A delayed presentation of vesicocutaenous fistula

A 60-year-old male presented to the emergency department (ED) with a six-month history of intermittent discharge from a lump in the right groin crease. In the days prior to presentation, there was increased volume of discharge of a fluid resembling urine. Inflammatory markers were normal and urine dipstick was unremarkable.

Imaging was degraded by artefact from previous pelvic internal fixation. Anteroposterior and lateral view pelvic radiographs demonstrate two fixation plates with six screws running anteroposterior (Figure 1). Fluoroscopic fistulogram confirms a vesicocutaneous fistula (Figure 2). A CT cystogram demonstrated a fistula tract running from the right anterolateral aspect of the bladder, adjacent to the fixation plate and most inferolateral screw in the right superior pubic ramus to the right groin crease (Figure 3). A flexible cystoscopy confirmed the presence of ectopic metal within the bladder.

Background

A vesicocutaneous fistula (VCF) is an abnormal tract formed between the bladder and the skin. It is an uncommon entity ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S0022-5347(17)59681-0","abstract":"A case of spontaneous vesicocutaneous fistula caused by actinomycosis is reported in a 57 yr old woman. The sinus tract was curetted and the cultures revealed 2 strains of actinomyces.","author":[{"dropping-particle":"","family":"Deshmukh","given":"A. S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kropp","given":"K. A.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Urology","id":"ITEM-1","issue":"2","issued":{"date-parts":[["1974"]]},"page":"192-194","title":"Spontaneous vesicocutaneous fistula caused by actinomycosis: case report","type":"article-journal","volume":"112"},"uris":["http://www.mendeley.com/documents/?uuid=eafd17cf-22f6-3d83-b543-face228a3a13"]}],"mendeley":{"formattedCitation":"[1]","plainTextFormattedCitation":"[1]","previouslyFormattedCitation":"[1]"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[1].

