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Martins FE, Lumen N, Holm HV. Management of the Devastated Bladder Outlet after Prostate CANCER Treatment. Curr Urol Rep 2024; 25:149-162. [PMID: 38750347 DOI: 10.1007/s11934-024-01206-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE OF REVIEW Devastating complications of the bladder outlet resulting from prostate cancer treatments are relatively uncommon. However, the combination of the high incidence of prostate cancer and patient longevity after treatment have raised awareness of adverse outcomes deteriorating patients' quality of life. This narrative review discusses the diagnostic work-up and management options for bladder outlet obstruction resulting from prostate cancer treatments, including those that require urinary diversion. RECENT FINDINGS The devastated bladder outlet can be a consequence of the treatment of benign conditions, but more frequently from complications of pelvic cancer treatments. Regardless of etiology, the initial treatment ladder involves endoluminal options such as dilation and direct vision internal urethrotomy, with or without intralesional injection of anti-fibrotic agents. If these conservative strategies fail, surgical reconstruction should be considered. Although surgical reconstruction provides the best prospect of durable success, reconstructive procedures are also associated with serious complications. In the worst circumstances, such as prior radiotherapy, failed reconstruction, devastated bladder outlet with end-stage bladders, or patient's severe comorbidities, reconstruction may neither be realistic nor justified. Urinary diversion with or without cystectomy may be the best option for these patients. Thorough patient counseling before treatment selection is of utmost importance. Outcomes and repercussions on quality of life vary extensively with management options. Meticulous preoperative diagnostic evaluation is paramount in selecting the right treatment strategy for each individual patient. The risk of bladder outlet obstruction, and its severest form, devastated bladder outlet, after treatment of prostate cancer is not negligible, especially following radiation. Management includes endoluminal treatment, open or robot-assisted laparoscopic reconstruction, and urinary diversion in the worst circumstances, with varying success rates.
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Affiliation(s)
- Francisco E Martins
- Department of Urology, University of Lisbon, School of Medicine, Centro Hospitalar Universitário, Lisboa Norte (CHULN), Lisbon, Portugal
| | - Nicolaas Lumen
- Department of Urology, Ghent University Hospital, 9000, Ghent, Belgium
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2
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Viegas V, Freton L, Richard C, Haudebert C, Khene ZE, Hascoet J, Verhoest G, Mathieu R, Vesval Q, Zhao LC, Bensalah K, Peyronnet B. Robotic YV plasty outcomes for bladder neck contracture vs. vesico-urethral anastomotic stricture. World J Urol 2024; 42:172. [PMID: 38506927 DOI: 10.1007/s00345-024-04814-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 01/16/2024] [Indexed: 03/22/2024] Open
Abstract
PURPOSE To compare the outcomes of patients undergoing robotic YV plasty for bladder neck contracture (BNC) vs. vesico-urethral anastomotic stricture (VUAS). METHODS A retrospective study included male patients who underwent robotic YV plasty for BNC after endoscopic treatment of BPH or VUAS between August 2019 and March 2023 at a single academic center. The primary assessed was the patency rate at 1 month post-YV plasty and during the last follow-up visit. RESULTS A total of 21 patients were analyzed, comprising 6 in the VUAS group and 15 in the BNC group. Patients with VUAS had significantly longer operative times (277.5 vs. 146.7 min; p = 0.008) and hospital stay (3.2 vs. 1.7 days; p = 0.03). Postoperative complications were more common in the VUAS group (66.7% vs. 26.7%; p = 0.14). All patients resumed spontaneous voiding postoperatively. Five patients (23.8%) who developed de novo stress urinary incontinence had already an AUS (n = 1) or required concomitant AUS implantation (n = 3), all of whom were in the VUAS group (83.3% vs. 0%; p < 0.0001). The proportion of patients improved was similar in both groups (PGII = 1 or 2: 83.3% vs. 80%; p = 0.31). Stricture recurrence occurred in 9.5% of patients in the whole cohort, with no significant difference between the groups (p = 0.50). Long-term reoperation was required in three VUAS patients, showing a statistically significant difference between the groups (p = 0.05). CONCLUSION Robotic YV plasty is feasible for both VUAS and BNC. While functional outcomes and stricture-free survival may be similar for both conditions, the perioperative outcomes were less favorable for VUAS patients.
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Affiliation(s)
- Vanessa Viegas
- Department of Urology, Hospital Universitario de La Princesa, Madrid, Spain.
| | - Lucas Freton
- Department of Urology, University of Rennes, Rennes, France
| | - Claire Richard
- Department of Urology, University of Rennes, Rennes, France
| | | | | | | | | | - Romain Mathieu
- Department of Urology, University of Rennes, Rennes, France
| | - Quentin Vesval
- Department of Urology, University of Rennes, Rennes, France
| | - Lee C Zhao
- Department of Urology, New York University, New York, USA
| | - Karim Bensalah
- Department of Urology, University of Rennes, Rennes, France
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3
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Burriss N, Abualruz AR. Pubosymphyseal Urinary Fistula Following Radiation Therapy of Bladder Sarcomatoid Tumor. Cureus 2023; 15:e46261. [PMID: 37908937 PMCID: PMC10615120 DOI: 10.7759/cureus.46261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2023] [Indexed: 11/02/2023] Open
Abstract
Pubosymphyseal urinary fistula (PUF) is a rare condition that involves an abnormal connection between the urinary bladder and the pubic bone. It can occur after trauma, radiation therapy, or surgery to the pelvis. It is also reported with chronic indwelling Foley catheter use. In this case report, we present a 56-year-old male who developed a fistula complicated by osteomyelitis pubis following external beam radiation for a urinary bladder sarcomatoid tumor. Patients at high risk of PUF may present with urinary leakage, pelvic pain, and infection, making diagnosis challenging. The condition can lead to chronic pelvic pain and long-term opioid use if left untreated. Diagnosis is typically made through imaging studies (CT scan or MRI) and confirmed with cystoscopy. Treatment usually involves urinary diversion/surgical repair of the fistula and management of any associated infection or complications. The prognosis is generally good if the condition is diagnosed and treated promptly. While it is rare, it can have significant consequences that require prompt diagnosis and treatment.
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Affiliation(s)
- Nathan Burriss
- Radiology, Medical College of Georgia at Augusta University, Augusta, USA
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4
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Moring N, Barrett S, Peterson AC, Inouye BM. Pelvic Extirpative Surgery for the "End-Stage Irradiated Bladder". Cancers (Basel) 2023; 15:4238. [PMID: 37686515 PMCID: PMC10486644 DOI: 10.3390/cancers15174238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/08/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Men with prostate cancer have the daunting task of selecting from multiple modalities of treatment. The long-term effects of radiation therapy are only now being recognized. For both patients and surgeons, the end-stage irradiated bladder poses numerous problems and challenges. Specifically, irradiated bladders with urosymphyseal fistula, radiation cystitis, and rectourethral fistula are challenging to manage and treat. This review outlines the presentation, workup, and management including cystectomy for these three devastating late complications of radiation therapy. There are special considerations when performing benign cystectomy that are not typically considered during oncologic cystectomy. We discuss an overview of the current literature regarding the "end-stage bladder" resulting from radiation therapy and the important considerations that must be acknowledged when managing these patients. It is shown that many of the less invasive and conservative options ultimately lead to cystectomy. Indeed, our review concludes that cystectomy with urinary diversion is a safe and viable option in select irradiated patients with the goal to improve quality of life.
