Unmasking of Urinary-Pubic Symphysis Fistula (UPF) after Implantation of Artificial Urinary Sphincter in Prostate Cancer Survivors - User Beware. Url-D-17-02187

To describe the dramatic and rapid unmaking of Urinary pubic symphysis fistula and chronic osteomyelitis (UPF) following artificial urinary sphincter implantation (AUS). This has never been reported as UPF is usually an insidious sequelae of radiotherapy/energy ablation for prostate cancer (PCa).

We prospectively identified men who underwent rapid clinical decline due to UPF soon after AUS implantation at our institution in the previous 24 months. Chart and imaging was reviewed to assess pre-operative and post-operative factors.

Three patients were identified. All men had undergone radiation therapy for PCa and all had undergone prior manipulation of the posterior urethra for complications of radiotherapy. Radiation cystitis was present and all had a low cystometric bladder capacity prior to surgery. All declined rapidly after surgery. UPF was diagnosed in two men after activation of AUS at 6-7 weeks postoperatively and one presented prior to activation at 3 weeks postoperatively. UPF tract was demonstrated with MRI in the acute phase in all three cases. Two have undergone cystectomy and loop diversion with resolution of symptoms and one is awaiting definitive surgery.

Unmaking of occult UPF resulted in rapid clinical decline following AUS implantation. Increased intra-vesicle filling pressure from increased urethral resistance likely resulted in opening of occult fistula tracts. UPF should be in the differential diagnosis if there is history of radiotherapy or urethral instrumentation. An underlying and un-diagnosed UPF may lead to grave consequences following AUS implantation.

Urology. 2017 Dec 22 [Epub ahead of print]

Arman A Kahokehr, Andrew C Peterson

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