0022-534 7/79/1216-0831$02.00/0

Vol. 121, June

THE JOURNAL OF UROLOGY

Printed in U.S.A.

Copyright © 1979 by The Williams & Wilkins Co.

RECTOVESICAL FISTULA SECONDARY TO PROSTATIC CARCINOMA A. C. BUCK*

AND

G. D. CHISHOLM

From St. Peterls Hospital, Institute of Urology, London, England

ABSTRACT

Rectal invasion by carcinoma of the prostate occurs in a significant number of cases (approaching 10 per cent). A case of a rectovesical fistula owing to direct extension of a prostatic carcinoma is reported. This complication of the disease has not been described previously. When carcinoma of the prostate spreads posteriorly to involve the rectum it usually mimics a primary rectal carcinoma and presents with symptoms and signs of either large bowel obstruction, rectal bleeding or a stenosing rectal mass. 1- 5 Herein we report on a patient in whom a rectovesical fistula developed spontaneously as a complication of prostatic carcinoma. CASE REPORT

C. D., a 71-year-old man, presented in October 1973 with a 1-year history of difficulty in voiding, a poor urinary stream and perineal pain. Episodes of painless hematuria had occurred during the previous months. Rectal examination revealed a hard, craggy enlargement of the prostate and perinea! needle biopsy of the lesion showed an adenocarcinoma of the prostate of an intermediate grade with perineural invasion. Excretory urography (IVP) showed that both kidneys functioned normally and, although there was no ureteral obstruction, there was a large vesical residue after micturition. A chest x-ray, skeletal survey and nnmTc polyphosphate bone scan were negative. Hemoglobin was 13.3 gm./dl., white blood count 9,000 mm. 3 and erythrocyte sedimentation rate 3 mm. in 1 hour (Westergren). The blood urea and plasma electrolytes were normal. The serum acid phosphatase (prostatic fraction) was 2.1 King-Armstrong units (KAU)/100 ml. The patient was started on 5 gm. diethylstilbestrol 3 times daily. There was no improvement in either the symptoms of prostatism or episodic hematuria. However, the serum acid phosphatase decreased to 0.3 KAU/100 ml. In May 1974 a transurethral resection of the prostate resulted in marked improvement in the urinary symptoms. Six months later backache and diarrhea developed. In April 1975 the patient was rehospitalized because of profuse hematuria. On rectal examination there appeared to be an extension of the growth posteriorly involving the rectum, with ulceration of the rectal mucosa. Cystoscopic examination demonstrated a rigid prostatic urethra and infiltration of the trigone was believed to be the cause of the hematuria. A repeat skeletal survey and bone scan remained negative. The patient was rehospitalized as an emergency in August with retention of urine. A further transurethral resection of the prostate was done and the histology showed a moderately well differentiated adenocarcinoma of the cribriform type with squamous metaplasia of the duct epithelium. In March 1976 the tumor was noted to be extending locally and the serum acid phosphatase was elevated to 9.7 KAU/100 ml. Diethylstilbestrol was stopped and 280 mg. estramustine phosphate 3 times daily was started. There was no clinical improvement after 4 months of treatment and the serum acid phosphatase continued to increase to 16.3 KAU/100 ml.

In November the patient was admitted to the hospital with the complaint of severe backache. He had noticed bubbles in the urine 10 days previously and 6 days later he began to pass urine via the rectum. On rectal examination there was an extensive fungating growth in the anterior wall with a large fistulous tract in the center of the growth through which the catheter in the urethra and bladder could be palpated. A cystogram demonstrated this fistula (see figure). The serum acid phosphatase was 93.0 KAU/100 ml. Treatment with cyclophosphamide, prednisone and a bis-dioxopiperazine (Razoxin, I. C. I.) was begun and during the next few weeks his condition improved sufficiently to enable an ileal conduit urinary diversion to be done. The patient recovered from this operation and the serum acid phosphatase decreased to 9.0 KAU/100 ml. However, 10 days postoperatively he suddenly became cyanosed, breathless, shocked and died. At postmortem examination there were bilateral pulmonary emboli with a small infarction in the right lower lobe. There was a large ante mortem thrombus in the left femoral vein. The right kidney was shrunken and showed pyelonephritic scarring. A large fistulous communication between the base of the bladder and the anterior wall of the rectum was seen. There was no evidence of skeletal metastases.