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Affiliation(s)
- Nikolas Moring
- Department of Urology, Albany Medical Center, Albany, NY 12208, USA; (N.M.); (S.B.)
| | - Seamus Barrett
- Department of Urology, Albany Medical Center, Albany, NY 12208, USA; (N.M.); (S.B.)
| | | | - Brian M. Inouye
- Department of Urology, Albany Medical Center, Albany, NY 12208, USA; (N.M.); (S.B.)
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5
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Patel N, Mehawed G, Dunglison N, Esler R, Navaratnam A, Yaxley J, Chung E, Tse V, Roberts MJ. Uro-symphyseal Fistula: A Systematic Review to Inform a Contemporary, Evidence-based Management Framework. Urology 2023; 178:1-8. [PMID: 37182647 DOI: 10.1016/j.urology.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/26/2023] [Accepted: 05/03/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To collate available data via systematic review considering etiology, presentation, and treatment of Uro-Symphyseal Fistula (USF) in order to inform a contemporary management framework. MATERIALS AND METHODS A systematic review was performed according to the Cochrane Handbook and registered in PROSPERO (CRD42021232954). MEDLINE and CENTRAL databases were searched for manuscripts considering USF published between 2000 and 2022. Full text manuscripts were reviewed for clinical data. Univariate statistical analysis was performed where possible. RESULTS A total of 31 manuscripts, comprising 248 USF cases, met inclusion criteria. Suprapubic pain and difficulty ambulating were common symptoms. MRI confirmed the diagnosis in 95% of cases. Radiotherapy for prostate cancer was the most common predisposing factor (93%). Among these patients, prior endoscopic bladder outlet surgery was common (83%; bladder neck incision/urethral dilatation n = 59, TURP/GLL PVP n = 34). In those with prior prostatic radiation, conservative management failed in 96% of cases. Cystectomy with urinary diversion (86% n = 184) was favored over bladder-sparing techniques (14% (n = 30) after prior radiation. In radiation naïve patients, conservative management failed in 72% of patients, resulting in either open fistula repair with flap (62%) or radical prostatectomy (28%). CONCLUSION Prior radiotherapy is a significant risk factor for USF and almost always requires definitive major surgery (debridement, cystectomy, and urinary diversion). On the basis of the findings within this systematic review, we present management principles that may assist clinicians with these complex cases. Further research into pathogenesis, prevention, and optimal treatment approach is required.
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Affiliation(s)
- Nishal Patel
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Georges Mehawed
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Urology, Redcliffe Hospital, Queensland, Australia
| | - Nigel Dunglison
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Rachel Esler
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Wesley Urology Clinic, The Wesley Hospital, Brisbane, Queensland, Australia
| | - Anojan Navaratnam
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - John Yaxley
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Wesley Urology Clinic, The Wesley Hospital, Brisbane, Queensland, Australia
| | - Eric Chung
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Urology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Vincent Tse
- Department of Urology, Macquarie University Hospital, Sydney, Queensland, Australia; Department of Urology, Concord Hospital, Sydney, Queensland, Australia
| | - Matthew J Roberts
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Urology, Redcliffe Hospital, Queensland, Australia; Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.
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Kunkel G, Patel H, Kaldany A, Allu S, Elsamra S, Cancian M. Pelvic radiation-induced urinary strictures: etiology and management of a challenging disease. World J Urol 2023; 41:1459-1468. [PMID: 37014391 DOI: 10.1007/s00345-023-04378-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/16/2023] [Indexed: 04/05/2023] Open
Abstract
Radiation is a common treatment modality for pelvic malignancies. While it can be effective at cancer control, downstream effects can manifest months to years after treatment, leaving patients with significant morbidity. Within urology, a particularly difficult post-radiation consequence is urinary tract stricture, either of the urethra, bladder neck, or ureter. In this review, we will discuss the mechanism of radiation damage and treatment options for these potentially devastating urinary sequelae.
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Affiliation(s)
- Gregory Kunkel
- Department of Urology, UMass Chan: University of Massachusetts Medical School, Worcester, MA, USA.
| | - Hiren Patel
- Division of Urology, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Alain Kaldany
- Division of Urology, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sai Allu
- Division of Urology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Sammy Elsamra
- Division of Urology, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Madeline Cancian
- Division of Urology, Brown University Warren Alpert Medical School, Providence, RI, USA
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Patel K, Butt H, Patel S, Roux J, Bhagat A. Imaging findings of urosymphyseal fistulas. BJR Case Rep 2022; 8:20210217. [PMID: 36632548 PMCID: PMC9809915 DOI: 10.1259/bjrcr.20210217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 11/07/2022] Open
Abstract
Prostate cancer accounts for 13% of all new cancer diagnoses in the UK. Urosymphyseal fistulas are a rare complication that can occur post-radiotherapy and surgery for prostate cancer. Patients often present with non-specific symptoms such as suprapubic tenderness, poor mobility, recurrent urinary infections, and difficulty passing urine. These can be difficult to diagnose clinically and extremely problematic and debilitating for patients. The management of these patients is often complex and requires input from urology, orthopaedics, and microbiology. At present, there are no clear guidelines for diagnosing these conditions. Recommended investigations include blood tests, urine culture, and imaging. The preferred imaging modality is pelvic MRI. This article explores three rare cases of such complications and the classic imaging findings on CT and MRI to aid the diagnosis of urosymphyseal fistula.
