Introduction: The current increase in radical prostatectomies has raised the incidence of urorectal fistulas. When the conservative management fails, a surgical solution should be considered. Urorectal fistulas are one of the most difficult problems a urologist can face. There is no standard surgical approach to treat such fistulas as few surgeons have enough large experience to deal with them. Several approaches have been described: transabdominal, posterior-sagittal (Kraske), posterior trans-sphincteric (York-Mason), transanal and perineal. The perineal approach grants a greater exposure of the rectum and the inferior urinary tract and allows the interposition of flaps if needed. But it is a surgical challenge since it is a narrow space surrounded by relevant structures. The objective of this video is to present the perineal approach of urorectal fistula repair. Methods: A 72-year-old patient is derived to a quaternary care urology center for a reconstructive solution. He had a radical assisted laparoscopic prostatectomy (RALP) performed one year ago due to a high-risk prostate cancer, complicated with a urorectal fistula. He was initially treated with a urethral catheter and a defunctioning loop colostomy. Patient was fit and well in our first assessment. A cystoscopy is performed to assess the location and size of the fistula, its relation to the ureter orifices and bladder neck, as well as the presence of visible health tissue near the fistula. An MRI gives information about the fistula tract and its relation to surrounding organs. The patient was put in for surgery. Results: An inversed U-shaped perianal incision is performed. A deepen dissection through the perineal body, levators ani and the anterior rectal wall leads to the fistula tract. Precaution is taken to follow the right directions of the dissection until the rectovesical pouch is reached. Bladder and rectal defects are closed separately with two layers of sutures. Levators ani are interposed, and dead space is obliterated with sutures. Urethral catheter is removed 4 weeks after the operation with confirmed leak tightness on the peri-catheter urethrogram. Conclusions: Urorectal fistulas are manageable through a perineal approach, which is part of the armamentarium of the urology reconstructive surgeon. SOURCE OF Funding: None.
