Presentation Authors: Jack Andrews*, Jason Joseph, Thanapoom Boonipatt, Lucas Rodrigues, Karim Bakri, Matthew Houdek, Boyd Viers, Rochester, MN
Introduction: Urosymphaseal fistula (UF) is a rare but debilitating complication of prostate cancer (CaP) treatment. Little is known about this complex clinical entity or best management strategies. As a result, UF is often unrecognized or temporized with long-term indwelling catheters without symptomatic relief. The objective of this study is to describe the natural history, reconstructive solutions, and functional outcomes of those men undergoing pubectomy with urinary reconstruction for UF after CaP treatment.
Methods: We retrospectively reviewed a total of 30 patients with UF treated with pubectomy and urinary reconstruction between 2009 and 2018 at our institution. Men who developed UF following CaP treatment (N=20) form the basis of this analysis.
Results: All patients (N=20) had a history of pelvic radiation for CaP. Mean time from primary CaP treatment to diagnosis of UF was 11.3 years. The majority of men (19/20; 95%) presented with pubic pain during ambulation. The diagnosis of UF was made or confirmed with MRI in all and 11 (55%) had evidence of abscess. A period of conservative management was trialed and failed in 19 (95%). History of posterior urethral stenosis or bladder neck contracture was common (16/20; 80%) with 50% having repetitive endoscopic treatments. Pubectomy was combined with varying extents of extirpative and reconstructive surgery including salvage prostatectomy (N=2), anterior exenteration (N=16), and combined anterior and posterior exenteration (N=2). The mean width of pubectomy defect was 58 mm (SD 21). Pedicle flap reconstruction was required in 10 patients. Major 90 day complications (Clavien 3a and 4a) occurred in 6 (30%) patients. Patient function significantly improved following reconstruction including mean pre to postoperative ECOG score (2.4 vs 0.4; p=0.035), pain improvement (19/20; 95%), and resolution of UF symptoms (18/20; 90%).
Conclusions: UF often presents in a delayed fashion (10-15 years) following CaP therapy as pain with ambulation. Radiation and endoscopic manipulation are significant risk factors for UF. Conservative treatments are unlikely to provide symptom resolution, however pubectomy with urinary reconstruction safely achieves durable improvement of symptoms, pain, and functionality in the majority of men.