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Affiliation(s)
- Kunj Patel
- West Hertfordshire NHS Trust, Hertfordshire, United Kingdom
| | - Hayan Butt
- West Hertfordshire NHS Trust, Hertfordshire, United Kingdom
| | - Shlok Patel
- West Hertfordshire NHS Trust, Hertfordshire, United Kingdom
| | - Jacques Roux
- West Hertfordshire NHS Trust, Hertfordshire, United Kingdom
| | - Ashish Bhagat
- West Hertfordshire NHS Trust, Hertfordshire, United Kingdom
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8
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Simultaneous treatment of a pubovesical fistula and lymph node metastasis secondary to multimodal treatment for prostate cancer: Case report and review of the literature. Open Med (Wars) 2022; 17:1715-1723. [DOI: 10.1515/med-2022-0577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/22/2022] [Accepted: 09/06/2022] [Indexed: 11/05/2022] Open
Abstract
Abstract
Pubovesical fistula (PVF) is a rare complication of radical treatments for prostate cancer (PCa), especially when a multimodal approach is performed. We present a case of PVF with extensive communication between the bladder and the pubic bones, and lymph node metastases of PCa treated by cystectomy and salvage lymphadenectomy. We describe a case of a 65-year old male patient who, after radical prostatectomy and adjuvant radiation therapy, suffered from suprapubic and perineal pain, ambulation difficulties and recurrent urinary tract infections. Cystoscopy, cystography and contrast-enhanced magnetic resonance imaging diagnosed a PVF. Choline positron emission tomography/computed tomography scan demonstrated PCa lymph node metastases. After the failure of conservative treatment, open radical cystectomy with ureterocutaneostomy diversion and salvage lymphadenectomy were performed with resolution of symptoms. At 3-month follow-up, the pelvic and perineal pain was completely regressed and 1-year later the patient was still asymptomatic. This clinical case shows efficacy and safety of combined salvage lymphadenectomy and cystectomy with urinary diversion for the treatment of late PCa node metastasis and PVF.
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9
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Complex Lower Genitourinary Fistula Repair. Urol Clin North Am 2022; 49:553-565. [DOI: 10.1016/j.ucl.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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10
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Blitz SE, Chua MMJ, Klinger NV, Chi JH. Spinal osteomyelitis and epidural abscess caused by ureterovertebral fistula: A case report. Surg Neurol Int 2022; 13:279. [PMID: 35855137 PMCID: PMC9282813 DOI: 10.25259/sni_479_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 06/09/2022] [Indexed: 11/08/2022] Open
Abstract
Background: Ureteral fistulas are abnormal connections between the ureters and other organs. Maintaining a high index of suspicion is important because they can precipitate dangerous complications such as sepsis and renal failure. Connections to a vertebral body have only been documented in the setting of trauma. Here, we present a 67-year-old female with a ureterovertebral fistula extending into the L3 vertebral body. Case Description: A 67-year-old female with a history of endometrial adenocarcinoma underwent surgery and radiation therapy complicated by a right ureteral obstruction requiring stent placement. Five months later, she developed back pain and MR-documented L2-L4 level osteomyelitis/discitis with a psoas phlegmon/abscess, which required drainage. A fistula was later identified between the right ureter and the psoas phlegmon. Despite percutaneous nephrostomy placement and aggressive IV antibiotic treatment, she was readmitted for persistent signs of infection over the next few months during which time she was repeatedly and unsuccessfully treated with multiple antibiotics. Sixteen months following her original stent placement, she developed right leg weakness and urinary incontinence attributed to the MR-documented ureteropsoas fistula extending into the L3 vertebral body. Following a nephrectomy with ureteral ligation, an L3 anterior corpectomy with interbody fusion for discitis at both L2-L3 and L3-L4, and an L1-L5 posterolateral fusion, she was discharged to a rehabilitation center. Conclusion: In patients with recurrent sepsis, osteomyelitis/discitis, or psoas abscess of unknown origin or who have a significant history (e.g., pelvic malignancy, radiation, and instrumentation), it is important to consider urodynamic testing to look for a ureteral leak or fistula.
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Affiliation(s)
| | | | - Neil Vernon Klinger
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, United States
| | - John H. Chi
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, United States
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Abstract
Pelvic radiation is increasingly being used for the neoadjuvant and definitive treatment of pelvic organ malignancy. While this treatment can be highly effective, and may assist in organ sparing, it is also associated with significant toxicity and devastating adverse events that need to be considered. In broad terms, pelvic radiation disease affects both the primary target organ as well as adjacent organs and soft tissue structures, with complications that can be classified and graded according to consensus criteria. The complication grade is often modality, dose, and area dependent. The most common manifestations are proctitis, cystitis, recto-urethral fistula, ureteric stricture, and bone involvement. Toxicity can be misdiagnosed for many years, resulting in significant management delays. Complications can be difficult to prevent and challenging to treat, requiring specialized multi-disciplinary input to achieve the best possible strategy to minimize impact and improve patient quality of life.
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Affiliation(s)
- Tarik Sammour
- Department of Colorectal Surgery, University of Adelaide, Royal Adelaide Hospital, Wayfinding, Adelaide, Australia,Address for correspondence Tarik Sammour, MBChB, FRACS, CSSANZ, PhD Colorectal Unit, Department of Surgery, Royal Adelaide HospitalWayfinding 5E.334, Port Road, Adelaide, SA 5000Australia
| | - Arman A. Kahokehr
- Department of Urology, Flinders University, Lyell McEwin Hospital, Adelaide, Australia
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12
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Martins FE, Holm HV, Lumen N. Devastated Bladder Outlet in Pelvic Cancer Survivors: Issues on Surgical Reconstruction and Quality of Life. J Clin Med 2021; 10:4920. [PMID: 34768438 PMCID: PMC8584541 DOI: 10.3390/jcm10214920] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022] Open
Abstract
Bladder outlet obstruction following treatment of pelvic cancer, predominantly prostate cancer, occurs in 1-8% of patients. The high incidence of prostate cancer combined with the long-life expectancy after treatment has increased concerns with cancer survivorship care. However, despite increased oncological cure rates, these adverse events do occur, compromising patients' quality of life. Non-traumatic obstruction of the posterior urethra and bladder neck include membranous and prostatic urethral stenosis and bladder neck stenosis (also known as contracture). The devastated bladder outlet can result from benign conditions, such as neurogenic dysfunction, trauma, iatrogenic causes, or more frequently from complications of oncologic treatment, such as prostate, bladder and rectum. Most posterior urethral stenoses may respond to endoluminal treatments such as dilatation, direct vision internal urethrotomy, and occasionally urethral stents. Although surgical reconstruction offers the best chance of durable success, these reconstructive options are fraught with severe complications and, therefore, are far from being ideal. In patients with prior RT, failed reconstruction, densely fibrotic and/or necrotic and calcified posterior urethra, refractory incontinence or severe comorbidities, reconstruction may not be either feasible or recommended. In these cases, urinary diversion with or without cystectomy is usually required. This review aims to discuss the diagnostic evaluation and treatment options for patients with bladder outlet obstruction with a special emphasis on patients unsuitable for reconstruction of the posterior urethra and requiring urinary diversion.
