2. UroToday Home
  3. Recent Abstracts
  4. Urologic Oncology
  5. Prostate Cancer

Vesicocutaneous fistula following adjuvant radiotherapy for pelvic malignancies, "Beyond the Abstract," by Derek B. Hennessey, MB, BAO, BCh, BMedSci, MRCSI, et al

BERKELEY, CA (UroToday.com) - Vesicocutaneous fistula (VCF) is defined as the abnormal connection between the bladder and the skin. It can be an extremely distressing condition as the constant leakage of urine results in maceration and destruction of skin, discomfort, and malodour. It is a very rare condition and the majority of reports in the literature pertain to single case reports and small case series. The surgical management of urinary fistulas is often advised as it offers symptomatic relief and improves the quality of life of patients above conservative management. In addition, conservative treatment has been reported to be generally ineffective.[1]

Aetiology

Various etiological factors have been reported to be the cause of a VCF.[2] VCF have occurred following multiple caesarean sections,[3] repair of bladder exstrophy,[4] post pelvic trauma,[5] or as a consequence of a large bladder stones or a large bladder diverticulum.[6] Radiation therapy for pelvic malignancies, in particular prostate cancer treatment, is recognised as an emerging cause of this rare condition.[1, 7]

Radiation-induced VCF

Fistula formation following radiotherapy for prostate cancer has been reported to occur in 0.3% to 3% of patients after brachytherapy (BT)[8] and up to 0.6% of those treated with external beam radiotherapy (EBRT).[9] The majority of fistulas reported are recto-urethral (RUF) or recto-vesical (RVF). The occurrence of VCF still remains infrequent.[1, 10] Fistula formation following radiation therapy is thought to be related to progressive micro-vascular injury and stromal fibrosis, resulting in mucosal erosions, ulcers and perforations, and ultimately leading to a fistula tract.[1]

Clinical Presentation

The mean duration from radiation therapy to the onset of symptoms of a VCF is between 36 and 49 months.[1] Classically, VCF presents as an abscess or gangrenous swelling in the upper thigh or lower abdomen. Eventually, a fistula tract will form and urine will start to drain from the site. The skin will appear macerated and a surrounding cellulitis may be present at the site. Recommended investigations include fisutulagram and magnetic resonance imaging (MRI).[7]

Management

The main principle in the management of urinary fistulas is to keep the bladder empty, preventing any raised intra-vesical pressure and urinary leakage. Conservative management of VCF has been described in the literature but cannot be advised, as it has been reported to be ineffective.[1] Various surgical options for fistula management have been reported in the literature.[11] Factors influencing the type of surgical procedure chosen include anatomic level of the fistula, cause of the VCF, underlying malignancy, previous radiotherapy, and patient co-morbidities.[12]

VCF may be repaired in a one-stage procedure (fistulectomy). Placement of an inter-posing tissue such as a myo-cutaneous or omental flap to aid wound healing is recommended. In the setting of radiation-induced VCF, urinary diversion is advised.[11] A safe reconstructive procedure cannot be guaranteed in such circumstances, as tissue healing in a previously irradiated field is compromised.[13] Furthermore, following EBRT and a history of recent surgery, pelvic tissue planes would be difficult to discern. The operative choice in this case would be diversion with an ileal-conduit, with or without cystectomy.[14]

Summary

VCF is a rare and extremely distressing condition. It can occur following multiple pathologies, but commonly occurs following radiotherapy for pelvic malignancies. Conservative management has been reported in the literature but surgical management is advised if the patient is fit for surgery. Fistulectomy with placement of an inter-posing tissue flap is recommended unless there is a history of radiotherapy, in such cases urinary diversion is advised.

References:

  1. Chrouser KL, Leibovich BC, Sweat SD, et al. Urinary fistulas following external radiation or permanent brachytherapy for the treatment of prostate cancer. J Urol 2005;173:1953-7.
  2. Kishore TA, Bhat S, John PR. Vesicocutaneous fistula arising from a bladder diverticulum. Indian J Med Sci 2005;59:265-7.
  3. Toufique H, Merani AJ. Vesicocutaneous fistula. J Pak Med Assoc 2011;61:918-9.
  4. Massanyi EZ, Shah B, Schaeffer AJ, Dicarlo HN, Sponseller PD, Gearhart JP. Persistent vesicocutaneous fistula after repair of classic bladder exstrophy: A sign of failure? J Pediatr Urol 2012.
  5. Kosaka T, Asano T, Azuma R, Yoshii H, Yamanaka Y, Hayakawa M. A case of vesicocutaneous fistula to the thigh. Urology 2009;73:929 e7-8.
  6. Kishore TA, Bhat S, John PR. Vesicocutaneous fistula arising from a bladder diverticulum. Indian J Med Sci 2005;59:265-7.
  7. Hennessey DB, Bolton E, Thomas AZ, Lynch TH. Vesicocutaneous fistula following adjuvant radiotherapy for prostate cancer. BMJ Case Rep 2013;2013.
  8. Stone NN SR. Complications following permanent prostate brachytherapy. Eur Urol 2002 Apr;41(4):427-33.
  9. Huang EH PA, Levy L, Starkschall G, Dong L, Rosen I, Kuban DA. Late rectal toxicity: dose-volume effects of conformal radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys 2002 Dec 1;54(5):1314-21.
  10. Moreira SG, Jr., Seigne JD, Ordorica RC, Marcet J, Pow-Sang JM, Lockhart JL. Devastating complications after brachytherapy in the treatment of prostate adenocarcinoma. BJU Int 2004;93:31-5.
  11. Lentz SS, Homesley HD. Radiation-Induced Vesicosacral Fistula: Treatment with Continent Urinary Diversion. Gynecologic Oncology 1995;58:278-80.
  12. Meng E CF, Wu S, Lee S, Sun G, Chen H, Chang S, Ma C, Yu D. Fistula Involving Urinary Bladder: Experience with the management of 23 cases. J Urol ROC, 12:121-125 2004.
  13. Lau KO CC. A case report--delayed vesicocutaneous fistula after radiation therapy for advanced vulvar cancer. Ann Acad Med Singapore 1998 Sep;27(5):705-6.
  14. Chrouser KL LB, Sweat SD, Larson DW, Davis BJ, Tran NV, Zincke H, Blute ML. Urinary fistulas following external radiation or permanent brachytherapy for the treatment of prostate cancer. J Urol 2005 Jun;173(6):1953-7.

Written by:
D. B. Hennessey, C. M. Casey, E. Bolton, A. Z. Thomas, and T. H. Lynch as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Derek Hennessey, MB, BAO, BCh, BMedSci, MRCSI, Department of Urology, 1 Lisburn Rd., Belfast, BT9 7AB

Vesicocutaneous fistula following adjuvant radiotherapy for prostate cancer - Abstract

More Information about Beyond the Abstract