CASE REPORT Ileo-Cavernosal Fistula after Radiotherapy: A Case Report and Review of the Literature Murat Gul,1* Necat Islamoglu,2 Mehmet Kaynar,3 Mustafa Koplay,4 Serdar Goktas3 Keywords: intestinal fistula; etiology; adverse effects; radiation ınjuries; carcinoma; radiotherapy; cystectomy; treatment outcome; urinary bladder neoplasms. INTRODUCTION Fistula is an abnormal connection between two hollow spaces that are lined with epithelial cells. Fistulas are usually caused by injury or surgery, but radiation, infection or inflammation may also result in fistula forma- tion. There are quite a few different types of fistula in human body. Gastrointestinal tract fistulas (GIF) may have various clinical presentation, etiology, and morbidity. Because definitions can be various on the literature perry and colleagues recommends to categorize GIF into two groups as congenital and acquired GIF. Acquired GIF can be classified as external or cutaneous if they connect with the skin or internal if they involve other organ systems including genitourinary system.(1) Here we present anextremely unusual case of an internal gastrointestinal fistula -ileo- penilecorpus cavernosum fistula, developingafter External Beam Radiation Therapy (EBRT). To the best of our knowledge, this is the first report in the literature demonstrating an ileo-corpus cavernosum fistula after EBRT. CASE REPORT A 67-year-old man who had undergone radical cystectomy with ileal loop one year ago due to muscle invasive bladder carcinoma (MIBC) was referred to our clinic with a complaint of common ache in his hips and suprapubic region. He did not report any trauma. He had a chronic kidney disease background preoperatively. His blood urea nitrogen and creatinine levels were113 md/dL and 2.5 mg/dL, respectively. Other hematological examination and 1Department of Urology, Van Training and Research Hospital,Van, Turkey. 2Department of Radiology, Van Training and Research Hospital, Van, Turkey. 3 Department of Urology, School of Medicine, Selcuk University, Konya, Turkey. 4Department of Radiology, School of Medicine, Selcuk University, Konya, Turkey. *Correspondence: Department of Urology, Van Training and Research Hospital, 65000 Van, Turkey. Tel: +90 505 6316913. Fax: +90 432 2157600. E-mail: drgulacademics@gmail.com. Received January 2015 & Accepted September 2015 Figure. Sagittal fat-sat T2 weighted (a, b) and sagittal T1 weighted images (c, d) show fistula (f) between ileum and penile corpus cavernosum. Penile corpus cav- ernosumcontains stool and air (arrowheads). Vol 12 No 05 September-October 2015 2377 biochemical profile was within normal limits. Imaging studies showed no recurrence or soft tissue metastasis. Bone scintigraphy revealed multiple metastatic lesions on pubic bone. Radiotherapy (RT) was given to pelvic area to relief his pain. Total dose of 3000 cGy (300cGy × 10 fractions) external beam radiotheraphy (EBRT) was administered. EBRT was well tolerated and pa- tient’s pain started to regress. Two months later patient applied to our clinic again with swelling and pain in his penis. Magnetic resonance imaging (MRI) detected a fistula between ileum and penile cavernosal body (Fig- ure). Then patient hospitalized, oral intake was stopped and parenteral nutrition was started. Infectious diseases treatment was began with vancomycin and meropenem administration. Surgery decided but patient’s general condition didn’t permit us to take him to surgery. He eventually died because of sepsis. DISCUSSION RT proved itself at palliation of painful bone metasta- ses with a 60%-80% likelihood of providing relief for localized pain.(2) But after administration of RTespe- cially to pelvic region, adjacent organs including gas- trointestinal systemmay be injured. The most common complications of gastrointestinal system injuries are obstruction, hemorrhage, strictures, and fistulas. Few reports of internal GIF caused by RT were reported. Levenback and colleagues described anenterovesical fistula following RT for gynecologic cancer.(3) Lewin- shtein and colleagues described recto-cavernosal fistu- la after radiation for rectal cancer.