PROSTATORECTAL FISTULA 14 YEARS FOLLOWING BRACHYTHERAPY FOR PROSTATE CANCER

Abstract

A 60-year-old white man was referred to us for evaluation of a unilobar induration noted on prostate examination in 1985. A transrectal prostate biopsy revealed well differentiated adenocarcinoma. Repeat histopathological examination 14 years later by a uropathologist assigned a Gleason 313. Serum acid phosphatase was 0.3 units per l. (normal less than 0.8) and radioimmunoassay was 1.4 ng./ml. (normal less than 3.9). Bone scan was negative for malignancy. Assigned clinical stage was B2 (cT2b). The patient underwent brachytherapy with 26.5 mCi. 125 I via open retropubic insertion. Lymph node histopathology was negative. Convalescence was uneventful. At 5-year followup prostate specific antigen (PSA) biochemical failure occurred, and at 11-year followup bone scan was positive. The patient was treated with combined androgen deprivation, which resulted in an undetectable PSA. Combined androgen deprivation was discontinued 14 months later as part of an intermittent androgen deprivation regimen. The patient returned 3 months later with gross blood per rectum, and an ulcer of the anterior rectal mucosa near the prostate was palpated. PSA remained less than 0.1 ng./ml. Biopsy revealed changes consistent with radiation. Watery diarrhea, hematuria and fecaluria developed 2 years later. Cystoscopic examination revealed a prostatorectal fistula, and the patient underwent diversion with a suprapubic tube. Reconstruction was contraindicated due to multiple medical problems, including severe atherosclerotic vascular disease and diabetes. DISCUSSION