Comparative outcomes of early and late rectourethral fistula: insights from a multicentric retrospective study on multidisciplinary management strategies

Pauline Jeannot; Edouard Roussel; Alexandre Dutoit; Maxime Collard; Niki Christou; Jérémie H. Lefevre; Amine Souadka; Alves Arnaud; Antonio Castaldi; Martin Bertrand; Nicolas Michot; Benjamin Faivre d’Arcier; Jean Jacques Tuech; Franck Bruyère; Urs Giger-Pabst; Mehdi Ouaïssi

doi:10.3393/ac.2025.00696.0099

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Original Article Complications Comparative outcomes of early and late rectourethral fistula: insights from a multicentric retrospective study on multidisciplinary management strategies: Pauline Jeannot¹, Edouard Roussel², Alexandre Dutoit³, Maxime Collard⁴, Niki Christou³, Jérémie H. Lefevre⁴, Amine Souadka⁵, Alves Arnaud⁶, Antonio Castaldi⁷, Martin Bertrand⁷, Nicolas Michot¹, Benjamin Faivre d’Arcier⁸, Jean Jacques Tuech², Franck Bruyère⁸, Urs Giger-Pabst⁹, Mehdi Ouaïssi¹, French Research Group of Rectal Cancer Surgery (GRECCAR); Annals of Coloproctology 2026;42(1):103-114.
DOI: https://doi.org/10.3393/ac.2025.00696.0099
Published online: February 23, 2026

¹Department of Digestive, Oncological, Endocrine, Hepatobiliary and Liver Transplant, Trousseau Hospital, University Hospital of Tours, Tours, France

²Department of Digestive, Oncological Surgery, CHU Rouen, Rouen, France

³Department of Digestive Surgery, Limoges Hospital, Limoges, France

⁴Department of Digestive Surgery, Hôpital Saint-Antoine, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Paris, France

⁵Department of Surgical Oncology, National Institute of Oncology, University Mohammed V in Rabat, Rabat, Morocco

⁶Department of Digestive Surgery, Inserm Unity UMR 1086 ANTICIPE, University of Caen Normandy, Caen, France

⁷Department of Digestive Surgery, University Hospital of Nîmes, Nîmes, France

⁸Department of Urology, Hôpital Bretonneau Hospital, CHU Tours, Tours, France

⁹Fliedner Fachhochschule, University of Applied Sciences Düsseldorf, Düsseldorf, Germany

Correspondence to: Mehdi Ouaïssi, MD, PhD Department of Digestive, Oncological, Endocrine, Hepatobiliary and Liver Transplant, Trousseau Hospital, University Hospital of Tours, Avenue de la République, Tours 37170, France Email: m.ouaissi@chu-tours.fr

• Received: May 28, 2025 • Revised: August 19, 2025 • Accepted: September 15, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
ARTICLE INFORMATION
REFERENCES

Abstract

Purpose
The objective of this study was to evaluate the natural history of early and late rectourethral fistulas (RUFs) and to determine the long-term outcomes of a multidisciplinary management approach.
Methods
A multicenter retrospective study was performed on patients with RUF who were treated by a combined colorectal and urological team. Early RUF (ERUF) was defined as occurring within 31 days after surgery, while late RUF (LRUF) was defined as occurring thereafter. Surgical procedures and the surgeons involved were recorded, in addition to clinical assessments, radiological findings, and oncological assessments.
Results
A total of 72 patients diagnosed with RUF were treated between January 1, 2010, and June 2023. Patients were divided into ERUF (n=37) and LRUF (n=35) groups. After conservative management, comparisons of success rates for graciloplasty, York-Mason, and delayed coloanal anastomosis as second and third treatments showed higher rates for graciloplasty in ERUF than in LRUF (83% vs. 40%, P=0.034; 71% vs. 33%, P=0.500; and 60% vs. 40%, P>0.999, respectively). The ERUF group demonstrated significantly higher cure rates after the second treatment (83.8% vs. 40.0%, P<0.001). At final follow-up, complete healing was significantly more frequent in ERUF than in LRUF (83.8% vs. 42.9%, P<0.005). Definitive digestive and urinary diversion rates were lower in ERUF (13.5% vs. 48.5%, P=0.001; and 13.5% vs. 25.7%, P=0.240, respectively).
Conclusion
These findings suggest that 30% of patients required a definitive colostomy, with a significantly higher proportion observed in the LRUF group. Moreover, repeated surgical procedures in the LRUF group were frequently unsuccessful.
Keywords: Rectourethral fistula; Prostate cancer; Colorectal surgery

INTRODUCTION

The incidence of rectourethral fistula (RUF) is relatively low, ranging from 0.5% to 3.3% [1, 2], most commonly following treatment for prostate or rectal cancer. Despite its rarity, RUF has a considerable impact on quality of life. Reported rates of permanent fecal and urinary diversion after treatment are 10.6% and 8.3%, respectively [3], with more recent reports indicating diversion rates as high as 20% [2, 4]. These rates rise to 45% to 84.2% after radiotherapy compared with 9% to 42.4% in patients without prior radiotherapy [5, 6]. The majority of RUFs are iatrogenic, arising as complications of prostate or rectal cancer therapy [2, 4]. The etiology of RUF is often multifactorial, influenced by multimodal treatments such as pelvic surgery, radiation therapy, and brachytherapy [3]. The risk of RUF also increases after rectal surgery in patients with a history of prostate cancer, independent of radiation exposure [7]. The complex etiology of RUF contributes to ongoing debates regarding optimal surgical management, both across specialties and within individual surgical fields. Approaches vary depending on factors such as fistula size, ischemic status, and prior radiation history, which explains the highly variable cure rates reported. Few studies have examined the median interval between diagnosis of RUF and the preceding causative surgical intervention [5, 8–10]. Reported median delays range from 3 to 20 days. Most RUFs develop within one month when rectal injury during urological surgery is missed or inadequately managed [5]. In colorectal surgery, the median onset of anastomotic fistulas is about 8 days postoperatively. While the median delay for RUF onset is approximately 3 weeks, delayed presentations ranging from one month to one year after the initial urological or colorectal insult have been documented [10]. These temporal patterns support the classification of RUFs into 2 categories—early and late—likely reflecting distinct pathophysiological mechanisms and necessitating different surgical strategies.

