Claire Haas: Thank you for having me. Great, thanks for having us. As mentioned, I'm Dr. Haas. I'm joined by my mentor, Dr. Patel. We're with Ohio State University and we're here to talk about urosymphyseal fistula and pubic osteomyelitis. Briefly, we'll touch on an overview, the clinical presentation findings, and specifically imaging. Then we'll talk a little bit about the pathogenesis and we'll end with our management algorithm at our institution. So most commonly, urosymphyseal fistula is seen in men in their late sixties. They generally speaking have a history of lower urinary tract radiation, specifically to the prostate, and subsequent instrumentation. Symptoms most commonly include debilitating pelvic pain, difficulty with ambulation often, recalcitrant urinary tract infections, and then also, as you can see on the right, we see some cutaneous drainage as well. Basic labs urinalysis will all be abnormal.
Generally speaking, you might see a leukocytosis, some elevated inflammatory markers. Everything will be non-specific, as you might imagine. So really what we look for is cross-sectional imaging. In literature, they describe using MRIs and CTs. We get a lot of MRIs at Ohio State University. And specifically, you'll see air in the fistula tract on occasion, but also just the fistula tract itself with contrast. Our two images to the right are some of our patients, and you can clearly see the contrast tracking to the pubic symphysis in both. Diagnosis technically includes a surgical culture. However, imaging and clinical symptoms are enough to take someone to the operating room of course. Pathogenesis, we have this really nice chart from a paper from Cleveland Clinic that shows a pretty significant case series and the timeline of their patients. Most patients start with some form of pelvic radiotherapy, generally speaking, to the prostate, and then they have various procedures, but ultimately end up with an endoscopic bladder outlet procedure.
And then urosymphyseal fistula diagnosis shortly after. The time from prostate cancer diagnosis and radiation to fistula can be many years. However, as you can see in the diagram, the time from the bladder outlet intervention to diagnosis is typically 10 months to a year or so. From an infectious standpoint, reviewing many studies, the infectious etiology varies quite a bit. It can be mono or polymicrobial. We see fungal infections, bacterial infections. There is a range of pathogens described, and specifically also though, important to note, is that there is, generally speaking, a lack of concordance between the preoperative urine cultures and ultimately surgically-collected bone cultures. Studies that we looked at range from reporting a concordance rate of anywhere from only 5% to 60%, so it's an important study to get, and we'll talk about how we use it, but it's not end-all be-all perfectly to treat this condition. At Ohio State, when you suspect urosymphyseal fistula in patients with pelvic pain, trouble with ambulating, some non-specific malaise, you might see recurrent UTI, fevers, skin infections, and drainage, initial evaluation would include a urine culture, obviously would include some basic labs. At Ohio State we also would obtain an MRI if they were sent to our department with contrast, plus or minus a cystoscopy and RUG to further kind of delineate the fistulous tract and anatomy. And then you may consider exam under anesthesia, flexible anoscopy, depending on the extent of the disease.
Then once you've decided someone has a urosymphyseal fistula, it's important to consider medical optimization because this is a significant chronic condition that is difficult to manage. And so at our institution, that includes nutritional supplementation preoperatively, addressing comorbidities, and really thorough counseling, because as we all know, these are big, big surgeries, they are not without risks, and important for patients to understand and have appropriate expectations. We also have them see our stoma nursing. Because these patients end up with stomas, it's important for them to have appropriate expectations, but also important for them to know how to manage their stoma postoperatively. And then we also recommend engaging infectious disease. As we talked about, these are kind of complex infections. And you may consider urine culture-directed antimicrobials while also keeping in mind that this is likely not going to be perfectly concordant with what you ultimately find intraoperatively. When it comes to intervention, the IV antibiotics, as I mentioned, postoperatively, these patients are on antibiotics for quite some time, and then the mainstay also is surgical debridement in addition to the antibiotics.
