EUS-guided cyanoacrylate glue injection for treatment of anourethral fistula

Radial EUS probe was positioned in the lower rectum and the prostate was identified anteriorly and, as the probe was pulled back towards the anal canal, the bulb of the urethra was seen anteriorly. A tortuous fistula was seen going from the 11 o’clock position from the prostatic urethra towards the right lateral wall of the anal canal. The presence of a fistula was appreciated due to air bubbles. Linear EUS showed the presence of an air bubble in the fistula. The fistula was seen going from the anal canal towards the base of the prostatic urethra just above the bulb. The upper part of the fistula was appreciated near the curving part of the urethra. Prior to injection of the cyanoacrylate glue, maximum zooming of the image was done. The presence of a Foley catheter helped in the clear demarcation of the prostatic and the bulbous part of urethra. The bulb of the penis was seen as a hypoechoic area anterior to the anal canal. The presence of a fistula into the prostatic part of the urethra was identified by real-time movement of the air bubble during imaging. The approximate length of the fistulous tract was 15.1 mm. Under EUS guidance, glue was injected into the middle part of the fistula. While injecting the glue, the Foley catheter was rotated clockwise and counterclockwise to avoid the glue sticking to the catheter. Glue injection resulted in an air bubble movement towards the prostatic part of the urethra. The rotation of the catheter was continued for 1 minute after a 0.5 mL injection of cyanoacrylate. This animation shows the introduction of scope, identification of fistula, and glue injection into the fistula tract.