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Urol Case Rep
Urol Case Rep
Urology Case Reports
2214-4420
Elsevier

S2214-4420(24)00181-5
10.1016/j.eucr.2024.102827
102827
Oncology
A case of recto-urethral fistula following MRI-guided transurethral ablation (TULSA) of the prostate
Meng Xiaosong
Costa Daniel N. costa.dn@gmail.com
⁎
Departments of Urology (X.M. and D.N.C) and Radiology (D.N.C), University of Texas Southwestern Medical Center, Dallas, TX, USA
⁎ Corresponding author. costa.dn@gmail.com
22 8 2024
9 2024
22 8 2024
56 10282717 8 2024
20 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
We describe the first case of a recto-urethral fistula following an MRI-guided transurethral prostate ablation procedure (TULSA). The patient experienced urine per rectum six weeks after the procedure. A voiding cystourethrogram confirmed the presence of a recto-urethral fistula, which was managed with a urethral catheter and a suprapubic tube. Patient was then asymptomatic, with spontaneous healing of the fistula and catheters removed after six weeks. Not previously reported following TULSA, rectourethral fistula is a rare but known complication with other focal therapy modalities. Awareness of this potential complication will help improve patient counseling, early detection and adequate management of this rare complication.

Highlights

• Focal therapy aims to target and ablate areas of cancer while preserving the surrounding normal prostate and critical structures to decrease side effects of treatment.

• Although extremely rare, recto-urethral fistula may be seen as a complication of the TULSA procedure.

• In the primary setting, conservative management appears to lead to spontaneous healing.

Keywords

Prostate cancer
Focal therapy
Ablation
Recto-urethral fistula
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pmc1 Introduction

Prostate cancer, as one of the most frequently diagnosed cancers in men, presents as a diverse spectrum ranging from indolent to aggressive disease. Traditionally, men with localized prostate cancer are faced with a choice between active surveillance (AS) or radical therapy with surgery or radiation. These options expose men to ongoing worry about living with an active malignancy when selecting AS, or the risks of incontinence, erectile dysfunction, and radiation side effects with radical therapy. Focal therapy represents the middle ground between AS and radical therapy by targeting and ablating areas of cancer while preserving the remaining prostate tissue and critical surrounding structures such as the external urinary sphincter, bladder neck and neurovascular bundles to decrease side effects of treatment. TULSA-Pro (Profound Medical Inc, Toronto, Canada) is a novel MRI-guided transurethral ultrasound ablation procedure performed in the MRI bore that enables the creation of a customized 3D ablation plan using MRI visualization and leverages MRI thermometry to dynamically adjust energy delivery and enable precise monitoring of treatment efficacy in real-time. This procedure utilizes a urethral device that emits directional high intensity ultrasound energy and an endorectal cooling device to protect the anterior surface of the rectum.1

Rectourethral fistula is a rare complication that has been described with other focal therapy modalities including focal laser ablation (FLA), cryotherapy and high-intensity focused ultrasound (HIFU), with reported rates of up to 1 % in the primary setting and up to 5 % in the salvage setting.2 Typical symptoms include fecaluria, pneumaturia and urine leakage per rectum during voiding. In the primary setting, initial treatment is usually conservative with indwelling Foley catheter.3 In cases where the fistula persists despite conservative treatment, a reconstructive procedure with excision of the fistulous tract or salvage prostatectomy and closure with interposition graft or flap is necessary. In our patient case, given resolution of urine per rectum with Foley catheter management and absence of more concerning symptoms like fecaluria or pneumaturia suggesting a smaller fistula tract, conservative management was the appropriate course of action with less patient morbidity than a reconstructive procedure.

2 Case presentation

2.1 Clinical history

A 78-year-old man on active surveillance for small volume grade group 2 adenocarcinoma of the prostate presented with rising PSA (9.6 ng/mL). Multiparametric MRI revealed a 61g prostate with a 15 mm PI-RADS 5 lesion in the right posteromedial apical peripheral zone (Fig. 1). A subsequent MRI-TRUS fusion biopsy demonstrated higher volume (4 of 14 cores) grade group 2 cancer, and the patient opted for treatment with MRI-guided transurethral ablation (TULSA). The treatment consisted of near whole-gland ablation with sparing of the left neurovascular bundle (Fig. 2). The patient was under general anesthesia and the procedure included 36 minutes of treatment planning and 1 hour and 19 minutes of ablation time, with one complete sweep starting at the 5 o'clock position, in a clockwise direction, followed by a second sweep in a counterclockwise direction from the 9 o'clock to the 5 o'clock position (Video 1). The ablation was uneventful without immediate complications and with good correlation between the planned treatment and the immediate verification of the non-perfused volume (Fig. 1).Fig. 1 Baseline MRI, treatment planning and immediate post-treatment verification. Diagnostic multiparametric MRI with axial T2-weighted (A), apparent diffusion coefficient (B) and high b-value diffusion-weighted (C) images demonstrating a 15 mm PI-RADS 5 lesion in the right posterior apical peripheral zone (yellow arrow in A). On the treatment day, the axial T2-weighted image (D) at the level of the MRI-visible index lesion, biopsy-proven cancer (asterisks) shows the prescribed treatment zone (outlined in orange and consisting of a near whole-gland approach with sparing of the left neurovascular bundle shown by the blue arrow), a cross-section of the urethral applicator (white arrow) and the endorectal cooling device (orange arrow). Post contrast images obtained immediately after the treatment (E) demonstrate expected lack of enhancing tissue in the treated area (asterisks) and usual appearance of the anterior rectal wall (arrows). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 1