At Ohio State, we have reconstructive urologists that feel comfortable doing several of these procedures alone. However, it's also worth considering engaging plastic surgery if you are considering using a flap for a repair that may require additional input. And then depending on comfortability with pubic dissection, also worth considering engaging orthopedic surgery. Urologists who do have some experience with posterior urethroplasty may feel comfortable doing some of this dissection, but if not always worth engaging orthopedic surgery, like I mentioned. Postoperatively, it's important to monitor for healing from our regard, but also plug them into infectious disease long-term because ultimately these patients do require a long course of antibiotics for quite some time after surgery and disease surveillance. So kind of the take-home message, urosymphyseal fistula, it's a chronic, difficult-to-manage disease. It affects men with a history of pelvic radiation and then urethral instrumentation. It requires a multidisciplinary approach often, including several different subspecialties and long-term follow-up. And then it's really important to do a good job with preoperative optimization and thorough and thoughtful surgical planning before you take these patients to the OR. So with that, thank you very much. That's all I have for you.
Alan Wein: Great summary. Thank you. So what's the initial symptom that people present with when they come to the office? I mean, generally?
Hiren Patel: Usually it's recurrent UTIs and then it's subsequent ongoing pelvic pain, especially with ambulation. Those are the two clinical hallmarks of urosymphyseal fistula that we've encountered here. And then when we go, and it usually warrants a cystoscopy and a thorough history and physical, and so delineating when they receive radiation, what endoscopic procedures they have had, oftentimes they've gotten radiation at one institution, have been monitored in the community, had an endoscopic procedure. And for us, it's really delineating is this truly a urosymphyseal fistula or is there some other entity involved as well? So rectourethral fistula is also possible in this scenario. Concomitant urosymphyseal and a rectourethral fistula if they've had endoscopic procedures.
Alan Wein: So what's the usual endoscopic procedure that these people have had?
Hiren Patel: Oftentimes it's a TURP or they've had some sort of laser procedure on their prostate. Aggressive resection in the anterior part of the prostate can cause this or also any of the UroLift or any of those procedures can sometimes cause this as well.
Alan Wein: I mean, is the fistula always evident on a contrast study or on MRI or does it ever present just like osteitis pubis?
Hiren Patel: It can. If the fistulous tract is really small, sometimes it's difficult to delineate cystoscopically. So MRI is usually really sensitive for this. You can see on T2 signaling urine crossing across from the prostate into the pubic symphysis, and that usually is a pretty good indicator. If you have a really high clinical suspicion and you can see the fistulous tract, that is also appropriate indication for a cystectomy. If they're having debilitating pain, if you can also say that their bladder is not functional or salvageable, it may be an indication of proceeding to cystectomy.
Alan Wein: Well, how long do you persist with conservative management before you decide to go to an open surgical procedure on this? [inaudible 00:09:37].
Hiren Patel: Usually we counsel with the patient early on to talk to them about their disease pathogenesis and what it looks like in terms of salvaging something like this. If medical management is warranted, first we let them cool down with a course of antibiotics, and if they're consistently having recurrent UTIs, then that may be an opportunity to reengage and consider surgical management. That usually takes, with pubic osteomyelitis, we're talking about weeks to months of antibiotics before there's a resolution of symptoms. In our series of probably, since we've been here, there's only been one patient where we've seen that the urosymphyseal fistula has actually closed itself. Subsequently, when they have stopped antibiotics and been monitored longer, the fistula came back because it ultimately is the path of least resistance for these patients. And so urine will track and cause pubic osteomyelitis, and the patient eventually did end up having a cystectomy conduit.
Alan Wein: And how successful is the surgical treatment? Does it usually involve an excision of part of the pubis?
Hiren Patel: Yeah, that's controversial. I think in the field of reconstruction, there are a lot of centers where they don't do pubic osteotomies to remove the pubic symphysis. We often see patients that have active osteo that would benefit from the resection of the bone, and so oftentimes at the time we remove the pubic bone, and it's just a small wedge that you're taking out until you get back to bleeding edges, and we send that off for bone culture. And oftentimes what we find is there's discordance between the urine culture or the preoperative culture that we obtained and the bone culture that we obtained intraoperatively. And that then ultimately guides the infectious disease doctors to specifically handle the antibiotic regimen. Oftentimes we see candida. In 20% of our patients we've seen candida, and that is not found on urine culture but it is in the bone culture. And that will alter the antifungal regimen that they're on postoperatively because they require long-term antifungals.
Alan Wein: Do all these people have a history of an endoscopic procedure following radiation or prostatectomy or can it result just from the prostatectomy itself or the radiation therapy itself?
