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Published online: 2024-01-16

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Rectal ulceration and rectourethral fistula as rare complications of radiotherapy for prostate cancer—a case report and literature review

Krzysztof Kowalik1, Anna Gruszczyńska2, Katarzyna Hetman3, Katarzyna Kołaczyk4, Michał Falco5, Krystian Kasperowicz6, Andrzej Modrzejewski1


We present a case of a patient with inoperable prostate cancer [Gleason 10 (5 + 5), cT3b]. The patient was treated with radical radiotherapy because he had numerous internal conditions, and he had been disqualified from radical prostatectomy. The man developed radiation colitis after radiotherapy. This inflammation led to rectal ulceration. Another complication of radical irradiation was a rectourethral fistula. In this case, the reaction occurred within 6 months of the initiation of irradiation, i.e. during the period of early effect, whereas the presentation of the reaction (ulcer, fistula) corresponded to the late effect. This led us to classify the presented case as a consequential late effect. This article presents possible complications and treatment options for prostate radiotherapy. We reviewed the available literature and discussed our patient’s case in the context of other authors’ experiences.

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  1. Bray F, Ferlay J, Soerjomataram I, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018; 68(6): 394–424; erratum in: CA Cancer J Clin. 2020;70(4):313.
  2. Guidelines NCCN for Treatment Prostate Cancer Version 4.2023.
  3. Cooperberg MR, Broering JM, Carroll PR. Time trends and local variation in primary treatment of localized prostate cancer. J Clin Oncol. 2010; 28(7): 1117–1123.
  4. Kramer KM, Bennett CL, Pickard AS, et al. Patient preferences in prostate cancer: a clinician's guide to understanding health utilities. Clin Prostate Cancer. 2005; 4(1): 15–23.
  6. Pawłowska E, Jassem J. Review of Polish and international guidelines on hormonal therapy in localized prostate cancer. Nowotwory. Journal of Oncology. 2017; 66(5): 403–407.
  7. Hunter GK, Reddy CA, Klein EA, et al. Long-term (10-year) gastrointestinal and genitourinary toxicity after treatment with external beam radiotherapy, radical prostatectomy, or brachytherapy for prostate cancer. Prostate Cancer. 2012; 2012: 853487.
  8. Rucińska M, Powikłania radioterapii. Onkol Dypl. 2023; 20(2).,powiklania-radioterapii.
  9. Common Terminology Criteria for Adverse Events (CTCAE). Version 5.0 Published: November 27, 2017 U.S. Department of Health and Human Services.
  10. Kim Y, Roscoe JA, Morrow GR. The effects of information and negative affect on severity of side effects from radiation therapy for prostate cancer. Support Care Cancer. 2002; 10(5): 416–421.
  11. Hamdy F, Donovan J, Lane J, et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. N Engl J Med. 2016; 375(15): 1415–1424.
  12. Donovan J, Hamdy F, Lane J, et al. Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med. 2016; 375(15): 1425–1437.
  13. Budäus L, Bolla M, Bossi A, et al. Functional outcomes and complications following radiation therapy for prostate cancer: a critical analysis of the literature. Eur Urol. 2012; 61(1): 112–127.
  14. Kuban D, Tucker S, Dong L, et al. Long-Term Results of the M. D. Anderson Randomized Dose-Escalation Trial for Prostate Cancer. Int J Radiat Oncol Biol Phys. 2008; 70(1): 67–74.
  15. Peeters STH, Heemsbergen WD, van Putten WLJ, et al. Acute and late complications after radiotherapy for prostate cancer: results of a multicenter randomized trial comparing 68 Gy to 78 Gy. Int J Radiat Oncol Biol Phys. 2005; 61(4): 1019–1034.
  16. Matzinger O, Duclos F, van den Bergh A, et al. EORTC Radiation Oncology Group. Acute toxicity of curative radiotherapy for intermediate- and high-risk localised prostate cancer in the EORTC trial 22991. Eur J Cancer. 2009; 45(16): 2825–2834.
  17. Zelefsky MJ, Deasy JO. Improved long-term outcomes with IMRT: is it better technology or better physics? Int J Radiat Oncol Biol Phys. 2013; 87(5): 867–868.
  18. Meerleer GDe, Fonteyne V, Meersschout S, et al. Salvage intensity-modulated radiotherapy for rising PSA after radical prostatectomy. Radiother and Oncol. 2008; 89(2): 205–213.
  19. Dutz A, Agolli L, Baumann M, et al. Early and late side effects, dosimetric parameters and quality of life after proton beam therapy and IMRT for prostate cancer: a matched-pair analysis. Acta Oncol. 2019; 58(6): 916–925.
  20. Matta R, Chapple CR, Fisch M, et al. Pelvic Complications After Prostate Cancer Radiation Therapy and Their Management: An International Collaborative Narrative Review. Eur Urol. 2019; 75(3): 464–476.
