The document discusses rectourethral fistulas, including their causes, presentations, diagnostic evaluations, and various surgical repair techniques. The York-Mason and transanal approaches are commonly used for surgical repair, with the York-Mason approach providing good results for distal fistulas not amenable to transanal repair. Conservative management may be attempted for select small fistulas but surgery is usually required.

1. By
M.A.Wadood Aref

2.  By defnition, a fistula is an extra-
anatomic, epithelialized tract between
two hollow organs or between a hollow
organ and the body surface.
 In case of urethrorectal fistulas, the tract
occur between the urethra and the
rectum.

3.  urethrorectal fistulas may be
congenital (associated with
imperforate anus & extremely rare)
or acquired (iatrogenic or non-
iatrogenic ).

4.  Acquired urethrorectal fistulas are
typically associated with iatrogenic
injury during pelvic surgical procedures
and uncommonly associated with
pelvic radiotherapy.
 Prtedisposing factors for post-
prostatectomy urethrorectal fistulas are:
radiation, previous rectal surgery, or
TURP.

5. Iatrogenic causes of URFs include:
1. Radical Prostatectectomy (RP)
 Incidence of Rectal injury during RP is
less than 1 - 2%,
 However, it is considered the most
common cause due to increased number
of radical prostatectomies done yearly.

6. 2. Local treatments for prostatic cancer:
including Radiotherapy, Brachytherapy
(0.4%), Cryotherapy (0.5 to 2%) or HIFU.
3. Open prostatectomy or TURP or overly
aggressive TUR of bladder neck
contracture.
4. Anorectal surgery: abdomino-perineal resect.
5. Urethral instrumentation is also a rare cause
of urethrorecal fistula

7. Non-iatrogenic causes of URFs include:
 Trauma: penetrating trauma.
 Malignancy: prostatic or rectal malignancy.
 Infection such as tuberculosis, Ruptured
prostatic abscess.
 Inflammatory diseases: such as Crohn's
disease (0.3%).
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8. Patient with URF can be presented by:
 Fecaluria.
 Hematuria.
 Recurrent UTI refractory to treatment .
 Peritonitis and sepsis.
 Fever, Nausea and vomiting.

9.  Digital rectal examination (DRE): during
rectal examination fistula track can be felt
along the anterior rectal wall.
 Cystoscopy and sigmoidoscopy can be used
for visualization of the fistula track & biopsy
for detection of malignancy.
 Upper tract imaging can be used to exclude a
related ureteral injury.

10.  Diagnosis of rectourethral fistula can be
confirmed with RUG or VCUG.

11.  Pre-op assessment of continence and
sphincteric function is important in
rectourethral fistula after radical
prostatectomy because most rectourethral
fistulas lie at or near the vesicourethral
anastomosis and membranous urethra.
 So, stress urinary incontinence can occur
after repair.
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12.  Conservative treatment can cure some
cases of post- prostatectomy URFs (open or
laparoscopic).
 Conservative treatment include catheter
drainage, NPO, IV Total parentral nutrition,
anal dilatation and Antibiotics

13.  Fecal diversion may be needed in
urethrorectal fistulas after brachytherapy
or cryosurgry.
 repair of such fistulas is quiet difficult
because it is usually large with
induration, fibrosis and ischemia.

14.  Surgery is the main line of treatment in
most of cases of urethrorectal fistulas.
 It can be performed as single stage or
staged repair.
 Some authors have advocated fecal
diversion and staged repair of all URFs.

15. Staged repair is done with fecal diversion
performed before repair of the rectourethral
fistula.
Staged repair is indicated in:
 large fistulas,
 post-radiation therapy,
 uncontrolled local or systemic infection,
 Immunocompromised,
 inadequate bowel preparation at initial oper.

16. Single stage repair
 Indicated in surgically induced Small fistula
with no infection, abscess.
 Advantage of a successful one-stage
approach is limiting the potential morbidity
and cost of multiple procedures with the
staged repair.
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17.  Tranarectal approach
 Without division of anal sphincter (Transanal)
 With division of anal sphincter (York-Mason)
 Transperineal approach
 Transabdominal approach
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18.  Transrectal approaches for URF rapair (York-
Mason approach or transanal approach) are
performed in the prone jackknife position.

19.  The transanal approach to rectourethral
fistula repair does not involve division of the
anal sphincter. In contrast to York-Mason
approach.
 Techniques include rectal advancement flap
or Latzko method.
 The main limitation of this approach is the
limited exposure and it is best suited for small
distal fistulae.
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20.  Exposure of the
fistula is provided by
dilation of the anus
and fixed retraction.
 Through the anal
canal, an ellipse of
rectal mucosa is
removed.