(4) Recurrent disease and prior surgery are the most common reason of fis- tulization in these cases. Our patient had both risks. Besides, some other reports described urethro-carver- nosal fistulas, mostly caused by blunt trauma, penile fracture and following shunt surgery for priapism.(5- 7) But none of them are related to RT. No other cor- pus cavernosum related fistula has been reported. Al- though fistulas can be demonstrated by conventional radiography or contrast-enhanced studies, today the advanced techniques and increased availability, has become cross sectional imaging modalities more pop- ular. But it should be kept in mind that each fistula type has unique form and imaging studies may vary depending onfistula type.(1) In this case we showed the fistula tract by contrast enhanced MRI (Figure). In generally GIF management includes localization and describing the fistula’s anatomy, nutritional sup- port, detection and treatment of sepsis, and deciding to proper treatment. But the optimum management of a radiation induced fistula is unsettled yet. Because “Ra- diation Induced Fistula” term includes varying group of patientshaving different types of fistula anatomy, bowel properties, co-morbidity history and severity of radiation exposure. Therefore whether radiation-in- duced fistula requires repair at fistula site or a more aggressive approach such as permanent urinary diver- sion is unknown, and each patient should be evaluated on a case by case basis.(8) Because this is the first re- port of ileo-cavernosal fistula and penile corpus cav- ernosum is a highly vascularized tissue, we therefore assumed and treated our case as an intestino-arterial fistula. There are only three cases showing intestino-ar- terial fistula following urinary diversion. In these cas- es, sepsis was an inevitable result and represented the primary source of morbidity. Patients didn’t survive at all.(9)As soon as the diagnosis of fistula made by MRI we started to give total parenteral nutrition and proper antibiotics. Surgery was decided but patient got worse and we couldn’t perform it. We think that either diver- sion or fistulectomy would be beneficial to the patient. CONCLUSIONS EBRT is the mainstay for the treatment of painful bone metastases including pelvic malignancies. Although the early and late complications of EBRT are acceptable, clinical follow-up must absolutely be performed to make early diagnosis and treatment of radiation thera- py complications. Even the slightest symptom that may indicate a fistula should be carefully examined and the initial principle of care should be controlling and eradi- cating underlying sepsis followed by surgery if needed. CONFLICTS OF INTEREST None declared. REFERENCES 1. Pickhardt PJ, Bhalla S, Balfe DM. Acquired gastrointestinal fistulas: classification, etiologies, and imaging evaluation. Radiology. 2002;224:9-23. 2. Nieder C, Pawinski A, Dalhaug A. Continuous controversy about radiation oncologists’ choice of treatment regimens for bone metastases: should we blame doctors, cancer- related features, or design of previous clinical trials? Radiat Oncol. 2013;8:85. 3. Levenback C, Gershenson DM, McGehee R, Eifel PJ, Morris M, Burke TW. Enterovesical fistula following radiotherapy for gynecologic cancer. Gynecol Oncol. 1994;52:296-300. 4. Lewinshtein D, McCormack M, Péloquin F, Poljicak M, Karakiewicz P, Saad F. Recto- cavernosal fistula after radiation for rectal cancer. Can J Urol. 2006;13:2988-9. 5. Palaniswamy R, Rao MS, Bapna BC, Chary KS. Urethro-cavernous fistula from blunt penile trauma. J Trauma. 1981,21:242-3. 6. Juaneda Castell B, Montlleó González M, Ponce de León Roca X, Gausa Gascón L, Caparrós Sariol J, Villavicencio Mavrich H. Urethrocavernous fistula due to penile fracture. Actas Urol Esp. 2008;32:1043-5. 7. Manjunath AS, Mazur DJ, Han JS, Gonzalez CM. Simultaneous urethrocutaneous and urethrocavernous fistula after proximal corporospongiosal shunt for priapism. Urology. 2015;85:e13-4. 8. Sharma A, Kurtz MP, Eswara JR. Three Distinct Urethral Fistulae 35 Years After Pelvic Radiation. Nephrourol Mon. 2014;6:e14197. 9. Ferrie BG. Intestino-arterial fistula following urinary diversion. J R Soc Med. 1985;78:341. Ileo-Cavernosal Fistula after Radiotherapy-Gul et al. Case Report 2378