Fistulation into the Pubic Symphysis following treatment of Prostate Cancer - an important and surgically correctable complication

Chronic pubic pain following the treatment of prostate cancer is often attributed to 'osteitis pubis'. We have become aware of another complication, namely fistulation into the pubic symphysis, which is more serious and commoner than previously thought.

16 patients were treated for urosymphyseal fistulae (USF) following the treatment of prostate cancer between January 2011 and April 2014 Clinical presentation was characterised by chronic, debilitatating pubic/pelvic/groin pain in all Diagnosis was confirmed by MRI Conservative management was successful in only one patient The rest were managed surgically by excision of the fistulous track and involved symphyseal bone and omentoplasty followed by reconstruction where feasible

All 16 patients had had radiotherapy as their primary treatment (n=8) or following prostatectomy (n=8) 5 (31 3%) underwent various combinations of brachytherapy, EBRT and cryotherapy 13 (81 3%) developed bladder neck contractures whose management (endoscopic or open reconstruction) resulted in urinary leak leading to USF Reconstruction was possible in 7 of 15 patients (46 7%) by salvage radical prostatectomy and substitution/augmentation cystoplasty The other 8 (53 3%) underwent cystectomy and ileal conduit diversion All patients experienced resolution of symptoms, most significantly the almost immediate resolution of pain

A high index of suspicion must be maintained in irradiated patients presenting with symptoms suggestive of USF especially after having undergone treatment of bladder neck contractures or prostatic urethral stenoses Surgery for USF, though extensive, with a high risk of morbidity and mortality and a protracted recovery, leads to an immediate and dramatic improvement in symptoms

The Journal of urology 2015 Aug 21 [Epub ahead of print]

Simon Bugeja, Daniela E Andrich, Anthony R Mundy

University College London Hospital, Reconstructive Urology Unit Electronic address: simbugi@gmail com , University College London Hospital, Reconstructive Urology Unit , University College London Hospital, Reconstructive Urology Unit