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York Mason Procedure
15
Ariane M. Abcarian and Herand Abcarian
The transsphincteric approac h to the rectum was originally proposed by Aubrey
York Mason for the surgical management of postoperative rectourethral fistulas
(RUF) in 1969 [1]. Until that time most RUFs were approached through an anterior
pubic splitting incision which was extremely complicated and morbid. He subsequently utilized this approach to gain access to and locally excise certain low rectal
cancers [2]. Similar operations had been advocated by Arthur Dean Bavan in 1917
for small low rectal cancers “without any radial involvement [3].” As quoted by
Corman “Bavan did not repair the sphincter”, simply stating “I did not hope to
attain anything like complete continence” and he did not comment about the risk of
development of a fistula [4].
In 1970, Mason described the transsphincteric procedure as special access to the
rectum and since then this operation has become popular and named the “York
Mason procedure [5].” The surgical technique is described and illust rated in detail
by Prasad and Abcarian in 1983 [6]. In brief, the patient receives full bowel
preparation and preoperative antibiotic prophylaxis. The procedure can be performed under spinal or general anesthesia. A Foley catheter is inserted (mandatory
for cases of RUF) and the patient is placed in prone jackknife position (Fig. 15.1).
and the buttocks are taped apart (Fig. 15.2).
A 10 cm incision is made starting at the posterior anal verge and carried to the
right or left of the coccyx (paracoccygeal) (Fig. 15.3).
A.M. Abcarian
Division of Colon and Rectal Surgery, John H. Stroger Hospital of Cook County,
1900 W. Polk Street, Chicago, ILL 60612, USA
H. Abcarian (&)
Division of Colon and Rectal Surgery, University of Illinois at Chicago,
840 S. Wood Street, MC 958, Chicago, IL 60612, USA
e-mail: Abcarian@uic.edu
© Springer International Publishing AG 2017
H. Abcarian et al. (eds.), Complications of Anorectal Surgery,
DOI 10.1007/978-3-319-48406-8_15
265
266 A.M. Abcarian and H. Abcarian
Fig. 15.1 Position of patient for repair of rectoprostatic urethral fistula
Fig. 15.2 Incision
The incision is deepened in subcutaneous fat to reach the lower border of the
gluteus maximus. The fascia and lower fibers (3–4 cm) of this muscle is divided to
achieve exposure to the retrorectal space. The exter nal sphincters, levator ani,
puberictalis muscle, and internal sphincter are sharply divided and marked by
different colored paired sutures to facilitate identification of each muscle during
15 York Mason Procedure 267
Fig. 15.3 Skin incision is
made. Mucocutaneous
junction is marked with
sutures. Internal sphincter is
exposed
closure. The posterior rectal wall is then incised longitudinally to open the rectum
“like a book” and gain access to low and mid rectum (Fig. 15.4).
To repair the RUF, the fistula is cored out, the urethra repaired with 3/0
monofilament absorbable sutures over a silastic Foley catheter used as a stent. The
rectal wall is mobilized 2–3 cm and repaired in vest over pants fashion using
absorbable sutures (Figs. 15.5 and 15.6).
The rectal wall is closed and the individual layers of sphincter mechanism are
identified using the colored paired sutures and approximated with absorbable
sutures (Fig. 15.7).
The wound is irrigated and a suction drain is placed deep or superficial to the
gluteus, and its fascia reapproximated. The subcutaneous tissue is irrigated and the
skin closed with interrupted sutures after careful approximation of the anoderm and
the anal verge [6, 7]. If the York Mason procedure is done to remove a large rectal
villous adenoma, submucosal infiltration of dilute (1:200,000) epinephrine solution
will elevate the lesion, assist in dissection and decrease bleeding.
The York Mason procedure was expanded in later years to include repair of
suprasphincteric or extrasphincteric fistulas and approach to retrorectal (presacral)
cyst. In case of an extrasphincteric or high suprasphincteric fistulas, after opening
the rectum posteriorally the primary opening of the fistula is cored out the rectal
wall closed with vest over pants technique and the external fistula tract is drained
268 A.M. Abcarian and H. Abcarian
Fig. 15.4 Sphincter mechanism and posterior rectal wall divided exposing the fistula (F). Each
sphincter muscle is tagged with color-coded sutures. (M) Mucosa. (PR) puborectalis, (ES) external
sphincter, (MC) mucocutaneous junction
with a #12 or #14 mushroom or Mallicot catheter and the incision is closed.
A modification of the York Mason procedure, without division of the sphincter
mechanism has been used to gain access to retrorectal space for removal of presacral developmental cysts. In such cases, after division of fibers of gluteus maximus, the sphincter mechanism is retraced caudad and the presacral cyst is
visualized. Infiltration of dilute epinephrine solution between the cyst and the rectal
wall facilitated dissection and prevents injury to the posterior rectal wall. After
placement of suction drain within the dead space, the wound is closed per perineum
[8, 9].