Management options include conservative measures such as bladder drainage with or without colostomy, or restorative procedures including the transanorectal York-Mason approach [1, 11] or gracilis muscle interposition [3, 8]. The choice of surgical technique is influenced by the surgeon’s expertise, the treating specialty, established decision-making algorithms, and whether the RUF is early or late. Long-term outcomes, however, remain inconsistent and sometimes contradictory. Variability arises from differing definitions of success—whether measured as complete fistula closure or avoidance of permanent diversion—as well as differences in follow-up practices and the confounding impact of recurrent prostate or rectal cancer. Repair is notoriously difficult because inflammatory changes distort anatomy and complicate dissection, particularly in irradiated patients. Multiple procedures over extended periods are often required for definitive closure [9]. Given the range of available techniques, this study aimed to compare the natural course of early versus late RUFs and to evaluate the long-term results of a multidisciplinary treatment approach in multiple specialized colorectal surgery centers. A further objective was to identify the most effective surgical strategies for maximizing closure rates and improving outcomes in both early- and late-onset RUFs.

METHODS

Ethics statement

This study received approval from the French Committee on Informatics and Liberty (Direction de la recherche clinique et de l’innovation- Guichet unique des Promoteurs Académique et industriel de L’AP-HP; No. DRCI-ACA-2025/6271) and the Ethics Committee of CHRU Trousseau (No. 2025-003). Written informed consent was obtained from all participants included in the study. All procedures involving human participants adhered to the ethical standards set forth by the institutional and/or national research committees, as well as the 1964 Declaration of Helsinki and its subsequent amendments or comparable ethical standards.

Study population and patient data collection

A multicenter retrospective review was conducted on patients presenting with RUF at the University Hospital of Tours, Paris (Saint-Antoine), Limoges (Dupuytren Hospital), Nîmes, Rabat (National institute of oncology) Morocco, University hospital of Rouen and Caen between January 2010 and June 2023. RUF was defined as a pathological communication between the urethra and either the rectum or a colorectal anastomosis. Suspicion of RUF typically arose in patients presenting with a combination of preoperative symptoms such as pneumaturia, fecaluria, and rectal leakage of urine, often in the setting of recurrent urinary tract infections. Diagnosis was confirmed by comprehensive clinical evaluation, which included pelvic examination, anoscopy, and cystoscopy to assess the parietal defect. Imaging modalities such as computed tomography (CT), magnetic resonance imaging (MRI), and urethrocystography were used to provide further diagnostic clarity. Additional cystoscopies and flexible or rigid rectosigmoidoscopies were performed to assess the bladder and rectum, ensuring a thorough evaluation. Fistulas were classified as complex if they were larger than 2 cm, associated with severe radiotherapy sequelae, and/or accompanied by significant urethral stricture [1]. Patients were excluded if they had undergone emergency surgery or if the fistula was attributable to other etiologies, including inflammatory bowel disease, trauma, congenital anomalies, or post-bladder cancer. RUFs were categorized according to the Chen classification system [1]. Collected patient characteristics included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status, history of prior pelvic surgery, and prior pelvic radiation. Complications of radiotherapy, such as cystitis and rectitis, were documented. Pelvic sepsis was defined as the presence of a pelvic abscess and/or fever, or pelvic inflammation visible on CT imaging. All patients were managed within a multidisciplinary team framework, involving both urologists and colorectal surgeons, to optimize patient care.

In our study, the median time to RUF occurrence was 31 days following the causative surgery. Accordingly, 50% of patients developed RUF within 31 days and 50% after this period. Based on this distribution, we defined early RUF (ERUF) as occurring within 31 days after surgery and late RUF (LRUF) as occurring more than 31 days after surgery.

Surgery

Four treatment strategies were employed: (1) conservative management (bladder catheterization with or without colostomy); (2) fistula repair via perineal approach with or without graciloplasty [4, 9]; (3) the York-Mason technique [10, 12, 13]; and (4) delayed coloanal anastomosis (DCAA) [14]. The York-Mason technique involves a posterior median incision through the intergluteal sulcus with the patient in the prone position. The posterior rectal wall is opened to expose the fistulous tract, with traction sutures applied to delineate the margins while identifying sphincter structures essential for continence. The tract is dissected to the prostate or membranous urethra in post-prostatectomy patients, after which the urethral wall is closed vertically with interrupted absorbable sutures. Perirectal fat is interposed between the rectal and urethral closures, and the posterior rectal wall is repaired in 2 layers over a bougie using absorbable sutures. Finally, sphincter continuity is restored with resorbable mattress sutures [10, 12]. The perineal approach with graciloplasty is generally performed with a lateral diverting colostomy. The patient is placed in lithotomy position, and the bladder is decompressed via straight catheterization. A perineal incision is made, the fistulous tract is excised, and the rectal wall is closed in 2 layers. The gracilis muscle is mobilized and interposed between the urethral suture line and the rectal repair, after which the urethral wall is closed with absorbable sutures [8]. The DCAA procedure, described in the GRECCAR study [14, 15], is a 2-step approach. First, an anterior resection of the rectum or resection of the previous colorectal anastomosis containing the RUF is performed. The urethral wall is then closed with absorbable sutures, and urinary catheterization is maintained for 4 weeks. The colon is pulled through the anus for 5 to 10 cm, and coloanal anastomosis is performed 5 to 7 days later.

Conservative treatment was initially employed in patients with asymptomatic fistulas smaller than 2 cm, without abscess, pelvic sepsis, or fecaluria. Adequate rectal vascularization and absence of prior radiotherapy were additional requirements. Colostomy was performed when pelvic sepsis or worsening symptoms (e.g., pain, fecaluria, or contamination) occurred, at the surgeon’s discretion. Conservative treatment was deemed unsuccessful if closure was not achieved within 6 weeks, as confirmed by imaging.