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Affiliation(s)
- Francisco E. Martins
- Department of Urology, School of Medicine, University of Lisbon, Hospital Santa Maria/CHULN, 1649-035 Lisbon, Portugal
| | | | - Nicolaas Lumen
- Department of Urology, Ghent University Hospital, 9000 Ghent, Belgium;
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13
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Martins FE. Editorial Comment from Dr Martins to Deep lateral transurethral incision for vesicourethral anastomotic stenosis after radical prostatectomy. Int J Urol 2021; 28:1127-1128. [PMID: 34519112 DOI: 10.1111/iju.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Francisco E Martins
- Faculty of Medicine, Santa Maria Teaching Hospital, University of Lisbon, Lisbon, Portugal
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14
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Anele UA, Wood HM, Angermeier KW. Management of Urosymphyseal Fistula and Pelvic Osteomyelitis: A Comprehensive Institutional Experience and Improvements in Pain Control. Eur Urol Focus 2021; 8:1110-1116. [PMID: 34479839 DOI: 10.1016/j.euf.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/18/2021] [Accepted: 08/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Urosymphyseal fistula (USF) is an uncommon but painful and devastating condition typically occurring after radiotherapy for pelvic malignancy, with a delayed diagnosis and a risk of opioid dependence. OBJECTIVE To characterize our institutional experience and determine the impact of intervention for USF on pain control and opioid use. DESIGN, SETTING, AND PARTICIPANTS We evaluated data for 33 adult patients diagnosed with USF and managed at a quaternary institution between 2009 and 2021. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We assessed chronic opioid use, pain scores, prior therapy for pelvic malignancy, prior endoscopic procedures, microbiology and histology congruence, and postoperative complications. For comparative analyses we used a χ2 test or Fisher's exact test for categorical variables and a Wilcoxon signed-rank test for continuous variables. RESULTS AND LIMITATIONS Nearly 94% of the patients had received prior pelvic radiotherapy and >80% occurred in 2016-2021 but were not diagnosed until a median of 10 mo (interquartile range [IQR] 3.5-19.5) following endoscopic procedure(s). Osteomyelitis was suspected in 78.8% of imaging reports and nearly 70% had a positive preoperative urine culture. Over 90% of patients underwent cystectomy, pubic bone debridement or resection, and a soft-tissue pedicle flap. Preoperative urine cultures were concordant with 60% of intraoperative tissue/bone cultures. Histologic osteomyelitis was identified in 85% and concordant with 80% of preoperative imaging. Clavien-Dindo grade ≥3 complications occurred in 15.6%. The median pain score decreased from 4 (IQR 0-8) preoperatively to 0 (IQR 0) postoperatively (p < 0.001). Chronic opioid use decreased from 39.4% to 21.2% (p = 0.02). CONCLUSIONS Pelvic osteomyelitis may complicate USF and commonly manifests with severe, persistent pain. USF incidence may be increasing or at least increasingly recognized, but diagnosis is delayed. Definitive management results in significant improvements in pain perception and a decrease in chronic opioid use. PATIENT SUMMARY We examined features of urinary fistulas, which are abnormal openings or connections between part of the urinary tract and another structure. Patients with a urinary fistula involving the pelvic bones can present with severe pain, but diagnosis of the condition is often delayed. Removal of some pelvic bone with bladder removal or repair can result in a decrease in long-term pain and in the use of opioid drugs for pain relief.
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Affiliation(s)
- Uzoma A Anele
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Hadley M Wood
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kenneth W Angermeier
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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15
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Hoeh B, Müller SC, Kluth LA, Wenzel M. Management of Medium and Long Term Complications Following Prostate Cancer Treatment Resulting in Urinary Diversion - A Narrative Review. Front Surg 2021; 8:688394. [PMID: 34434956 PMCID: PMC8381645 DOI: 10.3389/fsurg.2021.688394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/09/2021] [Indexed: 12/24/2022] Open
Abstract
The purpose of this narrative review is to discuss and highlight recently published studies regarding the surgical management of patients suffering from prostate cancer treatment complications. Focus will be put on the recalcitrant and more complex cases which might lead to urinary diversion as a definite, last resort treatment. It is in the nature of every treatment, that complications will occur and be bothersome for both patients and physicians. A small percentage of patients following prostate cancer treatment (radical prostatectomy, radiation therapy, or other focal therapies) will suffer side effects and thus, will experience a loss of quality of life. These side effects can persist for months and even years. Often, conservative management strategies fail resulting in recalcitrant recurrences. Prostate cancer patients with "end-stage bladder," "devastated outlet," or a history of multiple failed interventions, are fortunately rare, but can be highly challenging for both patients and Urologists. In a state of multiple previous surgical procedures and an immense psychological strain for the patient, urinary diversion can offer a definite, last resort surgical solution for this small group of patients. Ideally, they should be transferred to centers with experience in this field and a careful patient selection is needed. As these cases are highly complex, a multidisciplinary approach is often necessary in order to guarantee an improvement of quality of life.
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Affiliation(s)
- Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
| | - Stefan C Müller
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
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16
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Anele UA, Wood HM, Angermeier KW. Urosymphyseal fistulas in women: identification and characterization of a previously undescribed phenomenon. J Surg Case Rep 2021; 2021:rjab331. [PMID: 34386191 PMCID: PMC8354677 DOI: 10.1093/jscr/rjab331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/10/2021] [Accepted: 07/13/2021] [Indexed: 12/05/2022] Open
Abstract
Urosymphyseal fistula (USF) is a very uncommon but catastrophic condition which typically occurs in the setting of previous radiation treatment for prostate cancer. As a result, USF has only been described in male populations. For the first time, we characterize this phenomenon in a series consisting of four women managed at our quaternary institution. We found that most patients presented with pubic pain and all were diagnosed with USF on CT or MRI. Imaging commonly demonstrated features suggesting osteomyelitis which was confirmed on histology. Patients experienced significant decreases in peri-operative pain scores following extirpative surgery with urinary diversion, bone debridement/resection and tissue interposition. This case series highlights the rarity of USF in women in order to help promote increased recognition and timely management.
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Affiliation(s)
| | - Hadley M Wood
- Center for Genitourinary Reconstruction, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kenneth W Angermeier
- Center for Genitourinary Reconstruction, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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17
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Complicated pubovesical fistula on PET/CT and MRI. Eur J Nucl Med Mol Imaging 2021; 48:3335-3336. [PMID: 33742237 DOI: 10.1007/s00259-021-05305-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
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18
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Lower Urinary Tract Symptoms in Prostate Cancer Patients Treated With Radiation Therapy: Past and Present. Int Neurourol J 2021; 25:119-127. [PMID: 33504132 PMCID: PMC8255820 DOI: 10.5213/inj.2040202.101] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/05/2020] [Indexed: 12/16/2022] Open
Abstract
The incidence of prostate cancer (PCa) is increasing concomitantly with population aging. Accordingly, interest in radiation therapy (RT) and the frequency of RT are also increasing. The types of RT can be broadly divided into external beam RT (EBRT), brachytherapy (BT), and combination therapy (EBRT+BT). Lower urinary tract symptoms (LUTS) after RT for the treatment of PCa are common; however, there are few reviews on the relationship between RT and LUTS. Herein, we review the causes and incidence of LUTS, as well as the evaluation and treatment options. Because of the reported risks of RT, patients undergoing RT should be counseled regarding the challenges of treatment and informed that they may have higher failure rates than nonirradiated patients. Moreover, thorough evaluation and treatment strategies are needed to support treatment recommendations. With a review of the existing literature, this narrative article provides an overview to aid urologists in treating patients presenting with complications associated with RT for the treatment of PCa. Further research is required to provide evidence of the effectiveness and feasibility of the management approach to the care of patients with LUTS after RT for the treatment of PCa.