Results of the York Mason procedure are difficult to assess due to the paucity of
reports of large series in the literature. Mason reported recurrence rate of 13% in his
original series of rectal cancers treated with this procedure [2]. Allogower and
associates reported 36 patients treated for rectal cancer through sphincter splitting
transsphincteric approach [10]. There were no operative deaths and nine recurrences
(25%). He recommended frozen section examination of margins and depth of
invasion in “superficial” cancers. Allogower and colleagues reported a larger series
of parasacral approach to the rectum. These included 116 patients with various
indications, with nearly 50% done for malignancies [11]. There is little information
15 York Mason Procedure 269
Fig. 15.5 Incision around fistula (a). Excised fistulous tract exposing catheter in prostatic urethra
(b). Undermining of rectal wall. Dotted line represents the extent of rectal wall mobilization (c)
available on the outcomes of the patients. The same authors subsequently published
on the anatomy of the pelvic floor for translevator-transsphincter operations [12].
Huber reported on 106 cases of sphincter splitting parasacral approach performed between 1974 and 1985. The procedure was done in deep lithotomy
position and “very good results” were obtained when the technique was applied for
benign rectal tumors (villous adenomas), fistulas and traumatic lesions [13]. Radical
resection of the bowel wall could be accomplished and the prolapsed rectosigmoid
could be resected and the lax pelvic floor tightened through this approach. He
concluded that “transsphincteric” approach is a highly desirable technique in the
treatment of high fistulas and traumatic lesions. “Severe complications are rare
among accurate preliminaries and surgical skills [ 13].”
Arnaud and colleagues reported on 35 patients (20 ♂,15♀) who had posterior
transsphincter approach for villous adenoma, rectal prolapse, rectal stricture, or high
fistula [14]. No complications were seen in 20 patients, but delayed fistula occurred
in seven patients, four of whom healed spontaneously, and three needed colostomy
and surgical repair. Pathology of villous tumors showed invasive malignant
changes in three patients requiring proctectomy and end-to-end coloanal anastomosis. Two patients had mild incontinence and were treated with biofeedback. Two
270 A.M. Abcarian and H. Abcarian
Fig. 15.6 Closwe of prostatic urethra (a). Sagittal section showing sumre line after repair of
fistula (b). Magnified view of suture lines. (F) Foley catheter, (P) prostatic urethra,
(M) full-thickness rectal wall flaps sutured “vest over pants” technique. Note that the suture
lines do not overlie each other (c)
patients developed sacrococcygeal hernia and delayed recto-perineal pain was
reported in another two patients [14].
Recently, Qui and colleagues reported their experience of 102 patients with mid
to low lying rectal neoplasms treated between 1990 and 2006, (40 ♂,62♀ average
age 55.5) [15]. Surgical indications were: rectal villous adenoma 36, early rectal
cancer 43, advanced rectal cancer 10, and submucosal rectal wall neoplasm 13.
Operating time was 75 min, blood loss average 60 ml, and hospital stay was
8 days. All 102 rectal n eoplasms were resected completely with partial proctectomy
in 96 and segmental proctectomy in 6 all with clear resected margins. Three patients
(2.5%) had postoperative infection and 4 (3.9%) had fecal fistula. The authors used
15 York Mason Procedure 271
Fig. 15.7 Suture of rectal
wall completed. Sphincter
muscle being approximated
Williams incontinence score and reported 33 patients (32.4%) with postoperative
incontinence to flatus (26) and liquid stool (7) within 1 week. Three months
postoperatively 94 patients (92.2%) achieved grade 1 continence and only eight had
occasional episodes of flatus incontinence (grade 2). There were no operative deaths
and no incidence of rectal stricture. Three patients (2.9%) developed local recurrence during median follow-up of 76.8 months [15].
Poirier and Abcarian collected their experience of 28 patients (18 ♂;10♀)
operated in a 14 year period. Indications in decreasing frequency were rectal villous
adenoma 36%, retrorectal cyst 29%, rectourethral fistula 21%, supras phincteric
fistula 7% and low coloanal/ileoanal anastomotic leak 7%. All patients underwent
the standard York Mason procedure with the exception of those with retrorectal
(presacral) cyst who had modified, (sphincter sparing) York Mason procedure.
Twenty-seven of 28 patients completed the follow-up. Twenty-three patients had
successful outcomes, four failed and one was lost to follow-up. A total of ten
complication occurred in six patients. They conclude that morbidity occurred in
21% of the patients and success in 85% of completely followed patients. There
were no deaths in this series [15].