The York-Mason technique was selected for fistulas larger than 2 cm, those associated with prior radiotherapy, or those persisting after failed conservative therapy. This decision was typically made by the urologist.

Graciloplasty was indicated for defects exceeding 2 cm, in cases of poor vascularization, significant urethral tissue loss (>2 cm), or in the presence of a septic focus. It was also considered after failure of conservative or York-Mason procedures and was usually performed by the colorectal surgeon. The colorectal surgeon chose whether to perform graciloplasty.

DCAA was reserved for complex fistulas involving colorectal anastomoses or inadequate rectal vascularization. In recurrent cases after initial surgical or urological treatment, management strategies were developed collaboratively by urologists and colorectal surgeons. Colostomies were reversed after 3 months in patients with septic symptoms (e.g., fever, soiling, abscess), provided healing was confirmed with contrast-enhanced CT and MRI. No ileostomies were performed. In patients with persistent fistula or poor functional outcomes for both urinary and bowel systems, a Bricker ileal conduit was created for urinary diversion. Total pelvic exenteration was performed in cases of chronic pelvic sepsis.

Postoperative morbidity, mortality, and recurrence

The surgical technique selected and the experience of the operating surgeon were documented. Clinical evaluation included symptom assessment, physical examination, and radiologic investigations with MRI and CT scans to determine oncologic status. Data collected comprised patient demographics, clinical presentation, etiology, diagnostic procedures, and the use of fecal and/or urinary diversion. Operative details, definitive treatments, and morbidity and mortality outcomes were also recorded. Follow-up information was obtained during outpatient clinic visits. Together, this systematic data collection and a review of relevant literature provided the basis for evaluating and discussing management strategies for these patients.

Oncological monitoring

The choice of surgical technique and the surgeon performing the procedure were documented, with final decisions made at the discretion of the surgical team. Patient consultations included detailed symptom review, clinical observations, and radiologic evaluations such as MRI and CT, along with comprehensive oncologic assessments. Data gathered encompassed demographics, clinical presentation, underlying etiology, diagnostic modalities, use of fecal and/or urinary diversion, definitive treatment strategy, operative details, and outcomes, including morbidity and mortality. Follow-up data were systematically collected at outpatient visits. The compiled dataset, combined with an extensive review of the literature, was analyzed to develop a systematic algorithm for patient management. Prostate cancer patients were monitored at three-month intervals with prostate-specific antigen (PSA) testing and clinical examination, including digital rectal examination. If PSA levels remained undetectable, monitoring was extended to 6-month intervals for 3 to 5 years, and then annually, without routine imaging. Long-term follow-up was performed at clinic visits, with urinary and digestive functional outcomes assessed on December 31, 2024. Median follow-up duration was 68 months (range, 3–150 months).

Statistical analysis

Comparisons between ERUF and LRUF were performed using IBM SPSS ver. 20 (IBM Corp). For categorical variables, the chi-square test was used, or the Fisher exact test when the chi-square assumptions were not met. For continuous variables, comparisons were performed using the Mann-Whitney nonparametric rank-sum test in cases of non-normality. Continuous variables are presented as median values with ranges (minimum to maximum), and categorical variables as frequencies and percentages. For qualitative variables, comparisons of percentages employed the chi-square test or the Fisher exact test, as appropriate. A P-value of <0.05 was considered statistically significant.

RESULTS

Preoperative characteristics of patients

Seventy-two patients with RUF were treated between January 1, 2010, and June 2023. The etiologies of RUF are summarized in Table 1. The median patient age was 69 years (range, 30–85 years), and the median BMI was 25 kg/m² (range, 17–40 kg/m²). Patients were divided into 2 groups: ERUF (n=37, 51.4%) and LRUF (n=35, 48.6%). No significant differences were found between groups with respect to ASA physical status, diabetes mellitus, chronic renal insufficiency, pulmonary disease, peripheral vascular disease, hypertension, congestive heart failure, or coronary artery disease. The main etiology for ERUF was prostate pathology, consistently associated with surgical treatment (n=37, 100%). In contrast, the primary causes of LRUF were prostate pathology (n=24, 68.6%) and colorectal cancer (n=11, 31.4%), with 20 patients (57.1%) also having received concomitant radiotherapy (P<0.001). Minimally invasive surgical approaches were significantly more frequent in the ERUF group compared with the LRUF group, including laparoscopy (36.1% vs. 19.4%) and robotic procedures (30.6% vs. 6.4%, P=0.002). Perioperative rectal injuries occurred in 15 patients (20.8%) and were significantly more frequent in the ERUF group than in the LRUF group (32.4% vs. 8.6%, P=0.019). Concerning the 15 patients with perioperative rectal injury, 13 (86.7%) were managed by simple rectal suturing without colostomy. The last 2 patients required colostomy with rectal suturing (1 patient in each group).

Clinical presentations

A comparison of clinical presentations between the ERUF and LRUF groups is presented in Table 2. In the study, 28 patients (38.9%) had fecaluria, 33 (45.8%) had pneumaturia, and 23 (31.9%) had pelvic sepsis, defined as pelvic abscess, fever, and pelvic inflammatory disease. There were no significant differences in clinical symptoms or imaging findings. The median time from onset of symptoms after the first procedure was significantly shorter in the ERUF group (8 days; range, 1–31 days) compared with the LRUF group (6.6 months; range, 2–156 months; P<0.001). The median fistula size was 10 mm (range, 1–50 mm) across all patients, with no significant difference between groups (P=0.763). According to the Chen classification system, complex fistulas were observed in 36 RUF cases (50.0%) and were significantly less frequent in the ERUF group compared with the LRUF group (35.1% vs. 65.7%, P=0.017).

