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Organ-Sparing USF Repair with Interposition Flap

In selected urosymphyseal or anterior prostatosymphyseal fistulas, the urinary defect can be repaired while retaining the bladder and prostate. Kaufman and colleagues described pubic-symphysis debridement, fistula closure and a rectus abdominis muscle interposition flap in four irradiated patients. This establishes feasibility; it does not prove this is the least morbid operation or guarantee normal voiding.[1]

See USF / PPF Bladder-Sparing Approaches for selection, salvage prostatectomy for a more extensive reconstruction, and the male fistula atlas for diversion options.

Patient Selection​

Assess bladder capacity and symptoms, urethral patency, baseline continence, fistula extent, tissue viability, prior treatment and the patient's ability to tolerate reconstruction. A patent or reconstructable outlet and a useful bladder are central to preservation. Extensive necrosis, severe radiation cystitis or a poorly functioning outlet may favor another reconstruction or cystectomy/diversion; no single percentage or prostate-cancer treatment history defines eligibility.[2][3]

Preserving the prostate does not treat every radiation-associated stenosis or sphincter problem. Discuss possible persistent incontinence, repeat outlet procedures and eventual diversion even if the fistula closes.[2]

Operative Principles​

  1. Define the urinary and bone disease. MRI, urinary-tract imaging and endoscopic assessment guide exposure and the feasibility of preserving the outlet. Coordinate orthopedic, infectious-disease and reconstructive expertise as needed.[2][3]
  2. Debride infected and nonviable tissue. The extent of pubic resection follows the disease. Prior pelvic-ring injury or insufficiency fracture warrants particular attention to stability. Obtain bone and tissue specimens for microbiology and pathology.[3]
  3. Repair a viable urinary defect without tension. Confirm that distal obstruction and major tissue loss have been addressed. The closure and urinary drainage must fit the remaining anatomy.[1][2]
  4. Interpose vascularized tissue. In the Kaufman series a rectus muscle flap separated the urinary repair from the debrided symphysis. Plan a viable pedicle, sufficient reach and dead-space coverage, together with donor-site closure. A muscle-only rectus flap is distinct from a skin-bearing VRAM flap; neither is free of abdominal-wall morbidity.[1][3][4]

For flap anatomy, see Rectus Abdominis / VRAM. Assess prior incisions, pedicle integrity, available tissue and the actual defect before flap harvest.

Choosing an Interposition​

Omentum, rectus muscle and gracilis have been used in anterior urinary fistula reconstruction. Choice depends on exposure, tissue availability and the cavity to fill. The TURNS cohort included both flap and no-flap bladder-preserving repairs; it is not a separate standardized operation.[2]

A 2026 retrospective comparison suggests a favorable association for omentum relative to primary repair, but it mixes local reconstruction with extirpative surgery and does not establish a universal flap hierarchy. See the comparative-evidence discussion.[5]

A perivesical fat flap has been described in other difficult urinary reconstructions. The cited three-case report does not establish efficacy for USF with pubic osteomyelitis or demonstrate that local fat remains suitable in every irradiated pelvis.[6]

Outcomes and Follow-Up​

Kaufman 2016: all four patients had prior pelvic radiation and pubic osteomyelitis; all achieved closure after one reconstruction, with median follow-up of 27 months. No prostatectomy or urinary diversion was required in that series. Its small size cannot establish comparative morbidity, late durability or an individual success probability.[1]

TURNS 2017: 12 of 31 men underwent bladder-preserving repair and 19 cystectomy/diversion. One recurrence after repair required subsequent cystectomy. Pain improvement was reported for the overall cohort, not specifically for the rectus-flap subgroup. Bladder preservation, closure, continence and avoidance of future procedures are separate outcomes.[2]

Use operative cultures to guide infection treatment. Andrews found discordant urine/bone organisms in 21/22 paired samples within a 25-patient irradiated cohort. Antibiotic duration and route, catheter/imaging plans, drains, mobilization and abdominal-wall restrictions should be individualized; a fixed six-to-eight-week antibiotic or weight-bearing schedule is not a validated universal protocol.[7][3]

References​

1. 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

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. Kim E, Fernando C, McCombie A, et al. "Abdominal and perineal hernia rates following vertical rectus abdominis myocutaneous (VRAM) flap reconstruction — a supraregional experience." J Plast Reconstr Aesthet Surg. 2022;75(3):1158–1163. doi:10.1016/j.bjps.2021.11.002

5. Escandón JM, Kreutz-Rodrigues L, Fadel AE, et al. "Optimizing flap selection for urosymphyseal fistula repair: a comparative analysis of surgical outcomes." Microsurgery. 2026;46(3):e70197. doi:10.1002/micr.70197

6. Hwang A, Watson M, Talluri S, Okafor H, Singh A. "A novel perivesical fat rotational flap as an alternative to omental interposition in challenging urological reconstruction." Urology. 2023;182:e262–e263. doi:10.1016/j.urology.2023.08.023

7. Andrews JR, Hebert KJ, Boswell TC, et al. "Pubectomy and urinary reconstruction provides definitive treatment of urosymphyseal fistula following prostate cancer treatment." BJU Int. 2021;128(4):460–467. doi:10.1111/bju.15333