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Kutchukian S, Chapelle C, Huguier V, Le Moal G, Bernardeau S, Pries P, Ayoub E, Vallée M. Management of urosymphyseal fistula and pubic bone osteomyelitis: Description of a new surgical technique by cystectomy, urinary diversion and pelvic filling flap by unilateral pedicled myocutaneous vertical rectus abdominus muscle flap. THE FRENCH JOURNAL OF UROLOGY 2024; 34:102589. [PMID: 38354684 DOI: 10.1016/j.fjurol.2024.102589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 01/01/2024] [Accepted: 01/22/2024] [Indexed: 02/16/2024]
Abstract
Pubic bone osteomyelitis is a rare infection, mostly related to urinary fistula. The published data about the medical or surgical management of this type of infection is relatively poor. In this case study of three patients, we describe our surgical technique for the management of urosymphyseal fistula complicated with pubic bone infection using pelvic filling flap by unilateral pedicled myocutaneous vertical rectus abdominus muscle flap. The first patient had the pelvic space filled with omentum flap. Unfortunately, the patient presented, postoperatively, an enteric fistula resulting from intestine incarceration on the resected bone. Considering this failure, the next two cases, have benefited from a Taylor flap to protect the peritoneal cavity by covering the residual pubic bone. Early complications were pyelonephritis and anemia (Clavien-Dindo 2), but no repeat surgery was required afterwards. The hospital stay for both cases were 26- and 12-days contrary to the first case who was hospitalized for 180-days. In conclusion, despite our limited experience in managing complicated urosymphyseal fistula, Taylor's flap, mainly used for gynecological or rectal surgery, might be a good reproducible solution for the surgical management of this kind of fistula with pubic debridement. It allows to protect the peritoneal cavity with fewer postoperative complications.
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Affiliation(s)
- Stessy Kutchukian
- Department of Urology, Poitiers University Hospital, 2, rue de la Milétrie, 86021 Poitiers, France
| | - Caroline Chapelle
- Department of Urology, Poitiers University Hospital, 2, rue de la Milétrie, 86021 Poitiers, France
| | - Vincent Huguier
- Department of Plastic surgery, Poitiers University Hospital, 2, rue de la Milétrie, 86021 Poitiers, France
| | - Gwenaël Le Moal
- Department of Infectious disease, Poitiers University Hospital, 2, rue de la Milétrie, 86021 Poitiers, France
| | - Simon Bernardeau
- Department of Urology, Poitiers University Hospital, 2, rue de la Milétrie, 86021 Poitiers, France
| | - Pierre Pries
- Department of Orthopedic surgery, Poitiers University Hospital, 2, rue de la Milétrie, 86021 Poitiers, France
| | - Elias Ayoub
- Department of Urology, Poitiers University Hospital, 2, rue de la Milétrie, 86021 Poitiers, France
| | - Maxime Vallée
- Department of Urology, Poitiers University Hospital, 2, rue de la Milétrie, 86021 Poitiers, France; Poitiers University, Inserm U1070, "Pharmacologie des Anti-Infectieux", UFR Médecine-Pharmacie, Pôle Biologie Santé, 1, rue Georges-Bonnet, bâtiment B36 TSA 51106, 86073 Poitiers cedex, France.
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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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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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Madhusoodanan V, Katz JE, Bhat A, Shah HN. Endourological management of osteitis pubis secondary to a calcified prostate ossifying into the pubic symphysis. BMJ Case Rep 2021; 14:14/5/e242009. [PMID: 34016634 DOI: 10.1136/bcr-2021-242009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Osteitis pubis is a rare but known complication of multiple urological procedures including transurethral resection of the prostate, prostate cryotherapy, photovaporisation of the prostate, high-intensity focused ultrasound treatment of the prostate, prostatectomy and cystectomy, especially in the context of salvage therapy for prostate cancer. Patients can present with significant often intractable pain secondary to this condition. We report a case of a patient with a history of radiation therapy and salvage cryoablation who presented with osteitis pubis, calcification of the prostatic tissue bed which was inseparable from the pubic symphysis. Treatment with salvage holmium laser enucleation of the prostate and holmium lithotripsy was demonstrated to be effective for palliative management of osteitis pubis from prostatic calcification ossifying into the pubic symphysis.
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Affiliation(s)
| | - Jonathan E Katz
- Urology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Abhishek Bhat
- Urology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Hemendra N Shah
- Urology, University of Miami Miller School of Medicine, Miami, Florida, USA
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Nosé BD, Boysen WR, Kahokehr AA, Inouye BM, Eward WC, Hendershot EF, Peterson AC. Extirpative Cultures Reveal Infectious Pubic Bone Osteomyelitis in Prostate Cancer Survivors With Urinary-Pubic Symphysis Fistulae (UPF). Urology 2020; 142:221-225. [PMID: 32389815 DOI: 10.1016/j.urology.2020.04.095] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To examine the infectious features of patients with urinary pubic symphysis fistula (UPF) and their association with osteomyelitis. METHODS We conducted a review of our quality improvement database for 36 patients with UPF undergoing bone resection and extirpative surgery from October 2012 to January 2019. An assessment of bone and urine cultures was carried out along with surgical, radiologic, and demographic data. We analyzed descriptive statistics and used Fisher Exact Tests and unpaired Welch t tests to assess for associations with positive bone cultures. RESULTS In our cohort, 33 patients (91.7%) had positive bone cultures with the 3 most common organisms being candida (22.0%), enterococcus (18.0%), and pseudomonas (10.0%). There was a correlation between positive preoperative urine culture and positive bone culture (P <.01), with 63.0% of those with positive urine cultures growing the same organism on bone culture. CONCLUSION In this series, 91.7% of patients undergoing extirpative surgery for UPF at our institution have positive bone cultures at time of pubic bone debridement. Additionally, we demonstrate a statistically significant correlation between positive urine cultures and positive bone cultures in these patients. This supports the need for a multidisciplinary approach including infectious disease, orthopedic surgery and reconstructive urology in order to address this complex clinical condition.
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Affiliation(s)
- Brent D Nosé
- Genitourinary Cancer Survivorship Program, Division of Urology, Duke University Medical Center, Durham, NC
| | - William R Boysen
- Genitourinary Cancer Survivorship Program, Division of Urology, Duke University Medical Center, Durham, NC
| | - Arman A Kahokehr
- Genitourinary Cancer Survivorship Program, Division of Urology, Duke University Medical Center, Durham, NC
| | - Brian M Inouye
- Genitourinary Cancer Survivorship Program, Division of Urology, Duke University Medical Center, Durham, NC
| | - William C Eward
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | | | - Andrew C Peterson
- Genitourinary Cancer Survivorship Program, Division of Urology, Duke University Medical Center, Durham, NC
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