21.  A full-thickness U-
shaped flap of
rectal wall is
elevated above the
fistula.

22.  The full-thickness flap of rectal wall is
brought down over the fistula and sutured in
two layers to the rectal wall.

23.  The technique is similar to the Latzko
method for transvaginal VVF repair .
 Exposure of the fistula is provided by dilation
of the anus and fixed retraction.
 The fistula track and surrounding rectal
mucosa are denuded in all four quadrants.
 The fistula is then closed in three layers.
 The major disadvantages to this approach
are the relatively poor exposure.
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24.  York-Mason procedure is a transrectal,
transsphincteric approach that has been
shown to be effective with low morbidity.
 Staged York-Mason approach is the
classically described repair.
 Single-stage York-Mason approach can be
used in patients with small, non-irradiated
fistulas with vigorous bowel preparation and
broad-spectrum antibiotics.
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25.  performed in a prone
jackknife position with
the buttocks taped
laterally.
 Incision is performed
from the sacrococcygeal
juncture to the anus.

26.  incision is deepened
through the posterior
anus and dorsal rectal
wall and deepened
down to the level of the
coccyx through the
external anal sphincter

27.  The fistula track is excised,
and the anterior rectal wall is
mobilized circumferentially
around the fistula margins.
 The urethra is closed.
 Anterior rectal wall is closed.
 Rectal mucosa is re-
approximated
 This provides 3-layer closure.
 reapproximating the post.
rectal wall & anal sphincter.

28.  Results of York-Mason procedure are excellent.
 Based upon literature reports, the York-Mason
approach has become the favored repair for URFs not
amenable to a transanal approach.
 Renschler and Middleton in 2003 reported a
successful repair in 22 of 24 patients.
 No serious complications were reported, and no
patient developed anal incontinence or stenosis.
 Similar excellent results have been noted by other
authors ( Prasad et al, 1983 ; Bukowski et al, 1995 ;
Fengler and Abcarian, 1997) .

29.  A perineal approach to rectourethral fistula
has been described in selected cases with
good results.
 Advocated by:
 Bukowski et al, 1995.
 Nyam and Pemberton, 1999.
 Youssef et al, 1999.
 Zmora et al, 2003.

30.  Advantages of perineal approach include:
being a familiar approach for many urologists
and local accessability to a variety of
potential interpositional flaps.
 Perineal approach with interpositional flap
provided Excellent results.

31.  Interposition grafts include:
 Gracilis muscle: Ryan et al, 1979 ; Rius et al,
2000 ; Zmora et al, 2003.
 Pedicled dartos muscle: Venable, 1989 ;
Youssef et al, 1999 ; Yamazaki et al, 2001.
 Penile skin: Morgan, 1975.
 levator muscle: Goodwin et al, 1958.
 Bladder: Kokotas and Kontogeorgos, 1983.

32.  patient in the extended
lithotomy position.
 a 20 F 30-ml filled
balloon catheter is
inserted.
 Use retractors to bring
fistula into the wound,
and insert a finger into
the rectum as a guide.
 Divide the fistula and
excise all surrounding
scar tissue.

33.  assistant draw up on
the catheter.
 blunt and sharp
dissection between
the rectum and
prostate well above
the fistula to reach
normal tissue.
 Closure of the rectal
fistula.
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34.  Graft can be
interposed between
urethra & rectum esp.
in teneous repair.
 urethral defect is
closed in two layers
with 4-0 absorbable
suture.

35.  Transabdominal approach has been
described for URF rapair with limited success.
 Advocated by:
 Bukowski et al, 1995 ;
 Nyam and Pemberton, 1999 ;
 Shin et al, 2000.
 The principal advantage to this technique is
the availability of greater omentum for an
interpositional flap.

36. Potential disadvantages include:
 morbidity and prolonged postoperative
convalescence associated with a laparotomy
incision
 the poor exposure of the operative field
 limited maneuverability in the deep pelvis
 risk of urinary and fecal incontinence.

37.  Continue antibiotic administration and a low-
residue diet postoperatively.
 Shorten the drain in 3 days and remove it the
next day.
 Remove the catheter or cystostomy no
sooner than the 8th day.

38.  Rectourethral fistulas are uncommon
complication, it occur mostly after surgery,
radiotherapy or minimally invasive
treatments for prostatic cancer.
 Rare causes include surgery for BPH,
 rectourethral fistulas are usually suspected
clinically and diagnosis can be confirmed with
voiding cystourethrography or retrograde
urethrogram.
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39.  Treatment of rectourethral fistula most
commonly involves surgical repair; however,
select patients may respond to conservative
therapy.
 York-Mason approach have good results and
minimal morbidity in cases not amenable to
transanal approach.
 Transperineal approach with interpositional
graft is familiar with good results.
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