Managing Recto-Urethral Fistulas Post-RARP: York–Mason Technique Insights

Overview

Recto-urethral fistulas (RUF) are rare but serious complications following robot-assisted radical prostatectomy (RARP), significantly impacting patient quality of life. This report reviews a 13-year single-center experience using the York–Mason technique, a posterior transsphincteric surgical approach, demonstrating effective fistula repair after failed conservative management.

Background

RARP is a common treatment for localized prostate cancer with generally low complication rates. RUF, an abnormal connection between the rectum and urethra or bladder, occurs infrequently after RARP but leads to symptoms such as fecaluria and pneumaturia. Conservative management with prolonged catheterization is first-line for non-radiation-associated RUF, but persistent fistulas require surgical repair. The York–Mason technique offers direct access to the fistula through healthy tissue, allowing precise layered closure of the sphincter complex.

Data Highlights

The incidence of RUF after primary RARP is up to 0.53%, increasing to 2–16% after salvage prostatectomy. Conservative management involves at least three months of catheterization. The Low Anterior Resection Syndrome (LARS) score was used to assess bowel function post-colostomy reversal, with scores ranging from 0 (no symptoms) to 42 (severe dysfunction).

Key Findings

• RUF typically presents within days to weeks post-RARP, with symptoms including fecaluria and pneumaturia.
• Conservative management with prolonged catheterization can lead to spontaneous closure but is unsuccessful if epithelialization occurs.
• The York–Mason technique provides direct, layered access to the fistula, facilitating effective repair through healthy tissue.
• All patients undergoing York–Mason repair received diverting colostomy, with reversal considered after at least three months post-successful repair.
• Postoperative bowel function was assessed using the LARS score to monitor recovery and quality of life.

Clinical Implications

Clinicians should consider initial conservative management with prolonged catheterization for RUF after RARP without prior radiotherapy. Persistent fistulas confirmed by endoscopy warrant surgical repair, for which the York–Mason technique is a reliable option. Diverting colostomy is essential to optimize healing and reduce morbidity, with bowel function monitoring guiding postoperative care.

Conclusion

The York–Mason technique is an effective surgical approach for managing RUF following RARP when conservative treatment fails, offering precise repair with favorable functional outcomes. Early diagnosis and appropriate management strategies are critical to improving patient quality of life.

References

1. van Leeuwen et al. 2024 -- Approach to Managing Recto-Urethral Fistulas in Patients Undergoing Robot-Assisted Radical Prostatectomy: Insights on the York–Mason Technique