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Andrews JR, Hebert KJ, Boswell TC, Avant RA, Boonipatt T, Kreutz-Rodrigues L, Bakri K, Houdek MT, Karnes RJ, Viers BR. Pubectomy and urinary reconstruction provides definitive treatment of urosymphyseal fistula following prostate cancer treatment. BJU Int 2021; 128:460-467. [PMID: 33403768 DOI: 10.1111/bju.15333] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To describe the natural history, reconstructive solutions, and functional outcomes of those men undergoing pubectomy and urinary reconstruction after prostate cancer treatment. PATIENTS AND METHODS This study retrospectively identified 25 patients with a diagnosis of urosymphyseal fistula (UF) following prostate cancer therapy who were treated with urinary reconstruction with pubectomy. This study describes the natural history, reconstructive solutions, and functional outcomes of this cohort. RESULTS All 25 patients had a history of pelvic radiotherapy for prostate cancer. The median (interquartile range [IQR]) time from prostate cancer treatment to diagnosis of UF was 11 (6, 16.5) years. The vast majority of men (24/25; 96%) presented with debilitating groin pain during ambulation. Posterior urethral stenosis was common (20/25; 80%), with 60% having repetitive endoscopic treatments. Culture of pubic bone specimens demonstrated active infection in 80%. Discordance between preoperative urine and intraoperative bone cultures was common, 21/22 (95.5%). After surgery, major 90-day complications (Clavien-Dindo Grade III and IV) occurred in eight (32%) patients. Pain was significantly improved, with resolution of pain (24/25; 96%) and restoration of function, the median (IQR) preoperative Eastern Cooperative Oncology Group Performance Status (ECOG PS) was 3 (2, 3) vs median postoperative ECOG PS score of 0 (0, 1). CONCLUSION Endoscopic urethral manipulation after radiation for prostate cancer is a risk factor for UF. Conservative management will not provide symptom resolution. Fistula decompression, bone resection, and urinary reconstruction effectively treats chronic infection, improves pain and ECOG PS scores.
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Affiliation(s)
- Jack R Andrews
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Kevin J Hebert
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Timothy C Boswell
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Ross A Avant
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Thanapoom Boonipatt
- Department of Plastic Surgery, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | | | - Karim Bakri
- Department of Plastic Surgery, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - R Jeffery Karnes
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Boyd R Viers
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
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20
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Kahokehr AA, Boysen WR, Schild MH, Nosé BD, Huang J, Eward W, Peterson AC. Urinary Pubic Symphysis Fistula Leads to Histopathologic Osteomyelitis in Prostate Cancer Survivors. Urology 2020; 148:297-301. [PMID: 32763316 DOI: 10.1016/j.urology.2020.07.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the histologic findings in the pubic bone resected during extirpative surgery for urinary pubic symphysis fistula (UPF). The concurrent presence of osteomyelitis and the need for bone resection at time of extirpative surgery for UPF has been debated. We hypothesized that UPF results in histopathologically confirmed osteomyelitis, underscoring the importance of bone resection at the time of surgery. METHODS An IRB-approved retrospective review of all patients undergoing surgery for UPF from 2012 to 2019 was performed. Demographic data were recorded. A single pathologist performed histopathologic examination of bone tissue in each case. Logistic regression and Fisher exact test were used to assess association of osteomyelitis with clinical factors. RESULTS We identified 36 patients who underwent major extirpative surgery for UPF with bone pathology available for review. Bone histopathology findings confirmed presence of osteomyelitis in the majority (n = 32, 88.9%). This was characterized as chronic osteomyelitis in 15 (41.7%), acute osteomyelitis only in 1 (2.8%) and combined chronic, and acute osteomyelitis in 16 (44.4%). Osteonecrosis was seen in 11 cases (33.6%). There was no correlation between presence of osteomyelitis and age, timing from radiotherapy to diagnosis of UPF, type of radiotherapy, or history of endoscopic bladder outlet procedures. CONCLUSION Osteomyelitis is present on histology of the pubic bone resected during surgery for UPF in the majority of cases (88.9%). Osteonecrosis is also common. These findings underscore the critical importance of pubic bone resection at time of UPF surgery to adequately treat the diseased bone.
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Affiliation(s)
| | - William R Boysen
- Division of Urology, Duke University Medical Center, Durham, NC.
| | | | - Brent D Nosé
- Division of Urology, Duke University Medical Center, Durham, NC
| | - Jiaoti Huang
- Division of Urology, Duke University Medical Center, Durham, NC
| | - Will Eward
- Division of Urology, Duke University Medical Center, Durham, NC
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21
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Vanni AJ. EDITORIAL COMMENT. Urology 2019; 134:133. [PMID: 31789175 DOI: 10.1016/j.urology.2019.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Alex J Vanni
- Center for Reconstructive Urologic Surgery, Lahey Hospital and Medical Center, Burlington, MA
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22
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Robot Assisted Cystectomy With Holmium Laser Debridement for Osteomyelitis of the Pubic Symphysis With Urinary Fistula. Urology 2019; 134:124-134. [DOI: 10.1016/j.urology.2019.08.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/09/2019] [Accepted: 08/14/2019] [Indexed: 11/17/2022]
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23
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Magnetic resonance imaging features of pubic symphysis urinary fistula with pubic bone osteomyelitis in the treated prostate cancer patient. Abdom Radiol (NY) 2019; 44:1453-1460. [PMID: 30460532 DOI: 10.1007/s00261-018-1827-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Pubic bone osteomyelitis with pubic symphysis urinary fistula represents a debilitating complication of radiation and ablative treatments for prostate cancer. The definitive radiographic diagnosis of this clinical entity is not described. In this study, we characterize the plain film and magnetic resonance imaging findings of pubic osteomyelitis. MATERIALS AND METHODS We reviewed a database of prostate cancer survivors with diagnosed pubic osteomyelitis from 2011 to 2015. These patients underwent pelvic plain radiographs and magnetic resonance imaging with T1-weighted and fat-suppressed T2-weighted fast spin echo sequences. Intravenous gadolinium was utilized. The diagnosis was verified with extirpative surgery. 16 patients with diagnosed pubic osteomyelitis from 2011 to 2015 underwent imaging at our institution. RESULTS All patients demonstrated increased signal on T2- weighted sequences and decreased signal on T1-weighted sequences along the pubic symphysis and the marrow of the involved pubic rami. Inflammatory myositis with diastasis of the pubic symphysis and cortical bone erosion were identified in the majority of patients. Fluid collections were identified in 75% of patients. 63% of conventional radiographs demonstrated no radiographic evidence of pubic osteomyelitis. CONCLUSION Magnetic resonance imaging of pubic symphysis osteomyelitis in the prostate cancer survivor is characterized by high signal on T2-weighted images and low signal on T1-weighted images of the involved pubic rami, with the majority of patients demonstrating regional myositis. Imaging data combined with clinical assessment should prompt diagnosis and management of pubic osteomyelitis. Conventional radiography is generally insensitive to these findings. We consider magnetic resonance imaging to be the definitive diagnostic modality for this clinical entity.