Clinical Perspective

VCF represents a significant morbidity for patients, resulting in recurrent urinary tract infections (UTI), discharge, pain and social stigma ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.5152/TUD.2017.35929","PMID":"29511592","abstract":"A vesicocutaneous fistula (VCF) is a tract that is formed abnormally between the bladder and the external surface of the body. VCF results in a great deal of inconvenience, discomfort, and physical disability for the affected patient. This condition can be caused by extensive trauma with pelvic bone fracture, radical pelvic surgery, irradiation of pelvic malignancies, hip arthroplasty, a large bladder calculus, and various other pa-thologies. The management of VCF should be approached on a case-by-case basis because of the complexity of the disease. In this report, we present a case of VCF that was managed by using vacuum-assisted closure therapy. A 72-year-old female was diagnosed with VCF as a late complication after radiotherapy for cervical cancer. After radiotherapy, she had lower urinary tract symptoms and was diagnosed as a neurogenic bladder. She started to perform clean intermittent catheterization (CIC). She was subsequently diagnosed as chronic kidney disease stage 5 due to hypertensive nephrosclerosis, and started to receive hemodialy-sis. Recently, she avoided CIC because of decreased urine output. Despite urinary diversion and surgical debridement, the surgical wound had not healed after several days. After vacuum assisted closure therapy, the surgical wound healed and filled with granulation tissue. This case shows that vacuum-assisted closure therapy is efficient for complicated wound healing of a VCF after radiotherapy.","author":[{"dropping-particle":"","family":"Kim","given":"Sang Won","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lee","given":"Jun Nyung","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kim","given":"Hyun Tae","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yoo","given":"Eun Sang","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Turkish Journal of Urology","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2018","3","1"]]},"page":"185","publisher":"Turkish Association of Urology","title":"Management of a patient with vesicocutaneous fistula presenting 13 years after radiotherapy performed for cervical cancer","type":"article-journal","volume":"44"},"uris":["http://www.mendeley.com/documents/?uuid=652e2c41-b47e-335c-95fa-72bbea953323"]}],"mendeley":{"formattedCitation":"[2]","plainTextFormattedCitation":"[2]","previouslyFormattedCitation":"[2]"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[2]. Typically patients present with a discharging fistula in the groin or suprapubic area ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/BCR-2013-008986","ISSN":"1757-790X","PMID":"23625668","abstract":"Vesicocutaneous fistulas (VCF) are a rare complication of radical radiotherapy to the pelvis. Timely diagnosis and management are often difficult and complex. We report the unusual case of a 64-year-old gentleman who presented to the emergency department with worsening sepsis and profuse discharge from a cutaneous opening in the left groin. This presentation was 6 weeks following the completion of external beam radiotherapy for apical margin-positive prostate cancer (pT3a). A diagnosis of a VCF was confirmed after CT scanning of the abdomen and pelvis with contrast. Urinary diversion was achieved by a temporary urethral catheter insertion. Full resolution of this gentleman's symptoms was accomplished. In this article, we present a non-invasive approach to the management of VCF. This case raises intricate management issues in the atypical development of an early urinary tract fistula postradiotherapy.","author":[{"dropping-particle":"","family":"DB","given":"Hennessey","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"E","given":"Bolton","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"AZ","given":"Thomas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"TH","given":"Lynch","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BMJ case reports","id":"ITEM-1","issued":{"date-parts":[["2013"]]},"publisher":"BMJ Case Rep","title":"Vesicocutaneous fistula following adjuvant radiotherapy for prostate cancer","type":"article-journal","volume":"2013"},"uris":["http://www.mendeley.com/documents/?uuid=eed00741-6929-32c9-a0c2-677ae3d245b3"]},{"id":"ITEM-2","itemData":{"DOI":"10.1093/JSCR/2011.6.4","PMID":"24949699","abstract":"We report an interesting and rare case of a vesicocutaneous fistula, which was diagnosed only one year following radiotherapy. A 71 year old gentleman presented with a gangrenous swelling of his left thigh. A copius amount of urine was seen to be draining from the site after initial incision and drainage. Computed tomography with contrast confirmed the diagnosis of a vesicocutaneous fistula. Bilateral nephrostomies were inserted to aid spontaneous closure of the fistula. Previous case reports of vesicocutaneous fistulae involving radiotherapy have described the complication of a fistula occurring many years after the intervention.","author":[{"dropping-particle":"","family":"Yin","given":"Jonathan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Marino","given":"Anthony","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cooke","given":"Peter","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bitar","given":"Khaldoun","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Surgical Case Reports","id":"ITEM-2","issue":"6","issued":{"date-parts":[["2011","6"]]},"page":"4","publisher":"Oxford University Press","title":"Post-radiotherapy vesicocutaneous fistula presenting as gas/fluid-filled groin swelling","type":"article-journal","volume":"2011"},"uris":["http://www.mendeley.com/documents/?uuid=4dbdbfcb-2497-39a6-becb-39230bf28454"]},{"id":"ITEM-3","itemData":{"DOI":"10.1093/JSCR/2010.6.4","PMID":"24946330","abstract":"We present a rare case of a vesicocutaneous fistula secondary to two large bladder calculi in a patient with spina bifida. A 62 year old lady presented with swelling of her right thigh and a calcified mass protruding through the subcutaneous tissues of her right groin. Urine was seen to be draining from around the area and plain radiographs and a computed topography (CT) scan confirmed the presence of two bladder calculi with a vesicocutaneous fistula. Vesicolithotomy was performed and the fistula tract left to close spontaneously. Worldwide this is only the fourth case of a bladder calculus causing a vesicocutaneous fistula. , Copyright © JSCR.","author":[{"dropping-particle":"","family":"Horsnell","given":"Jonathan D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kinder","given":"Richard B","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Surgical Case Reports","id":"ITEM-3","issue":"6","issued":{"date-parts":[["2010","8"]]},"page":"4","publisher":"Oxford University Press","title":"A vesicocutaneous fistula secondary to bladder calculi in a patient with spina bifida","type":"article-journal","volume":"2010"},"uris":["http://www.mendeley.com/documents/?uuid=701d4a5b-b709-3352-822a-81dcbb9cd07f"]}],"mendeley":{"formattedCitation":"[3–5]","plainTextFormattedCitation":"[3–5]","previouslyFormattedCitation":"[3–5]"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[3–5].