Details about RUF management

Urologists managed 59.5% of ERUF cases and 37.1% of LRUF cases. All RUFs were treated in specialized centers after diagnosis. Patients who initially underwent urological or colorectal surgery at outside institutions frequently received rectal suturing upon diagnosis of RUF following urological procedures, with colostomy performed in 2 cases. Urologists and colorectal surgeons were responsible for the initial management in 48.6% and 16.7% of all cases, respectively, while in 34.7% of cases, both specialties collaborated. No significant differences were observed in management strategies between ERUF and LRUF; however, a trend was noted for complex, late-onset RUFs to be treated by combined urological and colorectal surgical teams. Complete cure after initial treatment was achieved in only 8.1% of ERUF cases compared with 17.1% of LRUF cases. Successful initial treatment for ERUF consisted of 2 conservative treatments and 1 York-Mason procedure. In contrast, successful initial treatment for LRUF required 5 surgical procedures: 2 York-Mason procedures, 1 DCAA, and 2 graciloplasty procedures. One healing occurred with conservative management alone.

Concerning ERUF, graciloplasty was often performed as the second or third treatment, with a success rate of 83.3% (15 of 18) after conservative treatment involving urinary drainage with or without colostomy. The York-Mason procedure was used in 7 patients following conservative management, with a success rate of 71.4% (5 of 7). DCAA was performed in 5 patients after conservative treatment, achieving a success rate of 60.0% (3 of 5). All procedures for ERUF performed are summarized in Fig. 1.

For LRUF, graciloplasty was performed in 10 patients as a second or third treatment, with a success rate of 40.0% (4 of 10) after conservative management (urinary drainage with or without colostomy). The York-Mason procedure was used in 3 patients, with a success rate of 33.3% (1 of 3), and DCAA was used in 5 patients, with a success rate of 40.0% (2 of 5). All procedures for RUF performed are summarized in Fig. 2.

When comparing second and third treatments after conservative management, success rates for graciloplasty, the York-Mason procedure, and DCAA were consistently higher in ERUF compared with LRUF: 83.3% vs. 40.0% (P=0.034), 71.4% vs. 33.3% (P=0.500), and 60% vs. 40% (P>0.999), respectively. By the end of follow-up, the rate of complete healing was significantly higher in the ERUF group (n=31, 83.8%) than in the LRUF group (n=15, 42.9%; P<0.005).

The ERUF group demonstrated higher cure rates after both first and second treatments: 54.0% vs. 40.0% after the first surgery (P=0.249) and 83.7% vs. 40.0% after the second surgery (P<0.005) (P<0.005) (Figs. 1, 3, 4). In the LRUF group, 2 pelvic exenterations and 2 Hartmann procedures were performed by the end of follow-up. Detailed surgical outcomes are summarized in Figs. 2 and 3.

Long-term outcomes

With a median follow-up of 68 months (range, 3–150 months), no significant difference in follow-up duration was observed between the ERUF and LRUF groups (68 months vs. 70 months, respectively). In both groups, 3 patients experienced cancer recurrence, resulting in 3 recurrence-related deaths in each.

The mean time to colostomy closure was 60 days (range, 10–365 days), with a shorter interval observed in the ERUF group compared with the LRUF group (55 days vs. 70 days, P=0.607). By the end of follow-up, statistically significant differences were observed between groups in diversion outcomes. The overall colostomy rate was 30.6% (n=22). Final colostomy was required in 5 ERUF patients (13.5%) compared with 17 LRUF patients (48.6%; P=0.001). Urinary diversion was performed in 5 ERUF patients (13.5%) vs. 9 LRUF patients (25.7%; P=0.240).

