This retrospective cohort study evaluated RUF cases in RARP patients from January 2011 to May 2024. Twelve cases of RUF were identified, all treated with the York Mason procedure. Ten occurred in patients treated with RARP only, and 8 of these underwent the York–Mason procedure as initial surgical treatment, achieving a 100% success rate. In contrast, its efficacy was limited in patients who had undergone radiotherapy after RARP, as well as in those for whom York–Mason was not the initial surgical intervention, highlighting the negative impact of salvage radiotherapy and previous failed surgeries on tissue healing and surgical outcomes.

The incidence of RUF in our cohort was 0.3% (12 out of 3,693 RARP procedures), including predominantly primary RARP cases with only one case after salvage RARP. This aligns with reported rates following primary RARP (up to 0.53%) and remains notably lower than those reported following salvage prostatectomy (2%–16%) [7,8,9]. In our study, four rectal injuries were identified intraoperatively and primarily closed, yet al.l of these patients developed RUF postoperatively. However, the majority of RUFs in our cohort occurred without intraoperative recognition of a rectal injury. This pattern is consistent with existing literature, where most RUFs are attributed to unrecognized rectal injuries during RARP [21]. These findings emphasize the importance of optimizing intraoperative techniques to minimize the risk of rectal injury and to enhance early recognition when it occurs [22]. In addition, when a rectal injury is identified, clear and immediate management appears critical, as this is considered the most determining factor in preventing RUF formation [23]. Some studies advocate for immediate drainage and interruption of surgery, while others suggest completing RARP with additional measures such as colostomy [24, 25]. The absence of systematic perioperative documentation of rectal injuries at our institution limits further analysis of this aspect.

Accurate diagnosis plays a critical role in achieving successful outcomes in RUF treatment. In our cohort, both cystoscopy and cystogram were performed and provided invaluable for diagnosing and localizing fistulas, consistent with findings in the literature [26,27,28]. The addition of proctoscopy in recent years has further enhanced surgical preparation by providing detailed insights into fistula size and location. These diagnostic improvements likely contributed to better selection of RUF patients for the most suitable repair strategies, thereby potentially improving surgical outcomes.

The York–Mason procedure demonstrated promising outcomes in our cohort when applied as a primary intervention in non-irradiated patients. Our success rate (100%) is comparable to previous reports using the York–Mason: one study reported by Dal Moro et al. and another by Crippa et al. each described 100% success in seven patients undergoing York–Mason. A larger series by Hadley et al. showed a success rate of 93%, while Bergerat et al. reported 80% success. In all cases, failures were associated with prior radiotherapy or when York–Mason was not used as the initial surgical approach. Collectively, these studies reinforce the value of early, definitive intervention in appropriately selected patients.

Management of RUF becomes considerably more complex in patients who have received radiotherapy. Radiotherapy significantly alters tissue properties, including reduced vascularization and increased fibrosis, which can impair healing and complicate surgical interventions [2, 11, 16, 17]. These histopathological changes can severely limit the success of conventional repair techniques such as the York–Mason. In our cohort, the single case of RUF following post-RARP radiotherapy was likely attributable to radiation-induced damage rather than the surgical procedure itself [2]. Given these challenges, conventional techniques like York–Mason may be insufficient. Based on our experience, we advocate for more aggressive approaches in irradiated patients, such as total pelvic exenteration with ORAM reconstruction.

Another aspect of RUF management is the use of a diverting colostomy during the York–Mason procedure. In our cohort, all patients underwent diverting colostomy, either prior to or during the York-Mason procedure. This approach aims to minimize fecal contamination and support optimal wound healing. However, there is still debate on it in the literature. Some authors argue that in selected cases, particularly with small fistulae (< 2 cm) or in patients with the RUF diagnosis 6–8 weeks postoperatively, primary repair without colostomy may be effective [28, 29]. In cases without a diverting colostomy, the patient is then placed on no oral intake until bowel function returns. In cases of large fistulous tract, or with previous radiotherapy, the creation of fecal diverson with colostomy is more advised [26]. These contrasting approaches suggest that while fecal diversion may not be universally required, it remains a prudent strategy in high-risk patients. Further research is needed to better define selection criteria for omitting colostomy in RUF management.

In our institute, the initial management of RUF following RARP consists of conservative treatment, involving prolonged bladder catheterization. Although existing studies are limited by small sample sizes, several have reported promising outcomes with this approach. Popov et al. described spontaneous closure in four out of five patients (80%) treated conservatively with catheterization, dietary restrictions, antibiotics and bowel rest [30]. Similarly, Noldus et al. reported complete healing in 7 out of 12 patients managed with prolonged catheter drainage alone, without surgical intervention [31]. These findings suggest that, in selected cases, conservative treatment may offer a viable, non-invasive alternative prior to surgical repair.

Although the York–Mason approach remains widely utilized, several alternative techniques have been described. These include transperineal repairs with interposition flaps, gracilis muscle transposition, and transanal minimally invasive surgery (TAMIS), each offering specific advantages and limitations. According to a comprehensive review by Chen et al., the choice of surgical strategy should be tailored based on factors such as fistula size and location, prior radiation therapy, and surgeon experience [21]. While no single technique has proven universally superior, literature suggests that flap-based approaches may offer higher success rates in irradiated patients, whereas TAMIS might reduce morbidity in select non-irradiated cases. Future comparative studies are warranted to better define optimal surgical pathways across diverse patient populations.

This study has several limitations. A key limitation is the small sample size of the cohort (12 patients), with only two patients with prior radiotherapy, which restricts the generalizability of subgroup analyses. Due to the retrospective design, there is a risk of selection and information bias, limiting the external validity of the findings. Another limitation is the absence of a standardized protocol for managing RUF, leading to variability in treatment approaches. Furthermore, as our center has focused primarily on the York–Mason procedure due to the rarity of recto-urethral fistulas, we could not perform a direct comparison with alternative surgical techniques. This limits the ability to evaluate the relative merits of different approaches. Future multicenter studies could help address this gap by comparing various surgical strategies. Additionally, the multicenter nature of our network resulted in incomplete follow-up data, potentially affecting the accuracy of our outcomes. Lastly, the limited success of the York–Mason procedure after radiotherapy warrants further investigation. Future studies need to explore innovative approaches to improve outcomes in this challenging subgroup. In this context, the emergence of minimally invasive surgical techniques, such as corrections using a TAMIS port, may offer less invasive alternatives [32, 33]. As these techniques evolve, the York–Mason procedure may increasingly be considered too invasive in selected cases. Moreover, emerging technologies like single-port Da Vinci robotic surgery and transvesical approaches may hold promise for less invasive fistula repair, although evidence is still lacking.

The York–Mason procedure provides promising results for managing RUFs in patients who have undergone RARP without salvage radiotherapy, where the fistula is attributed to surgical injury. Its effectiveness is particularly evident when used as the first surgical intervention.