BERKELEY, CA (UroToday.com) - There are many choices for the primary local treatment of adenocarcinoma of the prostate. For patients with moderate or high-risk prostate cancer (Gleason score 7 or greater, PSA over 10, and clinical stage greater than T2a) dose escalation of radiation therapy has been employed. This is commonly done by combining external beam radiation therapy (EBRT) and radioactive seed implants. This approach is intended to improve local control and disease-free survival. This combined approach, however, can be associated with an increased risk of rectal toxicity compared with either modality alone.

In a recent paper by C. Marguet and colleagues from Duke University Medical Center in Durham, North Carolina, the authors present their experience with 6 patients treated with combined prostate brachytherapy and EBRT who developed rectourethral fistula subsequent to rectal procedures. The manuscript is published in the May 2007 issue of Urology.

The mean patient age was 63.8 years and the mean biopsy Gleason score was 6. Two patients were implanted with palladium-103 seeds and four had iodine-125 seeds placed before EBRT. All patients were treated with 45 Gy of EBRT, achieved a mean PSA nadir of less than 0.3 ng/ml and none had biochemical recurrence at an average follow-up of 36 months. Five patients subsequently developed clinically documented radiation proctitis and underwent biopsy of the rectal ulcer. One of the patients underwent laser coagulation of the ulcer bed. The sixth patients underwent elective hemorrhoidectomy. All six patients subsequently developed a rectourethral fistula with a mean time to development of the fistula from the end of EBRT of 22.6 months. The fistulas developed within a mean of 4 months of the rectal procedure.

All patients underwent urinary diversion with either a SPT or a urethral catheter and 4 patients underwent a mean of 50 hyperbaric oxygen therapies that failed. Two patients underwent pelvic exoneration for symptomatic management. The remaining 4 patients underwent fecal diversion with interposition of a gracilis flap in 2 patients. Two patients had complete resolution of the fistula after their extensive abdominal procedures and one underwent permanent loop urinary diversion.

This study has shown that the development of a rectourethral fistula after combination radiation therapy for adenocarcinoma of the prostate is a rare but serious complication requiring extensive intraabdominal surgery fro definitive management. Biopsies of rectal ulcers in this clinical situation should be avoided and elective rectal surgery on irradiated tissues should be deferred. Conservative management with urinary diversion and hyperbaric oxygen therapy did not obviate the need for definitive surgical management of the fistula.

Marguet C, Raj GV, Brashears JH, Anscher MS, Ludwig K, Mouraviev V, Robertson CN, Polascik TJ

Urology. 69(5):898-901, May 2007
doi:10.1016/j.urology.2007.01.044

UroToday.com Urologic Trauma & Reconstruction Section

UroToday.com Prostate Cancer Section

Written by Michael J. Metro, MD, a Contributing Editor with UroToday.

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