Case Presentation JOHN HICKMAN MS 4 RADIOLOGY ROTATION

Case Presentation JOHN HICKMAN MS 4 RADIOLOGY ROTATION 4 A 6/16/17

HPI �F. O. 81 YOM with a PMH of colorectal cancer s/p abdominoperineal resection in Jan 2016 followed by chemo/radiation. �Sx c/b wound dehiscence/abscess formation �Presents as ED transfer following increasing rectal pain and “gushing” of fluid from around his sacrum for several days �CT obtained at OSH �Creatinine 2. 0, lactate 0. 8 �Foley placed in ED; CT Cystogram ordered

APR

Axial CT without contrast Presacral fluid collection

Axial CT without contrast Bilateral Hydros

Sagittal CT pre/post contrast Foley Bulb Presacral Fluid Collection

Axial CT post contrast Contrast tracking to skin

Axial CT without contrast Liver Lesions

Axial CT without contrast (lung window) Pulmonary nodule

Hospital Course � Urology, Heme/Onc, Surgery consulted; repeat catheter again placed into fluid collection. Third foley succesfully placed under direct visualization for urinary diversion � Poor candidate for sx and chemo at this point � Palliative consulted; discharged to home � Diagnosis: Posterior urethralcutaneous fistula; numerous liver lesions/pulmonary nodules suspicious for recurrent metastatic disease � Commonly caused by surgical procedures, post-radiation, trauma, and iatrogenic � Diagnosis can be made with fistulography/cystography with a CT scan recommended for complex fistulas or concern for assc neoplasm � Most require intervention to heal: Urinary/fecal diversion Cystectomy often required

References � Burivong W, Leelasithorn V, Varavithya V. Common lower urinary tract fistulas: A review of clinical presentations, causes and radiographic imaging. International Journal of Case Reports and Images 2011; 2 (1): 1 -7 � K. L. Chrouser, B. C. Leibovich, S. D. Sweat, et al. Urinary fistulas following external radiation or permanent brachytherapy for the treatment of prostate cancer. J Urol, 173 (6) (2005), pp. 1953 -1957