DISCUSSION

RUF is a rare but serious complication that profoundly affects urogenital function and overall quality of life. This French multicenter study, the largest of its kind to date, evaluated demographic and therapeutic risk factors for RUF development, as well as the effectiveness of multidisciplinary management strategies. A key aspect of RUF pathogenesis is the timing of its onset, which demonstrates a bimodal distribution—early versus late occurrence. Early RUFs typically arise within 30 days of prostatectomy, particularly in patients without prior radiotherapy, while late RUFs develop after 30 days and are more common in patients who have undergone radiotherapy for prostate or rectal cancer. Our findings confirm that ERUFs often result from rectal injuries sustained during prostate surgery, even when intraoperative rectal suturing is performed. This observation aligns with Romito et al. [16], who reported that more than 10% of rectal injuries identified during prostatectomy were associated with ERUFs, typically presenting with fecaluria or pneumaturia within 1 month. The pathogenesis of ERUFs may include misdiagnosed or inadequately treated rectal injuries during pelvic surgery. In most cases of ERUF, urinary diversion and colostomy were undertaken, yet only 8.1% (3 of 37 patients) achieved complete recovery after initial treatment—a finding consistent with prior studies [4, 6]. Although the role of this initial management remains uncertain, it may help reduce local inflammation in the pelvis, thereby facilitating subsequent surgical repair [4]. Among surgical strategies, graciloplasty was the most frequently performed procedure in our series and demonstrated a high rate of complete healing (83%). This is supported by prior literature [4]. The gracilis muscle is favored due to its robust vascular supply, mobility, and favorable donor-site healing, as well as its distance from radiotherapy fields. The transperineal approach is particularly advantageous for complex fistulas in irradiated tissue. Current evidence suggests closure rates approaching 90% regardless of prior radiotherapy or ablative treatment, and this approach accounts for about two-thirds of reported RUF repairs [3]. Nevertheless, stress urinary incontinence remains the most common complication, largely due to the proximity of the repair to the urethral sphincter, with reported rates of 60% to 70% [9, 17]. In our study, graciloplasty for ERUF yielded a success rate of 83%, outperforming York-Mason (71%) and DCAA (60%). Table 3 compares findings from prior studies with those of the current study [4–6, 9, 12, 17–20]. The lower success rate of DCAA is likely attributable to its use in treating more complex fistulas with poor vascularization and large rectal wall defects. In contrast, outcomes for LRUF were significantly worse, with success rates of 40% for graciloplasty and 33% for both York-Mason and DCAA. The York-Mason procedure, employing a transsphincteric perineal approach, has shown success rates of 80% to 92% in prior clinical studies and remains a popular option among urologists [12, 18, 19]. It is typically considered a third-line approach for persistent RUFs. However, in our series it was infrequently employed for either ERUFs or LRUFs, likely because most patients were managed by colorectal surgeons, who preferred graciloplasty due to its sphincter-preserving advantages. Instead, pull-through coloanal anastomosis was more often used, probably reflecting the fact that most RUFs in this study were secondary to complications of prostate surgery. By contrast, DCAA is more commonly indicated in LRUFs, which often result from prior rectal surgery or extensive rectal lesions. Comparisons between early and late RUFs also demonstrated strong associations between LRUF, prior radiotherapy, and previous rectal surgery, which may explain their poorer long-term outcomes. Surgical success rates for second-line procedures after failed initial management were especially poor in LRUF. We also attempted to identify the optimal surgical treatment and risk factors for poor healing using logistic regression. Initial variables included treatment type (graciloplasty, York-Mason, or DCAA, with or without digestive diversion), number of surgeries, and etiology. However, the null hypothesis could not be validated because of strong interdependence among these variables, preventing robust statistical conclusions about optimal surgical choice. This limitation underscores the heterogeneity of RUF management and highlights the impact of treatment variability on outcomes. One possible explanation is that not all patients were initially managed by collaborative teams of colorectal and urological surgeons, which may have influenced both procedure selection and outcomes. After conservative treatment, the success rates for graciloplasty, York-Mason, and DCAA as second or third procedures were 40.0%, 33.3%, and 40.0%, respectively, with no improvement after repeat surgery. This outcome contrasts with ERUF management, where cure rates increased significantly after successive treatments: 54.0% vs. 40.0% after the first surgical treatment and 83.3% vs. 40.0% after the second. While our study did not analyze functional outcomes, the rates of permanent urinary diversion and colostomy were significantly lower in ERUF compared with LRUF. Based on these findings, we recommend considering repeat surgery for early RUFs to promote fistula healing. In contrast, the poor prognosis of late RUFs underscores the importance of minimizing the number of procedures and prioritizing quality of life, which is often achieved through stoma formation. Patients must be informed at the outset about the potential for poor surgical outcomes, particularly when presenting with LRUF. The distribution of surgical approaches between abdominal procedures (DCAA, suture, epiploplasty) and perineal techniques was relatively balanced, with frequent collaboration between urologists and colorectal surgeons. More aggressive procedures such as pelvic exenteration were employed more often for LRUF than for ERUF. Consistent with the findings of Hanna et al. [5], our series showed lower stoma closure rates in LRUF, likely due to prior radiotherapy. Furthermore, our analysis confirmed a low probability of definitive cure in LRUF patients, even after repeated operations. This contrasts with meta-analyses reporting lower rates of definitive colostomy (10%) and urinary diversion (8%) compared with our observed rates of 30.6% and 19.4%, respectively [3]. However, many of these meta-analyzed studies had small sample sizes (<30 patients) and short follow-up (<24 months). By comparison, the long-term study of Bislenghi et al. [6] reported that 36.7% of patients underwent definitive urinary or colostomy procedures after 10 years of follow-up, with a significantly higher risk among those with prior radiotherapy (84% vs. 42%, P=0.004). Taken together, these results confirm that colostomy is the most effective initial treatment for patients with a history of radiotherapy before considering more complex pelvic reconstructive procedures such as graciloplasty or DCAA. Nevertheless, the social and psychological implications of colostomy remain considerable, particularly in France, where long postoperative delays can make acceptance challenging. Some patients required additional support to adjust to stoma formation, which was sometimes perceived as a recurrence of disease or as treatment failure. In these circumstances, conservative therapy was occasionally used as a compassionate approach to help patients accept eventual stoma formation. It is therefore essential that patients are fully informed early in the treatment pathway about the risks of repeated surgery and the potential for treatment failure, especially in cases of LRUF.

This study has limitations. First, it is a retrospective multicenter study. Second, treatment decisions were made according to the experience and preferences of each surgical team. Thus, the results reflect real-world clinical practice rather than a standardized protocol.

Conclusions

To date, no large multicenter study has compared the demographics, management strategies, and outcomes of early versus late RUFs. In our cohort, 30% of patients required definitive urinary or colostomy diversion, with significantly higher rates in LRUF. This may be attributable to the greater prevalence of radiotherapy in this group. In LRUF, complete healing was rarely achieved after second-line interventions, highlighting the importance of counseling patients early about the likelihood of suboptimal outcomes. A crucial component of RUF management is the initial strategy: colostomy with bladder catheterization when the fistula occurs after surgery, followed by reconstructive surgery. The choice between the York-Mason procedure and graciloplasty should be guided by surgeon expertise, with graciloplasty preferred for larger urethral defects.

ARTICLE INFORMATION

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

The authors declare that there are no financial ties or external funding to disclose. Administrative support was provided by the Association Tourangelle de Recherche en Oncologie du Val de Loire (AT-ROVL) and through institutional resources of the Fliedner Fachhochschule, University of Applied Sciences, Düsseldorf, Germany.

Acknowledgments

The authors would like to thank Guillaume Proutheau, the coordinator of all clinical studies in our department, for his invaluable secretarial assistance.

Author contributions

Conceptualization: PJ, MO; Data curation: PJ, ER, AD, MC, NC, JHL, AS, AA, AC, MB, NM, MO; Formal analysis: PJ, MO, AA, MC, NC, JHL, AS, BFdA, JJT, FB, UGP; Methodology: PJ, MO; Supervision: UGP, MO; Writing–original draft: MO, UGP; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Fig. 1.

Overview of all surgical procedures with the overall healing rate for early rectourethral fistula (ERUF). DCAA, delayed coloanal anastomosis.

Fig. 2.

Overview of all surgical procedures with the overall healing rate for late rectourethral fistula (LRUF). (A) After conservative initial management. (B) After initial surgery. DCAA, delayed coloanal anastomosis.

Fig. 3.

