ASCRS Ch14 — Rectourethral and Complex Fistulas: Evaluation and Management

Citation: Rakinic J, Perry WB. "Rectourethral and Complex Fistulas: Evaluation and Management." In: Steele SR, et al. (eds.), The ASCRS Textbook of Colon and Rectal Surgery, 4th ed. Springer Nature Switzerland AG; 2022. pp. 271–280 (PDF pp. 279–288 of the combined textbook file). Source file: raw/ASCRS Textbook 4th Ed.pdf (full 1,198-page textbook; cite by page range within the single PDF). Fourth chapter of Part II ("Anorectal Disease") — Chapter 13 preceded it.

Type: Specialty textbook chapter (reference/background, not primary literature).

Scope

Fourteenth chapter of the sequential full-textbook ingest (see ASCRS Ch01 - Anatomy and Embryology for the ingest's scope/plan). Covers acquired rectourethral fistula (RUF) in adults: etiology (overwhelmingly iatrogenic — radical prostatectomy, radiation, salvage therapy after radiation, plus rarer trauma/IBD/elective-surgery causes), clinical presentation, diagnostic evaluation, classification (Rivera staging and simple-vs-complex schemas), multidisciplinary management principles, and the full repair-approach ladder: transanal (endorectal advancement flap), transperineal (dartos or gracilis muscle interposition — the current procedure of choice for complex RUF), posterior (York-Mason, Kraske), and transabdominal approaches, plus outcomes data throughout emphasizing radiation as the dominant driver of permanent-diversion risk. Congenital RUF (neonatal) is explicitly out of scope.

Key content

Filed as a single new condition page, Rectourethral Fistula — unlike Ch12/Ch13, this chapter covers one cohesive clinical entity rather than two, so no split was needed. Minor cross-links added to Anal Fistula (shared ERAF technique, originally described in that chapter), Crohn Disease (a rare non-iatrogenic RUF etiology, explicitly deferred by this chapter to Crohn's- specific management), Rectal Cancer (low rectal resection/pelvic radiation as RUF risk factors), and Colorectal Anastomotic Complications (shared radiation/pelvic-fibrosis mechanistic themes with that page's chronic presacral sinus tract content).

Limitations

• Textbook chapter, not primary literature; nearly all cited outcome data are small case series — the chapter explicitly notes no RCTs exist for RUF given the condition's rarity.
• Outcome comparisons across approaches (transanal/transperineal/posterior/transabdominal) are not head-to-head — patient selection (radiated vs. nonradiated, simple vs. complex) varies substantially across the cited series, limiting direct comparability.
• The Rivera staging system is explicitly noted as not universally adopted; most cited outcome data instead uses the simpler simple-vs-complex framework.

Relevance

Fourteenth entry in the ASCRS ingest. Adds one new, genuinely distinct condition page — the wiki's first content on iatrogenic urologic-colorectal fistulizing disease. Chapter 15 continues Part II with "Rectovaginal Fistula," the anatomically analogous female-specific entity explicitly flagged as a related-but-separate topic by this chapter.