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Prostato-symphyseal Fistula after Photoselective Vaporization of the Prostate: Case Series and Literature Review of a Rare Complication
Alejandro Sanchez, MD, Dayron Rodriguez, MD, MPH, Jed-Sian Cheng, MD, MPH, Shahin Tabatabaei, M.D., Francis J. McGovern, MD.
Massachusetts General Hospital, Boston, MA, USA.
BACKGROUND: We report our experience with the management of prostato-symphyseal fistulae after photoselective vaporization of the prostate (PVP) and review cases of this rare complication in published reports.
METHODS: We report the management of three patients with prostato-symphyseal fistulae after PVP at our institution. A total of 5 published cases of prostato-symphyseal fistulae after PVP or transurethral resection of the prostate (TURP) were identified from the National Library of Medicine Medline database, which was restricted to English language.
RESULTS: At our institution, two of three patients required a retropubic radical prostatectomy (RRP). Intra-operatively both patients were found to have large defects in the anterior aspect of the prostate with direct communication to the pubic symphysis requiring debridement by orthopedic surgery. A review of the literature identified 5 case reports totaling 5 cases of prostato-symphyseal fistula after PVP or TURP. Combining our series with the literature, a total of 8 cases of prostato-symphyseal have been reported: 5 after PVP and 3 after TURP. The mean age for all patients was 71 years (range 50 - 83) and average follow-up for all 8 patients was 4.3 months (range 1 - 7). Mean prostate volume was 31.3 ml (range 16 - 38). The most common post-operative symptoms included difficulty ambulating and pubic, hip, and/or groin pain present in 62.5% of patients. Associated diagnoses included osteitis pubis and urinoma present in 62.5% and 37.5% of patients, respectively. Average time to diagnosis of PSF was 3.4 months (range 0.5 to 11). Operative intervention was necessary in 75% of patients.
CONCLUSIONS: This is the first reported case series on the management of prostato-symphyseal fistulae after PVP or TURP. This complication can be difficult to diagnose, manage, and may cause significant patient morbidity. Management requires a multidisciplinary approach with involvement of orthopedic surgery and infectious disease specialists. Open RRP and debridement of the pubic symphysis to excise the entire fistulous tract may be the optimal treatment for patients who develop this complication and do not respond to conservative management.
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