272 A.M. Abcarian and H. Abcarian
Complications and Management
Wound Infections
Despite all precautions (oral antibiotics, laxative bowel preparation, perioperative
antibiotics, and intraoperative rectal irrigation with dilute Betadine solution), would
infections can never be totally eliminated. John Alexander Williams of Birmingham, UK is credited with the famous quote “the only way to sterilize the bowel is to
remove it and boil it for 1 hour.” Despite this, the wound infection quoted in various
series is Smell 3/102 (3.5%) [15] and 4/28 (14%) [16]. Interestingly two of the four
patients who developed wound infection in the latter series had excision of presacral cyst without opening the rectum (sphincter sparing modified York Mason
procedure) [16].
This complication is usually treated with opening the wound and packing with
wet to dry dressings. A short course of intravenous antibiotics may be indicated in
febrile patients who have leukocytosis and most patients can be discharged to home
care with oral antibiotics for 10–14 days.
Fecal Fistula
Usually follow an apparent wound infection and it is caused by disruption of the
rectal wall closure in the classical York Mason procedure. In the sphincter sparing
operation it is related to the injury and repair of the rectal wall during excision of
infected presacral cysts especially after missed diagnosis and open or CT guided
drainage. This is the dreaded complication which has discouraged many surgeons
from attempting this approach. However, the incidence of this complication is quite
low, 3.9% in 102 patients reported by Qui [15] and 7 patients (20%) reported by
Around and colleges Four of whom healed spontaneously and the other three
needed colostomy and surgical repairs [14]. In the report by Poirier, of the four
patients with wound infections, two healed without any consequences, one needed
two debridement in the operating room and healed. Only one patient (1/27)
developed a rectocutaneous fistula together with sphincter defect. This patient had
temporary fecal diversion, followed by overlapping repairs of the sphincter and
closure of the rectal wall defect. Six weeks later when complete healing was
documented, the colostomy was closed. The patient remained well and fully continent in later follow-up.
Bleeding
This operation can be bloody due to sharp division of various muscle layers needed
to gain access to the rectum. Liberal use of 1:200,000 epinephrine solution aids in
obtaining dry field and reduce bleeding. To prevent postoperative bleeding, the
15 York Mason Procedure 273
wound must be thoroughly irrigated and hemostasis secured before proceeding to
the next level of closure. A soft suction catheter may be used either deep to or
superficial to the gluteus especially in cases of presacral cyst excision where a dead
space is inevitably left behind. Most minor bleeding will stop within 2–3 days of
continuous suction but if the patient passes clots from the rectum, return to the
operating room, evacuation of the clots and inspection of the rectal wall closure for
bleeding is mandatory.
Fecal Incontinence
Even though fecal incontinence remains a major concern due to the nature of this
procedure, its actual incidence is quite small. A transient weakness in the sphincter
in the immediate postoperative period is to be expected and most will resolve
spontaneously (92.2%) in 3 months, [15] and 2/35 patients with post York Mason
fecal incontinen ce in the Arnaund series were treated with biofeedback [14]. If
major incontinence (to solid stool) persists, the patient should have an endoanal
ultrasound to document the potential sphincter defect and be taken back to the
operating room for overlapping sphincteroplasty. In the Poirier series one patient
need overlapping sphincter repair with simultaneous rectal wall closure and
remained continent afterwards [16].
Recurrences
The various indicators for York Mason procedure each require careful scrutiny of
the pathologic specimen and close follow-up. Preoperative staging using ERUS and
MRI are invaluable.
Recurrence following excision of rectal neopla sm In cases of rectal villous
adenoma, pathologic report must exclude malignancy. If a T1 malignancy is
identified, the patient must be offered radiation therapy, as was successfully used
with excellent long-term outcome [16]. Adequacy of margins during surgery can be
ascertained using frozen section examination of the specimen [10, 11]. None of the
Poirier’s patients had any evidence of recurrence in up to 74 months followup [16]
In the Qui series 3 patients (2.9%) developed recurrence during the median
follow-up of 76.8 months [15].
Recurrence following excision of retrorectal (presacral) cyst Complete excision
of the lesion is imperative because of the potential for malignancy. Every effort
should be made to excise these lesions in total and obtain pathologic confirmation.
In such cases there should be no recurrence [16].
Recurrence after repair of rectourethral fistula is clearly dependent on the eti-
ology of the fistula. In cases when the RUF results from prostatectomy, whether
open or minimally invasive route, the closure is usually highly successful. On the
other hand, if the tissues surrounding the fistula are significantly radiated, the
closure is more apt to breakdown [16–18]. If the patient receives radiation therapy