Clinical and surgical management of recto-urinary fistula after radical prostatectomy: a systematic review on current evidence.

Abstract

Background: Management of rectourinary fistula (RUF) is challenging due to limited data and variability in presentation and treatment. We conducted a systematic review of radical prostatectomy (RP)-related RUF to assess clinical features, diagnostics, treatments, and outcomes, and to propose a structured algorithm to guide management.

Methods: We conducted a systematic review in accordance with PRISMA guidelines to evaluate the clinical presentation, diagnostic strategies, management approaches, and outcomes of RUF following RP. A comprehensive search of PubMed, Embase, and Web of Science was performed from database inception to January 2025. Data were extracted on patient demographics, symptoms, diagnostic modalities, management strategies, surgical repair techniques and treatment outcomes.

Results: A total of 455 cases of RUF following RP were identified across 34 studies. The reported incidence of RUF ranged from <0.01% to 1.5%. The most frequent presenting symptoms were urine leakage per rectum (60.7%), fecaluria (44.1%), and pneumaturia (50.0%). Fecal and/or urinary diversion was utilized in over 60% of cases, with a median stoma duration of 3 months and an indwelling urinary catheter duration of 1 month. Conservative management (observation, fluid replacement and antibiotic therapy) was attempted in a minority of patients and was generally associated with success rates below 50%. Surgical repair was performed in nearly all cases, with the transperineal and transsphincteric approaches being the most commonly employed techniques. The median time to fistula closure ranged from 0.5 to 30 months, with reported surgical success rates varying between 41% and 100%. We propose a management flowchart based on our clinical experience, outlining the diagnostic and therapeutic approach to rectal injury and RP-related RUF.

Conclusions: RUF after RP remains a challenging complication, often requiring stepwise management. Conservative treatments rarely succeed, and surgery is often necessary. Our proposed algorithm aims to standardize the approach to RI and RUF, guiding treatment decisions and improving outcomes.