Comparison of successful surgery between early and late urethrorectal fistulas as a function of the number of operations. ERUF, early rectourethral fistula; LRUF, late rectourethral fistula; NS, not significant. ^aOut of 37 ERUF patients, 2 conservative treatments and 1 York-Mason procedure;; out of 35 LRUF patients, 26 (74.2%) had conservative treatment with or without colostomy, 3 had York-Mason procedure, 3 had delayed coloanal anastomosis, 2 had graciloplasty, and 1 patient had Hartmann procedure and cystectomy. *P<0.05; ***P<0.001.

Fig. 4.

Comparison of surgical success in early rectourethral fistula (ERUF) and late rectourethral fistula (LRUF) as a function of the type of surgery. DCAA, delayed coloanal anastomosis.

Table 1.

Comparison between ERUF and LRUF regarding demographics and comorbidities

Characteristic	Total (n=72)	ERUF (≤31 days) (n=37)	LRUF (>31 days) (n=35)	P-value
Age (yr)	69 (30–85)	68 (30–76)	69 (41–85)	0.404
Body mass index (kg/m²)	25 (17–40)	25 (20–31)	26 (17–40)	0.885
ASA physical status				0.424
I	24 (33.3)	15 (40.5)	9 (25.7)
II	39 (54.2)	18 (48.6)	21 (60.0)
III	9 (12.5)	4 (10.8)	5 (14.3)
Comorbidity
Diabetes mellitus	9 (12.5)	2 (5.4)	7 (20.0)	0.081
Renal chronic insufficiency	3 (4.2)	0 (0)	3 (8.6)	0.109
Pulmonary disease	5 (6.9)	2 (5.4)	3 (8.6)	0.669
Peripheral vascular disease	7 (9.7)	3 (8.1)	4 (11.4)	0.706
Hypertension	33 (45.8)	16 (43.2)	17 (48.6)	0.637
Congestive heart failure	7 (9.7)	4 (10.8)	3 (8.6)	>0.999
Coronary artery disease	7 (9.7)	4 (10.8)	3 (8.6)	>0.999
Complication of radiotherapy	13 (18.1)	1 (2.7)	12 (34.3)	<0.001^*
Etiology of RUF				<0.001^*
Prostate cancer	58 (80.6)	37 (100)	21 (60.0)
Benign prostate pathology	3 (4.2)	0 (0)	3 (8.6)
Colorectal cancer	11 (15.3)	0 (0)	11 (31.4)^a
Treatment prior to RUF
Prostatectomy	50 (69.4)	36 (97.3)	14 (40.0)	<0.001^*
Prostatectomy post-radiotherapy/brachytherapy	6 (8.3)	0 (0)	6 (17.1)	0.010^*
Previous radiotherapy	22 (30.6)	2 (5.4)	20 (57.1)	<0.001^*
Only radiotherapy or brachytherapy	2 (2.7)	1 (2.7)	1 (2.9)	>0.999
Endoscopic treatment of benign prostate hypertrophy	3 (4.2)	0 (0)	3 (8.6)	0.109
Rectal surgery				0.002^*
Laparoscopy	19/67 (28.4)	13/36 (36.1)	6/31 (19.4)
Robotic surgery^b	13/67 (19.4)	11/36 (30.6)	2/31 (6.4)
Laparotomy	35/67 (58.2)	12/36 (33.3)	23/31 (74.2)
Treatment detail
Management by urologist	35 (48.6)	22 (59.5)	13 (37.1)	-
Management by colorectal surgeon	12 (16.7)	6 (16.2)	6 (17.1)	0.119
Other or interdisciplinary team	25 (34.7)	9 (24.3)	16 (45.7)	-
Rectal injury during surgery	15 (20.8)	12 (32.4)	3 (8.6)	0.019^*

Values are presented as median (range) or number (%).

ERUF, early rectourethral fistula; LRUF, late rectourethral fistula; ASA, American Society of Anesthesiologists; RUF, rectourethral fistula.

^aLaparoscopy, laparotomy and robotic surgery is for all patients and all etiologies; 5 patients had no surgical approach for treatment of urologic or rectal pathologies. ^bNo conversion in the robotic surgery group.

*P<0.05.

Table 2.

Comparison between ERUF and LRUF regarding symptoms and type of fistula

Symptom	Total (n=72)	ERUF (≤31 days) (n=37)	LRUF (>31 days) (n=35)	P-value
Clinical symptom
Fecaluria	28 (38.9)	14 (37.8)	14 (40.0)	>0.999
Pneumaturia	33 (45.8)	15 (40.5)	18 (51.4)	0.478
Pelvic sepsis	23 (31.9)	13 (35.1)	10 (28.6)	0.618
Imaging finding				0.060
CT	60 (83.3)	34 (91.9)	26 (74.3)
MRI	12 (16.7)	3 (8.1)	9 (25.7)
Onset of RUF symptom	1 mo (1 day–156 mo)	8 days (1–31 days)	6.6 mo (2–156 mo)	<0.001
Fistula size (mm)	10 (1–50)	10 (3–50)	10 (1–30)	0.763
Associated stenosis of urethra	12 (16.7)	3 (8.1)	9 (25.7)	0.060
Complexity of RUF^a				0.017^*
Simple	36 (50.0)	24 (64.9)	12 (34.3)
Complex	36 (50.0)	13 (35.1)	23 (65.7)

Values are presented as number (%) or median (range).

ERUF, early rectourethral fistula; LRUF, late rectourethral fistula; CT, computed tomography; MRI, magnetic resonance imaging; RUF, rectourethral fistula.

^aAccording to the Chen classification system [1].

*P<0.05.

Table 3.

