Simultaneous treatment of a pubovesical fistula and lymph node metastasis secondary to multimodal treatment for prostate cancer: Case report and review of the literature

Abstract

Pubovesical fistula (PVF) is a rare complication of radical treatments for prostate cancer (PCa), especially when a multimodal approach is performed. We present a case of PVF with extensive communication between the bladder and the pubic bones, and lymph node metastases of PCa treated by cystectomy and salvage lymphadenectomy. We describe a case of a 65-year old male patient who, after radical prostatectomy and adjuvant radiation therapy, suffered from suprapubic and perineal pain, ambulation difficulties and recurrent urinary tract infections. Cystoscopy, cystography and contrast-enhanced magnetic resonance imaging diagnosed a PVF. Choline positron emission tomography/computed tomography scan demonstrated PCa lymph node metastases. After the failure of conservative treatment, open radical cystectomy with ureterocutaneostomy diversion and salvage lymphadenectomy were performed with resolution of symptoms. At 3-month follow-up, the pelvic and perineal pain was completely regressed and 1-year later the patient was still asymptomatic. This clinical case shows efficacy and safety of combined salvage lymphadenectomy and cystectomy with urinary diversion for the treatment of late PCa node metastasis and PVF.

Keywords: lymphadenectomy; prostate cancer; pubovesical fistula; radical cystectomy.

Figure 1

Cystoscopy shows a suspected PVF at the 12 o’clock position of the bladder neck, close to the center of the eroded pubic symphysis (a and b).

Figure 2

MRI of the pelvis confirming the presence of pubovesical fistula. Axial (a) and sagittal (b) images.

Figure 3

Choline PET-CT detects a left external iliac lymphadenopathy and a further capture of the tracer at the level of other left external iliac lymph nodes and inguinal lymph nodes bilaterally (a). Choline PET-CT performed after cystectomy and lymphadenectomy where previously highlighted lymphadenopathies are no longer visible (b).