Introduction: Recto-urethral fistulas (RUF) remain a difficult management problem in reconstructive urology. The presence of posterior urethral stenosis or obliteration in association with RUF further complicates the situation and may have an impact on deciding whether the patient is a candidate for restorative reconstruction. To assess the impact of posterior urethral stenosis on outcomes following RUF repair, we present a cohort of 23 men who underwent posterior urethroplasty as part of their treatment. Methods: We identified 130 men who underwent RUF repair at our institution between 2003-2021. Of these, 23 (18%) also underwent simultaneous posterior urethroplasty and were selected for in depth review. Results: 15 men received prior radiation for prostate cancer: 6 EBRT and brachytherapy, 8 brachytherapy alone, and 1 EBRT alone. Of the 8 men who were not radiated, 4 underwent radical prostatectomy, 2 developed RUF following traumatic injuries, and 2 developed RUF in the setting of inflammatory bowel disease. 3 men (13%) underwent attempted RUF repair prior to referral. Initial management included fecal diversion in all 23 cases (mean 10.3 months prior to RUF repair) and suprapubic catheter placement in 20 (87%) at a mean of 6.4 months prior to surgery. RUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). At the time of surgery, 20 men (87%) had significant posterior urethral stenosis, and 3 (13%) had posterior urethral defects due to cavitation and tissue loss associated with RUF. Posterior urethroplasty involved the prostatomembranous urethra in 18 cases (79%), and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (79%) and using buccal mucosal graft in 5 (22%). Gracilis interposition was performed in 21 cases (91%). At a median follow up of 55.7 months (IQR, 23-82 months), 87% had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. 14 men (61%) developed urinary incontinence, with 7 (30%) ultimately undergoing AUS placement. There were no isolated stricture recurrences requiring instrumentation. Conclusions: Posterior urethral stenosis or obliteration associated with RUF complicates a challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis. SOURCE OF Funding: None