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24
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Kahokehr AA, Peterson AC, Lentz AC. Posterior urethral stenosis after prostate cancer treatment: contemporary options for definitive management. Transl Androl Urol 2018; 7:580-592. [PMID: 30211048 PMCID: PMC6127549 DOI: 10.21037/tau.2018.04.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Posterior urethral stenosis (PUS) is an uncommon but challenging problem following prostate cancer therapy. A review of the recent literature on the prevalence of PUS and treatment modalities used in the last decade was performed. A summative narrative of current accepted techniques in management of PUS is presented, and supplement with our own experience and algorithms.
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Affiliation(s)
- Arman A Kahokehr
- Division of Urology, Duke University Medical Center, Durham, NC 27710, USA
| | - Andrew C Peterson
- Division of Urology, Duke University Medical Center, Durham, NC 27710, USA
| | - Aaron C Lentz
- Division of Urology, Duke University Medical Center, Durham, NC 27710, USA
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25
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Kahokehr AA, Peterson AC. Unmasking of Urinary-pubic Symphysis Fistula After Implantation of Artificial Urinary Sphincter in Prostate Cancer Survivors—User Beware. Urology 2018; 114:202-206. [DOI: 10.1016/j.urology.2017.11.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 11/25/2017] [Accepted: 11/30/2017] [Indexed: 11/29/2022]
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26
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Shapiro DD, Goodspeed DC, Bushman W. Urosymphyseal Fistulas Resulting From Endoscopic Treatment of Radiation-induced Posterior Urethral Strictures. Urology 2018; 114:207-211. [DOI: 10.1016/j.urology.2017.12.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/14/2017] [Accepted: 12/20/2017] [Indexed: 10/18/2022]
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27
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Sivaraman A, Scardino P, Eastham J. Outcomes of salvage radical prostatectomy following more than one failed local therapy. Investig Clin Urol 2018; 59:152-157. [PMID: 29744471 PMCID: PMC5934276 DOI: 10.4111/icu.2018.59.3.152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 12/27/2017] [Indexed: 11/18/2022] Open
Abstract
Purpose To describe the salvage radical prostatectomy (sRP) experience in patients presenting with recurrent, clinically localized prostate cancer after multiple failed local treatments. Materials and Methods Among the 251 sRP performed during 2000–2016, 11 patients had failed multiple local therapies. We describe baseline clinical characteristics at primary cancer diagnosis and prior to sRP, surgical information, complications and oncological outcomes. Results The mean±standard deviation age at sRP was 65±5 years and the median (interquartile range) serum prostate-specific antigen (PSA) level was 2 (1.3) ng/mL. The most common first and subsequent treatments were radiotherapy and cryotherapy, respectively, with median time of 24 months from the last local treatment. The median operative time was 180 minutes and median estimated blood loss was 750 mL. Five (45.5%) patients underwent additional procedures during sRP for pre-operative morbidity from prior treatments (rectourethral fistula, urethral stricture, incontinence). Post-operative complications requiring invasive intervention occurred in 7 (63.6%) patients. Over a median follow-up of 29 (12–96) months, 10 of the 11 men (90.9%) achieved an undetectable PSA in after sRP. Three of these men with an initially undetectable PSA level experienced biochemical recurrence; the remaining 7 are without evidence of disease. Overall, no local recurrence or systemic metastasis was identified at last follow-up. Conclusions sRP is technically feasible and offers durable cancer control in patients with recurrent prostate cancer despite having undergone multiple prior attempts at cure. These patients experience higher rates of post-operative complications and such patients must be appropriately counseled regarding the potential risks and benefits.
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Affiliation(s)
- Arjun Sivaraman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter Scardino
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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28
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Degheili JA, Mansour MM, Nasr RW. Symphysis Pubis Osteomyelitis: An Uncommon Complication after Robotic Assisted Radical Prostatectomy-Case Description with Literature Review. Case Rep Urol 2018; 2018:5648970. [PMID: 29666747 PMCID: PMC5831911 DOI: 10.1155/2018/5648970] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 01/18/2018] [Indexed: 11/18/2022] Open
Abstract
Prostate cancer is the most common solid cancer among American men. Although there are various modalities for treatment, including radical prostatectomy among many others, the former is, nevertheless, not without any accompanied complications. Other than the well-known surgical complications such as erectile dysfunction, urinary incontinence, and voiding dysfunction, osteomyelitis of the symphysis pubis is not a well-understood complication, with various hypotheses explaining its pathogenesis. Although osteomyelitis of the pubis symphysis has been reported after endoscopic urological procedures such as transurethral resection of the prostate, it has rarely been reported after robotic surgeries. We hereby report, to the best of our knowledge, the first osteomyelitis of the pubis symphysis, after robotic prostatectomy, in a patient with prostate cancer and no previous radiation therapy.
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Affiliation(s)
- Jad A. Degheili
- Division of Urology and Renal Transplantation, Department of Surgery, American University of Beirut Medical Center, Riad El-Solh, Beirut 1107 2020, Lebanon
| | - Mazen M. Mansour
- Division of Urology and Renal Transplantation, Department of Surgery, American University of Beirut Medical Center, Riad El-Solh, Beirut 1107 2020, Lebanon
| | - Rami W. Nasr
- Division of Urology and Renal Transplantation, Department of Surgery, American University of Beirut Medical Center, Riad El-Solh, Beirut 1107 2020, Lebanon
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29
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Yamashita S, Kohjimoto Y, Iba A, Kikkawa K, Hara I. Necrotizing fasciitis after high-dose rate brachytherapy and external beam radiation for prostate cancer: a case report. BMC Urol 2017; 17:107. [PMID: 29162067 PMCID: PMC5697232 DOI: 10.1186/s12894-017-0299-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 11/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In recent years, the delayed side effects associated with radiotherapy for prostate cancer have drawn the interest of urologists. Although urosymphyseal fistula is one of these delayed side effects, this serious complication is rarely described in literature and is poorly recognized. CASE PRESENTATION We report our experience in treating a 77-year-old male patient with necrotizing fasciitis after high-dose rate brachytherapy plus external beam radiation for prostate cancer. The patient was referred to our hospital with complaints of inguinal swelling and fever. He had a past history of radiotherapy for prostate cancer and subsequent transurethral operation for a stricture of the urethra. Computed tomography showed extensive gas within the femoral and retroperitoneal tissues and pubic bone fracture. Surgical exploration suggested that necrotizing fasciitis was caused by urosymphyseal fistula. CONCLUSION To the best of our knowledge, this is the first case report of necrotizing fasciitis caused by urosymphyseal fistula after radiotherapy for prostate cancer. There is a strong association between urosymphyseal fistula and prostate radiotherapy with subsequent surgical intervention for bladder neck contracture or urethral stricture. Therefore, surgical treatment for bladder neck contracture or urethral stricture after radiotherapy for prostate cancer should be performed with care. The present case emphasizes the importance of early diagnosis of urosymphyseal fistula. Immediate removal of necrotic tissues and subsequent urinary diversion in the present case may have led to good patient outcome.