  21. Weiner J, Schwartz D, Martinez M, et al. Long-term results on the efficacy of argon plasma coagulation for patients with chronic radiation proctitis after conventionally fractionated, dose-escalated radiation therapy for prostate cancer. Pract Radiat Oncol. 2017; 7(1): e35–e42.
  22. Prabha V, Kadeli V. Repair of recto-urethral fistula with urethral augmentation by buccal mucosal graft and gracilis muscle flap interposition - our experience. Cent European J Urol. 2018; 71(1): 121–128.
  23. Sadighian M, Hakam N, Amend G, et al. Radiation-induced Fistulas in Patients With Prior Pelvic Radiotherapy for Prostate Cancer: A Systematic Review and Meta-analysis. Urology. 2023; 176: 121–126.
  24. Topazio L, Perugia C, Finazzi-Agro E. Conservative treatment of a recto-urethral fistula due to salvage HIFU for local recurrence of prostate cancer, 5 years after radical prostatectomy and external beam radiotherapy. BMJ Case Rep. 2012; 2012.
  25. Thompson IM, Marx AC. Conservative therapy of rectourethral fistula: five-year follow-up. Urology. 1990; 35(6): 533–536.
  26. Ahmed HU, Ishaq A, Zacharakis E, et al. Rectal fistulae after salvage high-intensity focused ultrasound for recurrent prostate cancer after combined brachytherapy and external beam radiotherapy. BJU Int. 2009; 103(3): 321–323.
  27. Wallis CJD, Mahar A, Cheung P, et al. Incidence of complications other than urinary incontinence or erectile dysfunction after radical prostatectomy or radiotherapy for prostate cancer: a population-based cohort study. Lancet Oncol. 2014; 15(2): 223–231.
  28. Mundy AR, Andrich DE. Posterior urethral complications of the treatment of prostate cancer. BJU Int. 2012; 110(3): 304–325.
  29. Bassett MR, Santiago-Lastra Y, Stoffel JT, et al. Neurogenic Bladder Research Group, Trauma and Urologic Reconstructive Network of Surgeons. Urinary Diversion for Severe Urinary Adverse Events of Prostate Radiation: Results from a Multi-Institutional Study. J Urol. 2017; 197(3 Pt 1): 744–750.
  30. Miller LE, Efstathiou JA, Bhattacharyya SK, et al. Association of the Placement of a Perirectal Hydrogel Spacer With the Clinical Outcomes of Men Receiving Radiotherapy for Prostate Cancer: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020; 3(6): e208221.
  31. Nasser NJ, Fenig E, Klein J, et al. Maintaining consistent bladder filling during external beam radiotherapy for prostate cancer. Tech Innov Patient Support Radiat Oncol. 2021; 17: 1–4.
  32. Rowe LS, Mandia JJ, Salerno KE, et al. Bowel and Bladder Reproducibility in Image Guided Radiation Therapy for Prostate Cancer: Results of a Patterns of Practice Survey. Adv Radiat Oncol. 2022; 7(5): 100902.
  33. Stenmark MH, Hamstra DA. Image-Guided Strategies for Prostate Cancer. In: Thomas CHR. ed. Radiation Medicine Rounds Prostate Cancer. Demos Medical Publishing 2011: 113–130.
  34. Randall JW, Rammohan N, Das IJ, et al. Towards Accurate and Precise Image-Guided Radiotherapy: Clinical Applications of the MR-Linac. J Clin Med. 2022; 11(14).
  35. Bruynzeel AME, Tetar SU, Oei SS, et al. A Prospective Single-Arm Phase 2 Study of Stereotactic Magnetic Resonance Guided Adaptive Radiation Therapy for Prostate Cancer: Early Toxicity Results. Int J Radiat Oncol Biol Phys. 2019; 105(5): 1086–1094.
  36. Kudchadker RJ, Lee AK, Yu ZH, et al. Effectiveness of using fewer implanted fiducial markers for prostate target alignment. Int J Radiat Oncol Biol Phys. 2009; 74(4): 1283–1289.
  37. Kupelian PA, Willoughby TR, Meeks SL, et al. Intraprostatic fiducials for localization of the prostate gland: monitoring intermarker distances during radiation therapy to test for marker stability. Int J Radiat Oncol Biol Phys. 2005; 62(5): 1291–1296.
  38. Willoughby TR, Kupelian PA, Pouliot J, et al. Target localization and real-time tracking using the Calypso 4D localization system in patients with localized prostate cancer. Int J Radiat Oncol Biol Phys. 2006; 65(2): 528–534.
  39. Litzenberg DW, Balter JM, Hadley SW, et al. Prostate intrafraction translation margins for real-time monitoring and correction strategies. Prostate Cancer. 2012; 2012: 130579.
  40. McNair HA, Mangar SA, Coffey J, et al. A comparison of CT- and ultrasound-based imaging to localize the prostate for external beam radiotherapy. Int J Radiat Oncol Biol Phys. 2006; 65(3): 678–687.
  41. Scarbrough TJ, Golden NM, Ting JY, et al. Comparison of ultrasound and implanted seed marker prostate localization methods: Implications for image-guided radiotherapy. Int J Radiat Oncol Biol Phys. 2006; 65(2): 378–387.