Management of prostatosymphyseal fistula following photoselective vaporization of the prostate: Case series and systematic review of the literature

Abstract

Background: This study is aimed to describe our institutional experience and review the literature to date on prostatosymphyseal fistula (PSF), or puboprostatic fistula, following bladder outlet procedures such as transurethral resection of the prostate (TURP) or laser photoselective vaporization of the prostate (PVP). Materials and methods: We retrospectively queried our institutional experience for management of PSF following PVP performed for symptomatic benign prostatic hyperplasia. We also performed a systematic literature review for PSF following PVP or TURP. Finally, we describe our surgical approach to the management of this challenging condition. Results: We identified 7 cases of PSF following PVP from our institution, as well as an additional 7 cases following PVP and 9 cases following TURP from literature review. The diagnosis of PSF was made between 0.5 and 24 months following PVP, and the most specific symptoms were pubic pain and difficulty ambulating. Most patients requiring several evaluations before the diagnosis was made using appropriate imaging studies. Seventy percent of patients required surgical intervention including fistula repair or prostatectomy. Our surgical approach has evolved, and we now routinely perform robotic fistula repair with Y-V plasty and interposition flap with excellent results. Conclusions: Puboprostatic fistula is a rare and poorly described complication of PVP or TURP. To the best of our knowledge, this case series of PSF following PVP represents the largest series to date and doubles the number of reported cases in the literature. Robotic fistula repair with interposition of either peritoneal or perivesical fat flaps appears to be a viable management strategy.

Narrative review of flaps and grafts in robotic reconstructive urologic surgery

“…Peritoneal flaps can be used for management of fistulae, including vesicovaginal fistulas and prostatosymphyseal fistulas ( 16 – 18 ). Additionally, the peritoneum is conveniently located to serve as a flap when rectal injuries occur in the course of the posterior dissection of a prostatectomy, which may reduce the risk of subsequent fistula formation ( 11 ).…”

“…Peritoneal flaps are associated with few complications even in the setting of complex surgeries ( 18 , 20 ). However, one study did report a fistula between the urethra and the neovagina following feminizing genitoplasty, without clearly implicating the peritoneal flap harvest as a contributing factor ( 24 ).…”