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Affiliation(s)
- Shimpei Yamashita
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan.
| | - Yasuo Kohjimoto
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Akinori Iba
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Kazuro Kikkawa
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Isao Hara
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
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30
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Kurtzhalts KE, Mergenhagen KA, Manohar A, Berenson CS. Successful treatment of multidrug-resistant Pseudomonas aeruginosa pubic symphysis osteomyelitis with ceftolozane/tazobactam. BMJ Case Rep 2017; 2017:bcr-2016-217005. [PMID: 28363945 DOI: 10.1136/bcr-2016-217005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
New antibiotic options are needed for the treatment of multidrug-resistant (MDR) Pseudomonas infections. We present a case of a man aged 64 years with a bladder fistula due to radiation, ultimately causing osteomyelitis of the pubic symphysis. Repeated antibiotic courses, without correcting the fistula, resulted in infection with MDR Pseudomonas aeruginosa. He was successfully treated for his osteomyelitis through cystectomy, aggressive debridement and a prolonged course of antimicrobials directed at the MDR Pseudomonas isolate.
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Affiliation(s)
- Kari E Kurtzhalts
- Department of Infectious Diseases, VA Western New York Healthcare System, Buffalo VA Medical Center, Buffalo, New York, USA
| | - Kari A Mergenhagen
- Department of Infectious Diseases, VA Western New York Healthcare System, Buffalo VA Medical Center, Buffalo, New York, USA
| | - Akshay Manohar
- Department of Infectious Diseases, VA Western New York Healthcare System, Buffalo VA Medical Center, Buffalo, New York, USA.,State University of New York at Buffalo, Jacob's School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Charles S Berenson
- Department of Infectious Diseases, VA Western New York Healthcare System, Buffalo VA Medical Center, Buffalo, New York, USA.,State University of New York at Buffalo, Jacob's School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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Abstract
BACKGROUND Radiotherapy plays a substantial role in the treatment of malignancies. More than 2/3 of all oncologic patients undergo radiotherapy during their specific treatment. Besides manifold side effects of radiotherapy, radiogenic fistulas of the urogenital tract are a potential severe complication. These fistulas might affect the female genital tract and the urinary tract. THERAPY Potential manifold variety of radiogenic urogenital fistulas requires a specific therapy. Radiation tissue damage includes severely disturbed local blood supply. Consequently, in some cases extremely complex reconstructive techniques are necessary to restore the functionality of the urinary tract. CONCLUSION The treatment of radiogenic urogenital fistulas is challenging. A successful therapy can only be achieved by local improvement of the blood supply in the damaged area.
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Affiliation(s)
- A Kocot
- Klinik und Poliklinik für Urologie und Kinderurologie, Julius Maximilians Universität Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - H Riedmiller
- Klinik und Poliklinik für Urologie und Kinderurologie, Julius Maximilians Universität Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
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32
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Radiation-induced complex anterior urinary fistulation for prostate cancer: a retrospective multicenter study from the Trauma and Urologic Reconstruction Network of Surgeons (TURNS). World J Urol 2016; 35:1037-1043. [DOI: 10.1007/s00345-016-1983-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 11/30/2016] [Indexed: 11/25/2022] Open
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33
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Lavien G, Chery G, Zaid UB, Peterson AC. Pubic Bone Resection Provides Objective Pain Control in the Prostate Cancer Survivor With Pubic Bone Osteomyelitis With an Associated Urinary Tract to Pubic Symphysis Fistula. Urology 2016; 100:234-239. [PMID: 27591809 DOI: 10.1016/j.urology.2016.08.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/21/2016] [Accepted: 08/26/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To investigate pain intensity perception in prostate cancer survivors with pubic bone osteomyelitis with an associated urinary tract to pubic symphysis fistula before and after definitive surgical management. MATERIALS AND METHODS We performed a review of an institutional review board-approved database of prostate cancer survivors with pubic bone osteomyelitis from 2010 to 2015. Demographic and clinical data were extracted. Pain scores were assessed in patients at varying points before and after definitive treatment using an 11-point numeric rating scale. Statistical analysis was performed using a Wilcoxon signed-rank test and NcNemar's test. RESULTS We identified 16 patients with a median age of 72 who met inclusion criteria. Chronic narcotic use for pain management was noted in 6 of 16 (37.5%) patients preoperatively. No statistical difference was identified between the pain score at the time of diagnosis and after completion of conservative measures (5.5 vs 5.5, P = .76). A statistically significant decrease in median pain score at the first follow-up appointment was seen compared to the preoperative pain score (0 vs. 5.5, P = .0005). At a median follow-up of 9.4 months (interquartile range 3.7-16.5), a sustained decrease in the median pain intensity score was noted in our cohort compared to their preoperative baseline pain score (5.5 vs 0, P = .0005) and pain score at the time of diagnosis (5.5 vs 0, P = .004.) CONCLUSION: Pubic bone resection provides immediate and sustained improvement in pain intensity perception in the prostate cancer survivor with pubic bone osteomyelitis with an associated urinary tract to pubic symphysis fistula.
