摘要
PURPOSE: Prostate brachytherapy is gaining wide popularity as an alternative t o resection for the treatment of locally advanced prostate cancer. Rectal-ureth ral fistula after prostate brachytherapy is a rare but serious complication, and its incidence, presentation, risk factors, and clinical management have not bee n well described. METHODS: From January 1997 to October 2002, seven patients wit h rectal-urethral fistulas were referred to two institutions (Brigham and Women ’s Hospital andWest Roxbury Veteran’s Administration Hospital) of a major teac hing referral center. Clinical presentation, risk factors, prostate staging, and clinical management were examined in a retrospective fashion. RESULTS: Seven re ctal-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 rec tal ulceration (43 percent). Coronary artery disease was a common comorbidity (7 1 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 diver ting 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 diversi on after definitive resection because of anorectal pain and a colocutaneous fist ula. Postoperative complications included myocardial infarction (14 percent), bl ood transfusion (14 percent), and bowel perforation (14 percent). Patients becam e symptom-free nine months after surgery. Six patients are alive and well today ; one died from an unrelated cause. CONCLUSIONS: Rectal-urethral fistula after prostate brachytherapy is a rare but devastating complication. Patients should b e followed for at least three years after prostate brachytherapy because symptom s can develop late in the course. Although diversion of fecal stream does not he al the fistula, all patients diagnosed with rectal-urethral fistula should firs t undergo diverting ostomy to alleviate symptoms. Then, one should consider defi nitive resection and ostomy closure.
PURPOSE: Prostate brachytherapy is gaining wide popularity as an alternative t o resection for the treatment of locally advanced prostate cancer. Rectal-ureth ral fistula after prostate brachytherapy is a rare but serious complication, and its incidence, presentation, risk factors, and clinical management have not bee n well described. METHODS: From January 1997 to October 2002, seven patients wit h rectal-urethral fistulas were referred to two institutions (Brigham and Women 's Hospital andWest Roxbury Veteran's Administration Hospital) of a major teac hing referral center. Clinical presentation, risk factors, prostate staging, and clinical management were examined in a retrospective fashion. RESULTS: Seven re ctal-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 rec tal ulceration (43 percent). Coronary artery disease was a common comorbidity (7 1 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 diver ting 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 diversi on after definitive resection because of anorectal pain and a colocutaneous fist ula. Postoperative complications included myocardial infarction (14 percent), bl ood transfusion (14 percent), and bowel perforation (14 percent). Patients becam e symptom-free nine months after surgery. Six patients are alive and well today ; one died from an unrelated cause. CONCLUSIONS: Rectal-urethral fistula after prostate brachytherapy is a rare but devastating complication. Patients should b e followed for at least three years after prostate brachytherapy because symptom s can develop late in the course. Although diversion of fecal stream does not he al the fistula, all patients diagnosed with rectal-urethral fistula should firs t undergo diverting ostomy to alleviate symptoms. Then, one should consider defi nitive resection and ostomy closure.
