A 73-year-old male had prostatic adenocarcinoma since 2003. After external-beam radiotherapy and cryotherapy had failed, the patient was treated with transrectal high-intensity focused ultrasound (HIFU). Because of recurrent hematuria, pneumaturia and urinary tract infection, a fistula to the urinary tract was suspected. Computed tomography raised the suspicion of rectourethral fistula. Sigmoidoscopy showed a large rectourethral fistula between the distal anterior rectal wall and the prostate bed. The urinary catheter and the inflated balloon could be easily inspected (Fig. 1A,B). No endoscopic attempt was made to close the fistula because of its size and location. The case was discussed in a multidisciplinary forum. The patient was sent for urinary and colonic diversion before transanal surgical fistula sealing.
Figure 1 (A) Endoscopic view from distal rectum. The rectal lumen and the urinary catheter can be seen. (B) The scope is inside the prostate bed
Transrectal HIFU is a relatively new technology [1] capable of inducing instantaneous and irreversible coagulative necrosis in all biologic tissue via a thermal effect (absorption of ultrasound energy converted into heat) and cavitation. Rectourethral fistula [2] is a possible but rare complication of the treatment of prostate cancer with transrectal HIFU treatment that inevitably requires stepped and complex reconstructive surgery.