Fig. 2 Treatment planning. T2-weighted axial images used for treatment planning. Each image corresponds to one of the first six treating ultrasound elements (A: element 1, B:2, C:3, D:4, E:5, F:6) in the urethral applicator (white arrow), element 1 (A) located at the inferior aspect of the apex and element 10 (not shown) located at the superior aspect of the base. Note the MRI-visible index lesion, biopsy-proven cancer at the level of element 2 (asterisk) and the partially imaged endorectal cooling device (orange arrow). The prescribed treatment zone (outline in orange) corresponds to a near whole-gland approach with sparing of the left posterolateral peripheral zone and neurovascular bundle (blue arrow). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 2

2.2 Post-ablation course, diagnosis and management

The patient tolerated the procedure well and was discharged on the same day with a Foley catheter, which was removed 8 days later. Two weeks after the procedure, he reported dysuria and was diagnosed with an E. faecalis urinary tract infection (UTI) for which he received ciprofloxacin with resolution of symptoms. Six weeks after the procedure, he reported repeat symptoms of dysuria and nocturia and was again diagnosed with E. faecalis UTI and prescribed Macrobid initially and then switched to ciprofloxacin with improvement in dysuria and nocturia. Eight weeks after the procedure, he called in with reports that he would have urine per rectum and urethra at the beginning of urination, which was progressively getting worse since it started two weeks prior. This was promptly evaluated by a voiding cystourethrogram and pelvic CT that confirmed the presence of a recto-urethral fistula (Fig. 3). A Foley catheter was placed under flexible cystoscopic guidance over a wire. Upon decompression of the bladder, the patient's symptoms improved significantly. However, he experienced repeated episodes of clogging of his urethral Foley catheter over the next 2 weeks with resultant urine per rectum, and an additional suprapubic tube (SPT) was placed in the operating room (OR). The patient was then maintained with dual urethral and SPT drainage for the following 4 weeks with resolution of urine per rectum. The patient was then taken back to the OR with colorectal surgery for diagnostic cystoscopy and flexible sigmoidoscopy where the fistulous communication between the prostate and rectum was noted to have healed spontaneously. The patient had both urethral Foley and SPT removed with no recurrence of his recto-urethral fistula. Persistent slow urinary flow motivated a TURP performed 6 months after the TULSA procedure where some residual bands of mucosa were resected. After this procedure, voiding returned to baseline and remains asymptomatic up to 18 months after the ablation treatment. The PSA remains undetectable, and the 12-month follow-up MRI demonstrates no evidence of a fistulous tract or suspicious lesion in the prostatic fossa (Video 2).Fig. 3 Recto-urethral fistula identification. Lateral (A) and oblique (B) radiographs obtained after the administration of 50 mL of contrast material through a catheter demonstrate opacification of the ablation cavity (yellow arrow), bladder (white arrow), and rectum indicating the presence of an anomalous communication (black arrow) between the ablation bed/prostatic urethra and the lower rectum (orange arrow). These findings were also confirmed by a same day CT of the pelvis as shown on this sagittal midline reformatted image (C). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 3

3 Conclusion

This case illustrates the first report of a recto-urethral fistula secondary to an MRI-guided transurethral ultrasound ablation of the prostate. Awareness of this potential complication will help improve patient counseling, early detection and adequate management of this rare complication.

CRediT authorship contribution statement

Xiaosong Meng: Conceptualization, Data curation, Formal analysis, Investigation, Writing – review & editing. Daniel N. Costa: Conceptualization, Data curation, Formal analysis, Investigation, Project administration, Supervision, Writing – original draft, Writing – review & editing.

Declaration of competing interest

X.M.: None.; D.N.C. has received honorarium as a consultant for Profound Medical Inc.

Appendix A Supplementary data

The following are the supplementary data related to this article:Multimedia component 1

Multimedia component 1

Multimedia component 2

Multimedia component 2

Appendix A Supplementary data related to this article can be found at https://doi.org/10.1016/j.eucr.2024.102827.
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References

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