VCF can be classified as congenital or acquired. Common acquired causes include pelvic trauma and prior radiation therapy ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S0022-5347(17)59681-0","abstract":"A case of spontaneous vesicocutaneous fistula caused by actinomycosis is reported in a 57 yr old woman. The sinus tract was curetted and the cultures revealed 2 strains of actinomyces.","author":[{"dropping-particle":"","family":"Deshmukh","given":"A. S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kropp","given":"K. A.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Urology","id":"ITEM-1","issue":"2","issued":{"date-parts":[["1974"]]},"page":"192-194","title":"Spontaneous vesicocutaneous fistula caused by actinomycosis: case report","type":"article-journal","volume":"112"},"uris":["http://www.mendeley.com/documents/?uuid=eafd17cf-22f6-3d83-b543-face228a3a13"]},{"id":"ITEM-2","itemData":{"DOI":"10.1093/JSCR/RJV004","abstract":"A fistula is defined as an abnormal association of two or more epithelial lining. Therefore, vesicocutaneous fistula (VCF) represents an extra anatomic communication between the bladder wall and the external surface of the skin. The most common cause is iatrogenic; however, numerous factors may play a role in the formation of VCFs. When a VCF is identified, it should be treated properly due to its bothersome complaints and social effects. Nonetheless, no certain consensus has been achieved, yet. In this case, we report the feasibility and efficacy of omental flap interposition during VCF repair.","author":[{"dropping-particle":"","family":"Basatac","given":"Cem","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cicek","given":"Mehmet Cagatay","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Surgical Case Reports","id":"ITEM-2","issue":"2","issued":{"date-parts":[["2015","2","1"]]},"page":"rjv004-rjv004","publisher":"Oxford Academic","title":"Vesicocutaneous fistula treatment by using omental flap interposition","type":"article-journal","volume":"2015"},"uris":["http://www.mendeley.com/documents/?uuid=58b8734b-d6ee-38b8-abde-b8dce7581052"]}],"mendeley":{"formattedCitation":"[1, 6]","plainTextFormattedCitation":"[1, 6]","previouslyFormattedCitation":"[1, 6]"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[1, 6]. The management of VCF varies based on the constellation of symptoms and aetiology ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.5152/TUD.2017.35929","PMID":"29511592","abstract":"A vesicocutaneous fistula (VCF) is a tract that is formed abnormally between the bladder and the external surface of the body. VCF results in a great deal of inconvenience, discomfort, and physical disability for the affected patient. This condition can be caused by extensive trauma with pelvic bone fracture, radical pelvic surgery, irradiation of pelvic malignancies, hip arthroplasty, a large bladder calculus, and various other pa-thologies. The management of VCF should be approached on a case-by-case basis because of the complexity of the disease. In this report, we present a case of VCF that was managed by using vacuum-assisted closure therapy. A 72-year-old female was diagnosed with VCF as a late complication after radiotherapy for cervical cancer. After radiotherapy, she had lower urinary tract symptoms and was diagnosed as a neurogenic bladder. She started to perform clean intermittent catheterization (CIC). She was subsequently diagnosed as chronic kidney disease stage 5 due to hypertensive nephrosclerosis, and started to receive hemodialy-sis. Recently, she avoided CIC because of decreased urine output. Despite urinary diversion and surgical debridement, the surgical wound had not healed after several days. After vacuum assisted closure therapy, the surgical wound healed and filled with granulation tissue. This case shows that vacuum-assisted closure therapy is efficient for complicated wound healing of a VCF after radiotherapy.","author":[{"dropping-particle":"","family":"Kim","given":"Sang Won","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lee","given":"Jun Nyung","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kim","given":"Hyun Tae","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yoo","given":"Eun Sang","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Turkish Journal of Urology","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2018","3","1"]]},"page":"185","publisher":"Turkish Association of Urology","title":"Management of a patient with vesicocutaneous fistula presenting 13 years after radiotherapy performed for cervical cancer","type":"article-journal","volume":"44"},"uris":["http://www.mendeley.com/documents/?uuid=652e2c41-b47e-335c-95fa-72bbea953323"]},{"id":"ITEM-2","itemData":{"DOI":"10.1136/BCR-2013-008986","ISSN":"1757-790X","PMID":"23625668","abstract":"Vesicocutaneous fistulas (VCF) are a rare complication of radical radiotherapy to the pelvis. Timely diagnosis and management are often difficult and complex. We report the unusual case of a 64-year-old gentleman who presented to the emergency department with worsening sepsis and profuse discharge from a cutaneous opening in the left groin. This presentation was 6 weeks following the completion of external beam radiotherapy for apical margin-positive prostate cancer (pT3a). A diagnosis of a VCF was confirmed after CT scanning of the abdomen and pelvis with contrast. Urinary diversion was achieved by a temporary urethral catheter insertion. Full resolution of this gentleman's symptoms was accomplished. In this article, we present a non-invasive approach to the management of VCF. This case raises intricate management issues in the atypical development of an early urinary tract fistula postradiotherapy.","author":[{"dropping-particle":"","family":"DB","given":"Hennessey","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"E","given":"Bolton","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"AZ","given":"Thomas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"TH","given":"Lynch","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BMJ case reports","id":"ITEM-2","issued":{"date-parts":[["2013"]]},"publisher":"BMJ Case Rep","title":"Vesicocutaneous fistula following adjuvant radiotherapy for prostate cancer","type":"article-journal","volume":"2013"},"uris":["http://www.mendeley.com/documents/?uuid=eed00741-6929-32c9-a0c2-677ae3d245b3"]}],"mendeley":{"formattedCitation":"[2, 3]","plainTextFormattedCitation":"[2, 3]","previouslyFormattedCitation":"[2, 3]"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[2, 3].

