Rectal complications after prostate brachytherapy

Prostate brachytherapy is gaining wide popularity as an alternative to resection for the treatment of locally advanced prostate cancer. Rectal-urethral fistula after prostate brachytherapy is a rare but serious complication, and its incidence, presentation, risk factors, and clinical management have not been well described.

From January 1997 to October 2002, seven patients with rectal-urethral fistulas were referred to two institutions (Brigham and Women's Hospital and West Roxbury Veteran's Administration Hospital) of a major teaching referral center. Clinical presentation, risk factors, prostate staging, and clinical management were examined in a retrospective fashion.

Seven rectal-urethral fistulas developed from roughly 700 (1 percent) patients treated with prostate brachytherapy for prostate cancer. The average patient age was 67.7 years, preimplant prostate-specific antigen was 7.1, and Gleason score was 3+3. Symptoms occurred at a mean of 27.3 months after prostate brachytherapy was started and included anorectal pain (57 percent), clear mucous discharge (57 percent), diarrhea (43 percent), and rectal ulceration (43 percent). Coronary artery disease was a common comorbidity (71 percent). Previous transurethral resection of prostate (28 percent) and pelvic irradiation or external beam radiation therapy (14 percent) were not associated with increased risk of rectal-urethral fistula. All patients underwent a diverting colostomy (86 percent) or ileostomy (14 percent), and four patients went on to have definitive therapy. Definitive resection was performed between 5 and 43 months after diverting ostomy and was chosen on the basis of comorbid disease, quality of life, and degree of operation. Two patients required a second diversion after definitive resection because of anorectal pain and a colocutaneous fistula. Postoperative complications included myocardial infarction (14 percent), blood transfusion (14 percent), and bowel perforation (14 percent). Patients became symptom-free nine months after surgery. Six patients are alive and well today; one died from an unrelated cause.

Rectal-urethral fistula after prostate brachytherapy is a rare but devastating complication. Patients should be followed for at least three years after prostate brachytherapy because symptoms can develop late in the course. Although diversion of fecal stream does not heal the fistula, all patients diagnosed with rectal-urethral fistula should first undergo diverting ostomy to alleviate symptoms. Then, one should consider definitive resection and ostomy closure.