A rectourethral fistula (RUF) is a complication of pelvic cancer treatment, with an incidence of 0.4–3%.  Most RUF are iatrogenic, either from surgery alone or from non-surgical, energy-ablation treatment modalities, or a combination of these. Conservative treatment is rarely successful, except in small, non-radiated fistulae.

A retrospective database search was performed in five centers to identify patients with RUF resulting from pelvic cancer treatment. Medical records were analyzed for demographics, comorbidities, diagnostic evaluation, fistula characteristics, surgical approaches and outcomes. Because of the heterogeneity of the RUF characteristics after radiation/energy-ablation, ranging from minimal changes in surrounding tissue to extensive local damage, there is no standardized approach for its treatment. Also therefore and the endpoints analyzed included a successful fistula closure following a repair and the impact of the potential adverse features on outcomes. Due to differences in treatment, outcomes and impact on the QoL, we divided patients into two major groups: (1) radiotherapy/energy-ablation ± surgery (G1); (2) surgery alone (G2).

43 patients, aged 57–79 years (median 68), underwent an RUF reconstruction. The median follow-up (FU) was 54 months (range 18–115). The patients were divided into two groups according to the etiology: radiation/energy-ablation treatments with or without surgery (G1, n = 25) and surgery only (G2, n = 18). All of the patients underwent a temporary diverting colostomy and suprapubic cystostomy. Currently, the main approaches to an RUF closure are the following: (1) transperineal; (2) transanal; and (3) abdominoperineal. Although we recognize the merits and efficacy in other techniques described in the literature, we believe the transperineal approach is a successful, single-stage method favored by many urologists for an RUF repair in most patients with significant advantages, including the possibility of flap interposition through the same incision. The transperineal approach also has the advantage of local access to a variety of potential interposition flaps with excellent results. Overall, a successful RUF closure was achieved in 33 (76,7%) patients. An interposition flap was used in 14 (56%) patients and 2 (11.1%) patient in groups G1 and G2, respectively (p = 0.019). The RUF was managed successfully in all 18 patients in group G2 as opposed to 10/25 (40%) in group G1 (p = 0.008).The patients in the radiation/energy-ablation group were more likely to require permanent dual diversion (50% vs. 0%, p < 0.0075). The combination of specific adverse features that induce severe damage to local surrounding tissues and the complexity of the surgical reconstruction, in the presence of these adverse features, significantly increase the potential for a fistula recurrence after the primary management.

Radiation/energy-ablation therapies are associated with a more severe RUF and more complex reconstructions. Most of these patients require an abdominoperineal approach and flap interposition. The failure of an RUF repair with the need for permanent dual diversion, eventually combined with extirpative surgery, is higher after previous radiation/energy-ablation treatment. Therefore, permanent dual diversion as the primary treatment should always be included in the decision-making process as reconstruction may be futile in specific settings.

Excellent results can be achieved for the primary repair of an RUF induced by surgery, even of a large size. Conversely, radiation/energy-ablation fistulae can be extremely difficult to successfully repair. Radiotherapy has a significant impact on the choice of surgical technique to treat the RUF. Patients who undergo multimodal therapies are at a higher risk of developing severe complications and repair failure, requiring more complex abdominoperineal operations with the interposition of vascularized tissue. Not uncommonly, patients with radiation/energy-ablation RUF will maintain dual diversion permanently, often after complex and repeated surgical, and eventually extirpative, procedures. The toxicity and quality of life following non-surgical treatments should be considered with extreme caution in individual patient counselling and treatment selection. Technological improvement is needed to enable a safe and more precise delivery of radiation.

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