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EUS-guided cyanoacrylate glue injection for treatment of anourethral fistula

Open AccessPublished:May 03, 2017DOI:https://doi.org/10.1016/j.vgie.2017.03.013
      Perianal fistulas are a frequent cause of morbidity. The causes of perianal fistula include cryptoglandular infection, Crohn’s disease, radiotherapy, and malignancy. Perianal fistula as an adverse event of anal canal surgery occurs infrequently. We report the EUS-guided management of a case of postsurgical perianal fistula with cyanoacrylate glue injection.
      A 35-year-old man presented with recurrent urinary tract infection requiring multiple courses of antibiotics for the past 15 years. He had undergone surgery for an imperforate anus at birth, and an anal stricture developed, which required repeated bougienage dilation until he was 4 years of age. After anal dilation, he had intermittent passing of urine through the anal opening and received a diagnosis of anourethral fistula. He underwent fistulectomy with urethral repair and anoplasty 1 year later and improved symptomatically, but he had recurrence of symptoms at 16 years of age and underwent fistulectomy again, with significant improvement. He became symptomatic again after remaining well for 4 years. He was reluctant to undergo further surgery.
      Radial EUS showed a tortuous fistula in the anal canal communicating with the prostatic urethra. The presence of a fistula was appreciated because of air bubbles (Fig. 1A). A linear EUS-guided glue injection was planned. Cyanoacrylate glue treatment has been used with some success in anal and rectovaginal fistulas, and in this case, glue injection of a postsurgical anourethral fistula was successful (Video 1, available online at www.VideoGIE.org).
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      Figure 1A, Radial EUS view showing presence of air bubbles in the fistula. B, EUS view showing Foley catheter in prostatic urethra. C, EUS view showing Foley catheter in membranous urethra. D, EUS view showing Foley catheter in penile urethra. E, All 4 parts of the urethra. F, Glue injection into the anourethral fistula with a 22G needle.
      The patient was catheterized before glue injection to obtain better visualization of the fistula tract and avoid leakage of glue into the urethra at the time of glue injection (Figs. 1B-D). Under EUS guidance, glue was injected into the middle part of the fistula (Fig. 1E). During the glue injection, the Foley catheter was rotated clockwise and counterclockwise to avoid glue sticking to the catheter. The rotation of the catheter was continued for 1 minute after 0.5 mL of cyanoacrylate injection. The fistula tract was successfully closed. The patient was symptom free at his 1-year follow-up visit.
      EUS-guided cyanoacrylate glue can be safely attempted to treat postsurgical anourethal fistulas. The procedure is easy and cost effective, with no significant morbidity. However, care should be taken to avoid inadvertent injection.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

      Supplementary data