Objectives: To describe 6 cases of rectourethral fistula in patients treated with brachytherapy plus external beam radiotherapy for localized prostate cancer and subsequent rectal biopsies or rectal surgery. Methods: A retrospective chart review was undertaken of patients with prostate cancer treated with brachytherapy who presented to our institution with the diagnosis of rectourethral fistula from February 1999 to June 2002. Potential contributing factors, including patient age, cancer grade and stage, cancer treatment, rectal procedure, and time to the complication, were evaluated. Potential approaches to rectourethral fistula treatment and their outcomes are reported. Results: The mean patient age was 63.8 years. All 6 men underwent combination prostate brachytherapy and external beam radiotherapy with subsequent rectal biopsy/hemorrhoidectomy. All 6 patients developed a rectourethral fistula, with an average time between the end of radiotherapy and fistula development of 22.6 months. Four patients underwent hyperbaric oxygen therapy, which failed. Three patients underwent fecal diversion with gracilis interposition flaps, and two underwent pelvic exenteration. Conclusions: The results of our study have shown that rectourethral fistula development is a serious complication of combination radiotherapy, with definitive repair requiring major intraabdominal surgery. Biopsy of rectal ulcers in the clinical setting of combined radiotherapy should not be performed. In addition, elective rectal surgery should not be performed on irradiated tissue. In our series, hyperbaric oxygen therapy and conservative treatment did not obviate the need for definitive surgical management of the rectourethral fistula.
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