Journal of urology. 2010;184(6):2400-4.
  15. Ghoniem G, Elmissiry M, Weiss E, Langford C, Abdelwahab H, Wexner S. Transperineal repair of complex rectourethral fistula using gracilis muscle flap interposition--can urinary and bowel functions be preserved?             The Journal of urology. 2008;179(5):1882-6.
  16. Harris CR, McAninch JW, Mundy AR, Zinman LN, Jordan GH, Andrich D, et al. Rectourethral Fistulas Secondary to Prostate Cancer Treatment: Management and Outcomes from a Multi-Institutional Combined Experience. The Journal of urology. 2017;197(1):191-4.
  17. Huang X, Tan SS, Chen Y, Li T. Acquired Rectourethral and Rectovaginal Fistulas in Children: A Systematic Review. Frontiers in pediatrics. 2021;9:657251.
  18. A A. Rectourethral Fistulas: A Review. Clinics in Surgery. 2016;1.
  19. Mundy AR, Andrich DE. Posterior urethral complications of the treatment of prostate cancer.                                      BJU international. 2012;110(3):304-25.
  20. Lane BR, Stein DE, Remzi FH, Strong SA, Fazio VW, Angermeier KW. Management of radiotherapy
    induced rectourethral fistula. The Journal of urology. 2006;175(4):1382-7; discussion 7-8.
  21. Eswara JR, Raup VT, Heningburg AM, Brandes SB. Pelvic radiation is associated with urinary fistulae repair
    failure and need for permanent urinary diversion. Urology. 2015;85(4):932-6.
  22. Linder BJ, Umbreit EC, Larson D, Dozois EJ, Thapa P, Elliott DS. Effect of prior radiotherapy and ablative
    therapy on surgical outcomes for the treatment of rectourethral fistulas.                                                                  The Journal of urology. 2013;190(4):1287-91.