Bladder-Sparing Approaches for Urosymphyseal / Puboprostatic Fistula
Bladder preservation can be considered when the remaining bladder, outlet and surrounding tissues support a useful reconstruction. In the 2023 systematic review of 248 reported USF cases, the post-radiation surgical counts were 184 cystectomy/diversions and 30 bladder-sparing procedures (86% and 14% of those 214 procedures). These are treatment proportions in published reports, not a validated 14% eligibility ceiling for current patients.[1]
The principal choices are local urinary repair with interposition, reconstruction involving prostatectomy and sometimes augmentation or a catheterizable channel, and cystectomy with diversion. The male fistula atlas links the individual operations.
Patient Selection
| Question | Why it matters |
|---|---|
| Can the bladder store urine comfortably and safely? | Severe radiation cystitis, a contracted reservoir, pain or bleeding may make preservation unhelpful. Assess symptoms and anatomy; use urodynamics when uncertainty about storage or emptying would change the plan.[2][3] |
| Is the outlet patent or reconstructable? | Distal obstruction and substantial tissue loss must be addressed rather than closing the tract over an unresolved problem.[2] |
| What are baseline continence and the patient's priorities? | Sphincter damage can leave severe incontinence despite successful closure. It does not automatically prevent voiding or mandate a catheterizable stoma.[2] |
| Can viable urinary tissue be separated from infected bone? | Extent of osteomyelitis, necrosis, prior repairs and available interposition determine reconstructive options.[3] |
| Is catheterizable reconstruction acceptable and practical? | A continent channel requires reliable lifelong catheterization, patient or caregiver ability and acceptance of revision/maintenance needs.[4] |
A prior radical prostatectomy eliminates the option of removing an intact prostate; it does not by itself require cystectomy. Conversely, having a prostate in situ does not make bladder preservation suitable. Discuss infection control, operative burden, likely function and possible subsequent diversion together.[2][3]
Local Repair with Interposition
For a localized defect with sufficient viable urinary tissue, organ-sparing repair combines debridement, fistula closure and vascularized coverage. Kaufman's four irradiated patients all achieved closure at median 27-month follow-up without prostatectomy or diversion. The described flap was rectus muscle, not automatically a skin-bearing VRAM flap; this small series cannot establish superiority or guaranteed native voiding.[5]
Prostatectomy with Further Bladder Reconstruction
When the diseased prostate or prostatic urethra must be removed, salvage prostatectomy for USF can be combined with a reconstruction tailored to the reservoir and outlet. In Bugeja's 16-patient USF series, one patient was treated conservatively; seven of the 15 surgical patients underwent salvage prostatectomy with substitution/augmentation cystoplasty and eight cystectomy with ileal conduit.[6]
Bladder-neck closure, augmentation and a continent catheterizable channel are possible components, not mandatory steps of every bladder-preserving repair. Much of the often-cited Pisters/Westney evidence concerns salvage surgery for recurrent malignancy rather than USF. At mean 61-month follow-up, the 2010 report found 10/12 patients dry and 4/12 with a history of revision; these are outcomes of that selected reconstruction cohort, not USF-specific comparative continence rates.[4][7]
Counsel about catheterization dependence, channel stenosis or leakage, bowel and metabolic complications, reservoir rupture and repeat surgery. In the earlier 13-patient recurrent-prostate-cancer series, one patient died after a small-bowel anastomotic leak and sepsis. Another small later series reporting no surgical deaths does not establish absence of that risk.[4][7][8]
What TURNS Adds
The 31-patient TURNS cohort included anterior urinary fistulas to the pubic symphysis or thigh after radiation: 19 men underwent cystectomy/diversion and 12 bladder-preserving repair. “Primary repair” included local closure or posterior urethroplasty, sometimes with tissue interposition. One recurrent fistula after repair required cystectomy. The reported 26/31 with pain resolution describes the overall cohort, not 12 bladder-sparing patients.[2]
Treatment was selected according to anatomy and function. A nonsignificant difference between these small groups does not establish equal safety or equivalent success. This study describes experience with these options rather than a distinct third operation.[2]
Function and Long-Term Care
Closure may leave persistent incontinence, stenosis or radiation-related bladder symptoms. Raup's frequently quoted 90% bladder-outlet dysfunction result was 18/20 irradiated patients in a mixed rectourinary/urinary-cutaneous fistula cohort, not a USF-only prognosis. Discuss these possibilities without applying that percentage to every USF repair.[9]
Coordinate antimicrobial treatment with operative cultures and source control. Follow-up should assess pain and mobility, recurrent infection/leakage, urinary storage and emptying, and any reconstruction-specific maintenance. A preserved bladder with a bowel augmentation or catheterizable channel requires ongoing surveillance and reliable access to urgent care for drainage problems.[3][4]
Videos
References
1. Patel N, Mehawed G, Dunglison N, et al. "Uro-symphyseal fistula: a systematic review to inform a contemporary, evidence-based management framework." Urology. 2023;178:1–8. doi:10.1016/j.urology.2023.05.002
2. Osterberg EC, Vanni AJ, Gaither TW, et al. "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. 2017;35(7):1037–1043. doi:10.1007/s00345-016-1983-3
3. Haas C, Feinberg A, Koch GE, Patel HV. "The diagnosis and management of urosymphyseal fistula with pubic osteomyelitis." Curr Urol Rep. 2025;26:62. doi:10.1007/s11934-025-01293-1
4. Zafirakis H, De EJ, Pisters LL, Pettaway C, Westney OL. "Long-term outcomes and patient satisfaction of continent catheterizable limb and augmentation cystoplasty simultaneous with salvage prostatectomy." Neurourol Urodyn. 2010;29 Suppl 1:S51–S56. doi:10.1002/nau.20898
5. Kaufman DA, Browne BM, Zinman LN, Vanni AJ. "Management of radiation anterior prostato-symphyseal fistulas with interposition rectus abdominis muscle flap." Urology. 2016;92:122–126. doi:10.1016/j.urology.2016.01.029
6. 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(2):391–398. doi:10.1016/j.juro.2015.08.074
7. Pisters LL, English SF, Scott SM, et al. "Salvage prostatectomy with continent catheterizable urinary reconstruction: a novel approach to recurrent prostate cancer after radiation therapy." J Urol. 2000;163(6):1771–1774. doi:10.1016/s0022-5347(05)67539-8
8. Ullrich NF, Wessells H. "A technique of bladder neck closure combining prostatectomy and intestinal interposition for unsalvageable urethral disease." J Urol. 2002;167(2 Pt 1):634–636. doi:10.1016/S0022-5347(01)69101-8
9. Raup VT, Eswara JR, Geminiani J, et al. "Gracilis muscle interposition flap repair of urinary fistulae: pelvic radiation is associated with persistent urinary incontinence and decreased quality of life." World J Urol. 2016;34(1):131–136. doi:10.1007/s00345-015-1597-1