Hiren Patel: Usually there's an inciting event that causes the fistula to form. So usually if there's a level of stability after they've received therapy, so whether it's surgical therapies or prostatectomy or radiation, that alone doesn't cause a fistula to form. I think in the Anelli series there were only two patients that had a fistula form without any endoscopic procedure. So most of the time, I would say majority to almost 98%, it's usually an endoscopic procedure that's the inciting event. The tissue in a radiated field is friable. It's not healthy, it's necrotic. Oftentimes after these procedures, patients don't heal well. It's not healthy, robust prostate tissue underneath. And so when that occurs, then the urine finds the path of least resistance, and it usually, anteriorly, will be the bone, and that's what causes this to start. And so you saw after the endoscopic management in that figure, usually within 10 to 12 months these patients are presenting with diagnosis of urosymphyseal fistula.
Alan Wein: So are there any precautionary things that you can do if you're aware of the fact that you may cause one of these afterwards? I mean, when I was at Penn we saw this typically in somebody that had had prostatectomy or prostatectomy radiation therapy when they had a transurethral resection of a bladder neck contracture, typically, when people try to do radial incisions, open it up. And so in a situation like that, when someone has, let's say, indications for a TUR prostate or they have a bladder neck contracture, are there any precautionary notes to people to stay away from doing something that might precipitate a urosymphyseal fistula?
Hiren Patel: Absolutely. I think being very mindful of where you're resecting is going to be critical. So resecting at the 12:00 and 6:00 positions are a no-no in my book in a radiated patient, partly because at 6:00 you're looking at the rectum, usually that area is very thin, it's not going to heal well, and so the rectum is right below. And at 12:00 you're looking at the pubic bone, and usually there's not a lot of tissue, especially if it's radiated there. So aggressive resections at 12:00 and 6:00, it should be avoided at all costs. Again, if you're going to resect and you need to resect patients to get their outlet open, then usually 3:00 and 9:00 positions are okay to resect. And usually using, if it's because of a bladder neck contracture or a vesicourethral anastomotic stenosis, then using a Collins knife, hot or cold, is appropriate at 3:00 and 9:00, but I wouldn't resect at the 12:00 or 6:00 positions.
Alan Wein: Is it reasonable to expect when counseling patients and you see this that they can ultimately expect a resolution of their pelvic pain, their pubic pain?
Hiren Patel: Absolutely. Once the inciting event or inciting series of anatomical issues are taken care of. So usually when we do a cystectomy, we remove the bladder, the prostate is left intact, it's a simple cystectomy, we take the pubic bone out. Now, there's no place, there's no urine that's crossing across that fistula anymore, and usually that in itself with a long course of antibiotics will provide symptomatic relief for these patients. Ultimately, what happens is these patients have been dealing with this for quite some time and they've also compromised part of their quality of life.
I had a patient of mine that didn't see their family or didn't leave their house for a significant amount of time. Now he's back golfing and he's an umpire for baseball. And he came to my office, I just saw him last week, and it was the most gratifying result to see to say we've restored a part of his quality of life. And we see this especially very commonly because they've had radiation in their medical history, but it's really 10, 15 years ago and now they're in the community getting managed with endoscopic treatments. So cautionary tale being just be careful and be mindful if there are patients that have radiation to not aggressively manage their outlet, because these problems do exist and they can occur, and oftentimes it can impair a patient's quality of life.
Alan Wein: Well, a great discussion and great precautionary notes for anybody who sees patients coming in with that history and pelvic pain. The pelvic pain is usually localized to the pubic area. I mean, is it ever generalized or?
Hiren Patel: Yes. It's usually the pubic area, there are recurrent UTIs. Oftentimes they can have urethral cutaneous fistulas as well, so either to the upper part of the thigh or over the suprapubic area, and those are also possible for some of these patients. I will say when we do these pelvic bone resections that we are mindful of our capabilities. And oftentimes if there is any question about pelvic instability, we bring in our orthopedic colleagues to fixate the pelvis or have them manage the pelvis. If it's someone that doesn't have any pelvic instability, then we can oftentimes do these pubic symphyseal resections ourselves.
Alan Wein: Great. Well, listen, thanks so much for providing all those helpful hints about diagnosing it, because sometimes it remains undiagnosed for a long time, and also managing it. But thank you so much for your time and for your expertise, both of you.
Hiren Patel: Thank you so much for having us, and thank you to UroToday for inviting us to this.
Alan Wein: Thank you.
Hiren Patel: All right.