Recto-urethral fistula (RUF) is a rare but severe problem after surgery or prostatic brachytherapy. We report a surgical technique for acquired RUF using a perineal approach with primary and independent repair of the rectal and urethral openings.

We present the case of a 71 year old male with an acquired RUF after iodine-seed brachytherapy for prostate cancer (Gleason 3+3). The patient failed hyperbaric oxygen therapy.

The procedure is performed in prone position. A semicircular incision is made centered in the perineum and outside of the external anal sphincter. The anal canal and distal rectum are separated from the urethra until the fistula tract is reached. The fistula tract is completely excised with the surrounding prostate tissue separating both rectal and urethral openings. The plane between the rectum and the urinary tract is dissected several centimeters cephalad to the fistulous opening to ensure an adequate mobilization of sufficient healthy to perform a tension-free repair. The remaining prostatic tissue harboring the seeds is then removed and the urethral stump anastomosed to the neck of the bladder. The fibrotic tissue in the rectal opening is excised and the defect closed with interrupted absorbable sutures. The wound is closed in layers over a Penrose drain. Finally, a diverting ileostomy is performed. The patient had an uneventful recovery and no anastomotic complications.

The primary repair of acquired RUF by a perineal approach is a relatively simple procedure that avoids division of the anal sphincters and in most patients does not require graft interpositions.