Different series reporting the results of RUF treatment

Study	Study period	No. of patients	Urologic etiology	No. of patients after radiotherapy	No. of treatments					No. of treatments included^a	Overall success rate (%)	Permanent colostomy	Permanent urinary diversion
Study	Study period	No. of patients	Urologic etiology	No. of patients after radiotherapy	Colostomy	Graciloplasty	York-Mason	DCAA	Other abdominal treatment	No. of treatments included^a	Overall success rate (%)	Permanent colostomy	Permanent urinary diversion
Hadley et al. [12]	2003–2011	51	51 (100)	7 (13.7)	0 (0)	0 (0)	51 (100)^a	0 (0)	0 (0)	-	92	-	-
Dafnis [18]	2002–2016	20	20 (100)	3 (15.0)	0 (0)	0 (0)	20 (100)^a	0 (0)	0 (0)	-	65	7 (35.0)	Urinary prothesis
Jeannot et al. [4]	2002–2020	20	20 (100)	3 (15.0)	13/47 (27.7)	12/47 (25.5)	12/47 (25.5)	0 (0)	10/27 (37.0)	47^b	95	4 (20.0)	4 (20.0)
Lainé et al. [19]	1997–2021	35	35 (100)	0 (0)	0 (0)	0 (0)	35 (100)	0 (0)	0 (0)	14	80	-	-
Hanna et al. [5]	1996–2012	37	34 (91.9)	21 (56.8)	22 (59.5)^a	11 (29.7)	10 (27.0)	0 (0)		-	75.6	6/22 (27.3)	-
Bislenghi et al. [6]	2002–2019	52	40 (76.9)	30 (57.7)	-	9/76 (11.8)	0 (0)	45/76 (59.2)	-	76^c	96.1	19 (36.5)
Emile et al. [20]	2000–2018	53	53 (100)	28 (52.8)	-	53 (100)	0 (0)	0 (0)	0 (0)	-	81.1	3 (5.5)
Wexner et al. [9]	1995–2007	36	36 (100)	27 (75.0)	-	36 (100)	0 (0)	0 (0)	0 (0)	-	97	6 (16.1)	-
Sbizzera et al. [17]	2008–2020	21	20 (95.2)	2 (9.5)	-	21 (100)	0 (0)	0 (0)	0 (0)	-	95	2/21 (9.5)
This study	2010–2023	72	61 (84.7)	22 (30.6)	81/142 (57.0)	30/142 (21.1)	14/142 (9.9)	11/142 (7.7)	6/142 (4.2)	142	73.6	22 (30.6)	14 (19.4)

Values are presented as number (%), unless otherwise indicated.

RUF, rectourethral fistula; DCAA, delayed coloanal anastomosis.

^aFirst treatment. ^bMedical or surgical procedures. ^cSurgical procedures.

REFERENCES

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13. Dal Moro F, Mancini M, Pinto F, Zanovello N, Bassi PF, Pagano F. Successful repair of iatrogenic rectourinary fistulas using the posterior sagittal transrectal approach (York-Mason): 15-year experience. World J Surg 2006;30:107–13. Article PubMed PDF
14. Collard MK, Rullier E, Tuech JJ, Sabbagh C, Souadka A, Loriau J, 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;278:781–9. Article PubMed
15. Collard MK, Tuech JJ, Sabbagh C, Souadka A, Loriau J, Rullier E, et al. Long-term bowel function following delayed coloanal anastomosis: analysis of a multicentric cohort study (GRECCAR). Colorectal Dis 2025;27:e70013. Article PubMed PMC
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Comparative outcomes of early and late rectourethral fistula: insights from a multicentric retrospective study on multidisciplinary management strategies

Ann Coloproctol. 2026;42(1):103-114. Published online February 27, 2026

DOI: https://doi.org/10.3393/ac.2025.00696.0099

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Figure

Comparative outcomes of early and late rectourethral fistula: insights from a multicentric retrospective study on multidisciplinary management strategies

Fig. 1. Overview of all surgical procedures with the overall healing rate for early rectourethral fistula (ERUF). DCAA, delayed coloanal anastomosis.

Fig. 2. Overview of all surgical procedures with the overall healing rate for late rectourethral fistula (LRUF). (A) After conservative initial management. (B) After initial surgery. DCAA, delayed coloanal anastomosis.

Fig. 3. Comparison of successful surgery between early and late urethrorectal fistulas as a function of the number of operations. ERUF, early rectourethral fistula; LRUF, late rectourethral fistula; NS, not significant. aOut of 37 ERUF patients, 2 conservative treatments and 1 York-Mason procedure;; out of 35 LRUF patients, 26 (74.2%) had conservative treatment with or without colostomy, 3 had York-Mason procedure, 3 had delayed coloanal anastomosis, 2 had graciloplasty, and 1 patient had Hartmann procedure and cystectomy. *P<0.05; ***P<0.001.

Fig. 4. Comparison of surgical success in early rectourethral fistula (ERUF) and late rectourethral fistula (LRUF) as a function of the type of surgery. DCAA, delayed coloanal anastomosis.

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

Comparative outcomes of early and late rectourethral fistula: insights from a multicentric retrospective study on multidisciplinary management strategies

