Rectourethral Fistula: Operative Technique and Outcomes

Rectourethral fistula (RUF) is an infrequent yet distressing pathology that can lead to significant complications for patients. Its management has been debated over the years and physicians have yet to reach a consensus on RUF treatment. In this review, we outline the status of the current literature on RUF from the initial diagnosis to the outcomes, complications, and surgical techniques available for RUF repair.

Higher rates of success are achieved on the first surgical attempt. Therefore, when deciding which surgical procedure to use, it is of vital importance to consider both patient characteristics (such as identifying if the fistula is simple or complex) and surgeon-related factors. Overall, many of the papers published reported good outcomes with several surgical techniques. However, most of the reports in the literature are retrospective in nature, reporting only small series with limited statistical merit. Through our analysis of the varying surgical techniques, we were able to identify the following suggestions: Conservative management should be performed with both urinary and fecal diversion, especially for simple fistulas. The transanal approach is an alternative approach for use in small simple fistulas as well as sealant glues. The transperineal approach has shown great results for complex fistulas in some series, but it also increases the risk for stress urinary incontinence. In some cases, the transsphincteric approach has been linked to fecal incontinence. Finally, the transabdominal approach in a robotic fashion may be a reliable technique. However, physicians must consider the high cost and the danger of invasion of the peritoneum before its use.

As of yet there is still not enough evidence to determine which surgical techniques are best for the varying scenarios of RUF. However, one point remains true for every RUF case: surgical repairs should only be done by an expert, after proper patient selection, and with the intention of both achieving success in the first repair. In order to advance our understanding of RUF occurrences and treatment, larger prospective and randomized studies are needed.