Comparison of rectourethral fistula repairs: york mason vs. transperineal repair with gracilis flap interposition.

INTRODUCTION: Rectourethral fistulas (RUFs) are rare but severe complications of prostate or rectal cancer treatment. The York Mason (YM) procedure and transperineal repair with gracilis muscle flap interposition (TPGF) are the two most frequently used approaches, but direct comparative data are limited. METHODS: We conducted a multicenter retrospective cohort study including all patients who underwent RUF repair with either YM or TPGF at four French tertiary referral centers between 2011 and 2024. Fistulas were classified using the Rivera and Mundy–Andrich systems. The primary endpoint was reintervention-free survival (RFS), assessed by Kaplan–Meier analysis and Cox regression. Secondary endpoints were first-attempt and overall closure rates, perioperative complications, and postoperative urinary and fecal continence. RESULTS: Fifty-seven patients were included (YM = 27, TPGF = 30). Median follow-up was 39 months (YM 27 vs. TPGF 53). Kaplan–Meier analysis showed superior RFS after TPGF (12-month estimates: 94.7% vs. 68.2%; log-rank p = 0.038). First-attempt success was higher with TPGF (77% vs. 44%; p = 0.013), as was overall success at last follow-up (94% vs. 70%; p = 0.046). Operating time and hospital stay were longer after TPGF, but complication rates were comparable (50% vs. 37%; p = 0.12). Stress urinary incontinence occurred in 53% of TPGF and 41% of YM patients (p = 0.34). No de novo fecal incontinence was observed. On Cox regression, complex fistula morphology predicted YM failure (HR 6.5, 95% CI 1.15–36.8), whereas no predictive factor for failure was identified in the TPGF group. CONCLUSION: In this multicenter cohort, TPGF achieved higher RFS than YM without increased morbidity. TPGF appears particularly suitable for complex or irradiated RUFs, while YM may remain appropriate for selected simple, nonirradiated cases.