Accepted for publication August 11, 1978. * Requests for reprints: Department of Urology, Royal Naval Hospital, Hasler P012 2AA, England.

Cystogram shows contrast material filling rectum through fistulous communication with bladder. 831

832

BUCK AND CHISHOLM

Incidence of rectal involvement in carcinoma of the prostate References Graves and Militzer• Kickham 7 Young• Arnheim 0 Winter 2 Becker• Olsen and Carlisle' Gengler and associates 10

Total No. Cases

Rectal Involvement

120 132 800 176 150 334 400 257

5 12 12 1 13 11 5 8

%

4.2

9.1 1.5 0.5 8.6 3.3 1.2 3.1

DISCUSSION

Rectal involvement by a malignant prostate is well recognized and occurs in approximately 10 per cent of the cases with advanced disease (see table). 2· 4--io The strong double layer of Denonvilliers' fascia, although not a barrier to the spread of a primary rectal or uterine carcinoma, is said to protect the rectum from invasion by prostatic carcinoma.2· 5• 8 • 10-12 Three ways in which the rectum may be invaded by prostatic carcinoma have been described. 1' 11 The tumor may present as a mass in the anterior rectal wall, which bulges into the lumen of the rectum. Most commonly (70 per cent), the tumor spreads circumferentially in the potential space between the 2 layers of Denonvilliers' fascia to encircle the rectum in an hourglass stricture, causing obstruction. 4 Rarely, the tumor may extend through the entire thickness of the rectal wall and present as a fungating growth with ulceration of the rectal mucosa. Young, in a review of 800 cases of prostatic carcinoma, found ulceration of the rectal mucosa in 3 cases. 8 Arnheim, in an autopsy study of 176 cases of prostatic cancer, found the rectal mucosa to be breached in 1 case only. 9 There appears to

be no previous report of a case of spontaneous rectovesical fistula owing to carcinoma of the prostate. REFERENCES

1. Jackman, R. J. and Anderson, J. R.: Proctologic manifestations of carcinoma of the prostate. Amer. J. Surg., 83: 491, 1952. 2. Winter, C. C.: Prostatic carcinoma involving the rectum. The problem of differentiation from other malignant lesions. Calif. Med., 82: 85, 1955. 3. Reay, E. R. and Utley, W. L. F.: Rectal manifestations of the malignant prostate. Aust. New Zeal. J. Surg., 24: 272, 1955. 4. Becker, J. A.: Prostatic carcinoma involving the rectum and sigmoid colon. Amer. J. Roentgen., 94: 421, 1965. 5. Olsen, B. S. and Carlisle, R. W.: Adenocarcinoma of the prostate simulating primary rectal malignancy. Cancer, 25: 219, 1970. 6. Graves, R. C. and Militzer, R. E.: Carcinoma of the prostate with metastases. J. Urol., 33: 235, 1935. 7. Kickham, C. J. E.: Diagnostic pitfalls in carcinoma of the prostate. J. Urol., 45: 92, 1941. 8. Young, H. H.: Cure of cancer of the prostate by radical perinea! prostatectomy (prostato-seminal vesiculectomy): history, literature and statistics of Young's operation. J. Urol., 53: 188, 1945. 9. Arnheim, F. K.: Carcinoma of the prostate: a study of the postmortem findings in one hundred and seventy-six cases. J. Urol., 60: 599, 1948. 10. Gengler, L., Baer, J. and Finby, N.: Rectal and sigmoid involvement secondary to carcinoma of the prostate. Amer. J. Roentgen., 125: 910, 1975. 11. Lazarus, J. A.: Complete rectal occlusion necessitating colostomy. Due to carcinoma of the prostate. Amer. J. Surg., 30: 502, 1935. 12. Green, N.: Value of radiotherapy for adenocarcinoma of the prostate simulating primary rectal carcinoma. J. Urol., 112: 247, 1974.

Rectovesical fistula secondary to prostatic carcinoma.

0022-534 7/79/1216-0831$02.00/0 Vol. 121, June THE JOURNAL OF UROLOGY Printed in U.S.A. Copyright © 1979 by The Williams & Wilkins Co. RECTOVESIC...
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