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High rectourethral fistula following TURP: repair possible only after transvesical prostatectomy. We report a case of iatrogenic rectourethral fistula (RUF) in an elderly man with benign prostatic enlargement and acute urinary retention, following a transurethral resection of prostate (TURP). This patient presented a unique challenge of tackling the RUF in the presence of a large residual prostate gland and urinary tract infection. RUF was repaired only after getting the access to the fistula following transvesical prostatectomy. Follow-up imaging showed well-healed repair of RUF. Transvesical prostatectomy is a useful adjunctive procedure in repair of RUF when associated with a large prostate. This case also highlights the importance of technique selection while planning for surgery on large prostate glands. TURP is not the preferred first modality of choice for larger glands as noted in this case.