A Rectourethral Fistula due to Transrectal High-Intensity Focused Ultrasound Treatment: Diagnosis and Management

Abstract

Colovesical fistula (CVF) is an abnormal connection between the enteric and the urinary systems. The rectourethral fistula (RUF) is a possible but extremely rare complication of treatment of prostate cancer with "transrectal High-Intensity Focused Ultrasound (HIFU) treatment." We present a case of CVF due to HIFU treatment of recurrent prostate cancer. The case was assessed with cystography completed with a pelvic CT scan-with MPR, MIP, and VR reconstruction-before emptying the bladder. Since the CT scan confirmed that the fistula involved solely the urethra and excluded even a minimal involvement of the bladder, it was possible to employ a conservative treatment by positioning a Foley catheter of monthly duration, in order to allow the urethra to rest. Still today, after 6 months, the patient is in a good clinical condition and has not shown yet signs of a recurrence of the fistula.

Figure 1

Retrograde cysto-uretrography. Oblique radiograms of bladder after full repletion with contrast media (a and b). The expansion of contrast media could be better observed in the oblique projections (a), especially when acquired after the space of a few minutes (b). In delayed oblique projection, as shown fistulous tract was more visible, as well as a certain amount of contrast in the rectum. It was not, however, possible to exclude with absolute certainty a partial involvement of the bladder.

Figure 2

Pelvic CT scan with VR reconstruction. Pelvic CT scan was acquired before emptying the bladder of the contrast media, in order to confirm and to be sure that the bladder was not involved in the problem and that only the urethra was affected by the fistula.(a)Axial plane. (b)VR reconstruction.The latterallows to see very well the fistolous tract that connects the bladder to the rectum.

Figure 3

Retrograde cysto-uretrography after conservative treatment. Oblique radiograms of bladder after full repletion with contrast media, acquired 70 days later, depict the closure of the fistolous tract.