Imaging Perspective

Plain film pelvic x-ray is helpful to delineate in-situ metal work, in the context of prior trauma.

Fluoroscopic fistulogram is the most direct method to confirm the diagnosis ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1148/RG.245035219","abstract":"Fistulas of the genitourinary tract have diverse anatomic locations, causes, and clinical features. They can involve the upper urinary tract (kidney, ureter), the lower urinary tract (bladder, uret...","author":[{"dropping-particle":"","family":"Yu","given":"Nam C.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Raman","given":"Steven S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Patel","given":"Monica","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Barbaric","given":"Zoran","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"https://doi.org/10.1148/rg.245035219","id":"ITEM-1","issue":"5","issued":{"date-parts":[["2004","9","1"]]},"page":"1331-1352","publisher":" Radiological Society of North America ","title":"Fistulas of the Genitourinary Tract: A Radiologic Review1","type":"article-journal","volume":"24"},"uris":["http://www.mendeley.com/documents/?uuid=52cbe505-cfe6-310c-b5b5-f60b7b626368"]}],"mendeley":{"formattedCitation":"[7]","plainTextFormattedCitation":"[7]","previouslyFormattedCitation":"[7]"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[7], demonstrating the flow of contrast from the fistula opening into the urinary bladder.

CT cystogram may be helpful particularly if the VCF is secondary to radiation. However, in this case, the in-situ metal resulted is significant image artefact.

Outcome

VCF is a condition associated with significant morbidity. Management varies depending on severity of symptoms and aetiology. Urinary diversion through the use of a urinary catheter has been proven to be an effective treatment strategy ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/BCR-2013-008986","ISSN":"1757-790X","PMID":"23625668","abstract":"Vesicocutaneous fistulas (VCF) are a rare complication of radical radiotherapy to the pelvis. Timely diagnosis and management are often difficult and complex. We report the unusual case of a 64-year-old gentleman who presented to the emergency department with worsening sepsis and profuse discharge from a cutaneous opening in the left groin. This presentation was 6 weeks following the completion of external beam radiotherapy for apical margin-positive prostate cancer (pT3a). A diagnosis of a VCF was confirmed after CT scanning of the abdomen and pelvis with contrast. Urinary diversion was achieved by a temporary urethral catheter insertion. Full resolution of this gentleman's symptoms was accomplished. In this article, we present a non-invasive approach to the management of VCF. This case raises intricate management issues in the atypical development of an early urinary tract fistula postradiotherapy.","author":[{"dropping-particle":"","family":"DB","given":"Hennessey","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"E","given":"Bolton","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"AZ","given":"Thomas","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"TH","given":"Lynch","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BMJ case reports","id":"ITEM-1","issued":{"date-parts":[["2013"]]},"publisher":"BMJ Case Rep","title":"Vesicocutaneous fistula following adjuvant radiotherapy for prostate cancer","type":"article-journal","volume":"2013"},"uris":["http://www.mendeley.com/documents/?uuid=eed00741-6929-32c9-a0c2-677ae3d245b3"]}],"mendeley":{"formattedCitation":"[3]","plainTextFormattedCitation":"[3]","previouslyFormattedCitation":"[3]"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[3]. However, in this case where the offending metal screw remained in-situ, open surgical removal of metal and bladder closure was required.

Take-Home Message/Teaching Points

VCF is a rare clinical presentation and each reported case adds to our knowledge of the condition.

Early diagnosis relies on radiologic investigations and may vary depending on the expected aetiology.