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Affiliation(s)
- Garjae Lavien
- Department of Urology, Regions Hospital, St Paul, MN; Division of Urology, Genitourinary Cancer Survivorship Program, Duke University Medical Center, Durham, NC.
| | - Godefroy Chery
- Division of Urology, Genitourinary Cancer Survivorship Program, Duke University Medical Center, Durham, NC
| | - Uwais B Zaid
- Division of Urology, Genitourinary Cancer Survivorship Program, Duke University Medical Center, Durham, NC
| | - Andrew C Peterson
- Division of Urology, Genitourinary Cancer Survivorship Program, Duke University Medical Center, Durham, NC
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34
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Mayer EN, Tward JD, Bassett M, Lenherr SM, Hotaling JM, Brant WO, Lowrance WT, Myers JB. Management of Radiation Therapy Oncology Group grade 4 urinary adverse events after radiotherapy for prostate cancer. BJU Int 2016; 119:700-708. [DOI: 10.1111/bju.13607] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Erik N. Mayer
- Department of Surgery; Center for Reconstructive Urology and Huntsman Cancer Institute; University of Utah; Salt Lake City UT USA
| | - Jonathan D. Tward
- Department of Surgery; Center for Reconstructive Urology and Huntsman Cancer Institute; University of Utah; Salt Lake City UT USA
| | - Mitchell Bassett
- Department of Surgery; Center for Reconstructive Urology and Huntsman Cancer Institute; University of Utah; Salt Lake City UT USA
| | - Sara M. Lenherr
- Department of Surgery; Center for Reconstructive Urology and Huntsman Cancer Institute; University of Utah; Salt Lake City UT USA
| | - James M. Hotaling
- Department of Surgery; Center for Reconstructive Urology and Huntsman Cancer Institute; University of Utah; Salt Lake City UT USA
| | - William O. Brant
- Department of Surgery; Center for Reconstructive Urology and Huntsman Cancer Institute; University of Utah; Salt Lake City UT USA
| | - William T. Lowrance
- Department of Surgery; Center for Reconstructive Urology and Huntsman Cancer Institute; University of Utah; Salt Lake City UT USA
| | - Jeremy B. Myers
- Department of Surgery; Center for Reconstructive Urology and Huntsman Cancer Institute; University of Utah; Salt Lake City UT USA
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Management of Radiation Anterior Prostato-symphyseal Fistulas With Interposition Rectus Abdominis Muscle Flap. Urology 2016; 92:122-6. [DOI: 10.1016/j.urology.2016.01.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 01/21/2016] [Accepted: 01/26/2016] [Indexed: 11/16/2022]
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Bugeja S, Ivaz S, Frost A, Andrich DE, Mundy AR. Complex Fistula Disease in the Pelvic Malignancy Cancer Survivor Who Has Been Treated with Radiation. CURRENT BLADDER DYSFUNCTION REPORTS 2016. [DOI: 10.1007/s11884-016-0358-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Sukumar S, Elliott SP. The Devastated Bladder Outlet in Cancer Survivors After Local Therapy for Prostate Cancer. CURRENT BLADDER DYSFUNCTION REPORTS 2016. [DOI: 10.1007/s11884-016-0355-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Bugeja S, Andrich DE, Mundy AR. Fistulation into the Pubic Symphysis after Treatment of Prostate Cancer: An Important and Surgically Correctable Complication. J Urol 2016; 195:391-8. [DOI: 10.1016/j.juro.2015.08.074] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Simon Bugeja
- Reconstructive Urology Unit, University College London Hospital, London, United Kingdom
| | - Daniela E. Andrich
- Reconstructive Urology Unit, University College London Hospital, London, United Kingdom
| | - Anthony R. Mundy
- Reconstructive Urology Unit, University College London Hospital, London, United Kingdom
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Gupta S, Zura RD, Hendershot EF, Peterson AC. Pubic symphysis osteomyelitis in the prostate cancer survivor: clinical presentation, evaluation, and management. Urology 2015; 85:684-90. [PMID: 25733290 DOI: 10.1016/j.urology.2014.11.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/19/2014] [Accepted: 11/22/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe pelvic bone osteomyelitis in the prostate cancer survivor, to report on clinical presentation and treatment, and to suggest an algorithmic approach to managing this syndrome complex. MATERIALS AND METHODS A retrospective chart review from January 2011 to June 2014 was performed to identify prostate cancer patients with pubic symphysis osteomyelitis at a tertiary-care academic medical center with emphasis on genitourinary cancer survivorship. Data on clinical presentation and outcomes were reviewed. RESULTS Ten patients were diagnosed with having osteomyelitis of the pubic symphysis with or without extension into the pubic rami. Three patients had associated rectal fistulas. Four patients had radical prostatectomy, 5 patients received radiotherapy, and 1 patient received high-intensity focused ultrasound as the primary treatment for prostate cancer. The most common presenting symptoms were pelvic and suprapubic pain, difficulty in walking, and recurrent urinary infections at a median of 7 years after prostate cancer treatment (range, 1.5-16 years). Eight of the 10 patients underwent pubic bone debridement with urinary and fecal diversion when needed. Two patients continue to be managed conservatively with suppressive antibiotics owing to low disease burden. Complete resolution of symptoms was noted in patients undergoing operative intervention, without any pelvic ring instability due to pubic bone resection. CONCLUSION The combination of pelvic pain, difficulty with ambulation, and recurrent infections in a prostate cancer survivor should prompt investigation for pubic bone osteomyelitis-a poorly recognized syndrome complex that is best managed in a multidisciplinary setting.
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Affiliation(s)
- Shubham Gupta
- Department of Urology, University of Kentucky, Lexington, KY.
| | - Robert D Zura
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC
| | | | - Andrew C Peterson
- Division of Urology, Genitourinary Cancer Survivorship Program, Duke University Medical Center, Durham, NC
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40
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LUTS After Radiotherapy for Prostate Cancer: Evaluation and Treatment. CURRENT BLADDER DYSFUNCTION REPORTS 2015. [DOI: 10.1007/s11884-015-0292-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Baco E, Gelet A, Crouzet S, Rud E, Rouvière O, Tonoli-Catez H, Berge V, Chapelon JY, Eggesbø HB. Hemi salvage high-intensity focused ultrasound (HIFU) in unilateral radiorecurrent prostate cancer: a prospective two-centre study. BJU Int 2014; 114:532-40. [DOI: 10.1111/bju.12545] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Eduard Baco
- Division of Surgery and Cancer Medicine; Department of Urology Oslo University Hospital; Aker Norway
| | - Albert Gelet
- Hospices Civils de Lyon; Department of Urology and Transplantation Surgery; Edouard Herriot Hospital; Lyon France
- Inserm; U1032; LabTau
| | - Sébastien Crouzet
- Hospices Civils de Lyon; Department of Urology and Transplantation Surgery; Edouard Herriot Hospital; Lyon France
- Inserm; U1032; LabTau
| | - Erik Rud
- Division of Diagnostic and Intervention; Department of Radiology and Nuclear Medicine; Oslo University Hospital; Aker Norway
| | - Olivier Rouvière
- Inserm; U1032; LabTau
- Department of Urinary and Vascular Imaging; Hospices Civils de Lyon; Edouard Herriot Hospital; Lyon France
- Faculté de Médecine; Hospices Civils de Lyon; Edouard Herriot Hospital; Lyon France
| | - Hélène Tonoli-Catez
- Hospices Civils de Lyon; Department of Urology and Transplantation Surgery; Edouard Herriot Hospital; Lyon France
| | - Viktor Berge
- Division of Surgery and Cancer Medicine; Department of Urology Oslo University Hospital; Aker Norway
| | | | - Heidi B. Eggesbø
- Division of Diagnostic and Intervention; Department of Radiology and Nuclear Medicine; Oslo University Hospital; Rikshospitalet Norway
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