Characteristic	Total (n=72)	ERUF (≤31 days) (n=37)	LRUF (>31 days) (n=35)	P-value
Age (yr)	69 (30–85)	68 (30–76)	69 (41–85)	0.404
Body mass index (kg/m²)	25 (17–40)	25 (20–31)	26 (17–40)	0.885
ASA physical status				0.424
I	24 (33.3)	15 (40.5)	9 (25.7)
II	39 (54.2)	18 (48.6)	21 (60.0)
III	9 (12.5)	4 (10.8)	5 (14.3)
Comorbidity
Diabetes mellitus	9 (12.5)	2 (5.4)	7 (20.0)	0.081
Renal chronic insufficiency	3 (4.2)	0 (0)	3 (8.6)	0.109
Pulmonary disease	5 (6.9)	2 (5.4)	3 (8.6)	0.669
Peripheral vascular disease	7 (9.7)	3 (8.1)	4 (11.4)	0.706
Hypertension	33 (45.8)	16 (43.2)	17 (48.6)	0.637
Congestive heart failure	7 (9.7)	4 (10.8)	3 (8.6)	>0.999
Coronary artery disease	7 (9.7)	4 (10.8)	3 (8.6)	>0.999
Complication of radiotherapy	13 (18.1)	1 (2.7)	12 (34.3)	<0.001^*
Etiology of RUF				<0.001^*
Prostate cancer	58 (80.6)	37 (100)	21 (60.0)
Benign prostate pathology	3 (4.2)	0 (0)	3 (8.6)
Colorectal cancer	11 (15.3)	0 (0)	11 (31.4)^a
Treatment prior to RUF
Prostatectomy	50 (69.4)	36 (97.3)	14 (40.0)	<0.001^*
Prostatectomy post-radiotherapy/brachytherapy	6 (8.3)	0 (0)	6 (17.1)	0.010^*
Previous radiotherapy	22 (30.6)	2 (5.4)	20 (57.1)	<0.001^*
Only radiotherapy or brachytherapy	2 (2.7)	1 (2.7)	1 (2.9)	>0.999
Endoscopic treatment of benign prostate hypertrophy	3 (4.2)	0 (0)	3 (8.6)	0.109
Rectal surgery				0.002^*
Laparoscopy	19/67 (28.4)	13/36 (36.1)	6/31 (19.4)
Robotic surgery^b	13/67 (19.4)	11/36 (30.6)	2/31 (6.4)
Laparotomy	35/67 (58.2)	12/36 (33.3)	23/31 (74.2)
Treatment detail
Management by urologist	35 (48.6)	22 (59.5)	13 (37.1)	-
Management by colorectal surgeon	12 (16.7)	6 (16.2)	6 (17.1)	0.119
Other or interdisciplinary team	25 (34.7)	9 (24.3)	16 (45.7)	-
Rectal injury during surgery	15 (20.8)	12 (32.4)	3 (8.6)	0.019^*

Symptom	Total (n=72)	ERUF (≤31 days) (n=37)	LRUF (>31 days) (n=35)	P-value
Clinical symptom
Fecaluria	28 (38.9)	14 (37.8)	14 (40.0)	>0.999
Pneumaturia	33 (45.8)	15 (40.5)	18 (51.4)	0.478
Pelvic sepsis	23 (31.9)	13 (35.1)	10 (28.6)	0.618
Imaging finding				0.060
CT	60 (83.3)	34 (91.9)	26 (74.3)
MRI	12 (16.7)	3 (8.1)	9 (25.7)
Onset of RUF symptom	1 mo (1 day–156 mo)	8 days (1–31 days)	6.6 mo (2–156 mo)	<0.001
Fistula size (mm)	10 (1–50)	10 (3–50)	10 (1–30)	0.763
Associated stenosis of urethra	12 (16.7)	3 (8.1)	9 (25.7)	0.060
Complexity of RUF^a				0.017^*
Simple	36 (50.0)	24 (64.9)	12 (34.3)
Complex	36 (50.0)	13 (35.1)	23 (65.7)

Study	Study period	No. of patients	Urologic etiology	No. of patients after radiotherapy	No. of treatments					No. of treatments included^a	Overall success rate (%)	Permanent colostomy	Permanent urinary diversion
Study	Study period	No. of patients	Urologic etiology	No. of patients after radiotherapy	Colostomy	Graciloplasty	York-Mason	DCAA	Other abdominal treatment	No. of treatments included^a	Overall success rate (%)	Permanent colostomy	Permanent urinary diversion
Hadley et al. [12]	2003–2011	51	51 (100)	7 (13.7)	0 (0)	0 (0)	51 (100)^a	0 (0)	0 (0)	-	92	-	-
Dafnis [18]	2002–2016	20	20 (100)	3 (15.0)	0 (0)	0 (0)	20 (100)^a	0 (0)	0 (0)	-	65	7 (35.0)	Urinary prothesis
Jeannot et al. [4]	2002–2020	20	20 (100)	3 (15.0)	13/47 (27.7)	12/47 (25.5)	12/47 (25.5)	0 (0)	10/27 (37.0)	47^b	95	4 (20.0)	4 (20.0)
Lainé et al. [19]	1997–2021	35	35 (100)	0 (0)	0 (0)	0 (0)	35 (100)	0 (0)	0 (0)	14	80	-	-
Hanna et al. [5]	1996–2012	37	34 (91.9)	21 (56.8)	22 (59.5)^a	11 (29.7)	10 (27.0)	0 (0)		-	75.6	6/22 (27.3)	-
Bislenghi et al. [6]	2002–2019	52	40 (76.9)	30 (57.7)	-	9/76 (11.8)	0 (0)	45/76 (59.2)	-	76^c	96.1	19 (36.5)
Emile et al. [20]	2000–2018	53	53 (100)	28 (52.8)	-	53 (100)	0 (0)	0 (0)	0 (0)	-	81.1	3 (5.5)
Wexner et al. [9]	1995–2007	36	36 (100)	27 (75.0)	-	36 (100)	0 (0)	0 (0)	0 (0)	-	97	6 (16.1)	-
Sbizzera et al. [17]	2008–2020	21	20 (95.2)	2 (9.5)	-	21 (100)	0 (0)	0 (0)	0 (0)	-	95	2/21 (9.5)
This study	2010–2023	72	61 (84.7)	22 (30.6)	81/142 (57.0)	30/142 (21.1)	14/142 (9.9)	11/142 (7.7)	6/142 (4.2)	142	73.6	22 (30.6)	14 (19.4)

Table 1. Comparison between ERUF and LRUF regarding demographics and comorbidities

Values are presented as median (range) or number (%).

ERUF, early rectourethral fistula; LRUF, late rectourethral fistula; ASA, American Society of Anesthesiologists; RUF, rectourethral fistula.

*P<0.05.

Table 2. Comparison between ERUF and LRUF regarding symptoms and type of fistula

Values are presented as number (%) or median (range).

ERUF, early rectourethral fistula; LRUF, late rectourethral fistula; CT, computed tomography; MRI, magnetic resonance imaging; RUF, rectourethral fistula.

^aAccording to the Chen classification system [1].

*P<0.05.

Table 3. Different series reporting the results of RUF treatment

Values are presented as number (%), unless otherwise indicated.

RUF, rectourethral fistula; DCAA, delayed coloanal anastomosis.

^aFirst treatment. ^bMedical or surgical procedures. ^cSurgical procedures.