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Bladder-Sparing Approaches for Urosymphyseal / Puboprostatic Fistula

Bladder-sparing approaches for urosymphyseal (USF) and puboprostatic (PPF) fistula are feasible in select patients but represent the minority of cases — only 14% of irradiated patients in the largest systematic review underwent bladder-sparing surgery, compared to 86% who required cystectomy with urinary diversion.[1] Three principal strategies exist: salvage radical prostatectomy + augmentation cystoplasty + continent catheterizable stoma (Pisters / Westney / MD Anderson), organ-sparing fistula repair with rectus abdominis flap (Kaufman / Vanni), and primary fistula repair within the TURNS multicenter algorithm.

For the cystectomy + ileal conduit endpoint see the male fistula treatment atlas. For background on USF / PPF as an entity see Campbell & Vanni 2022.[4]

Patient Selection — Bladder-Sparing vs Cystectomy​

FactorFavors bladder sparingFavors cystectomy
Bladder capacity / functionAdequate capacity, no severe radiation cystitisEnd-stage irradiated bladder, contracted, intractable hematuria[1][2]
Fistula characteristicsLocalized, single tractExtensive necrosis, cavitation, multiple tracts[4][5]
Prostate statusProstate in situ (for salvage RP + augmentation)Prior radical prostatectomy[7][8]
Sphincter functionViable (for organ-sparing repair) or patient willing to CIC (for augmentation)Destroyed, patient unwilling to CIC[3][6]
Prior treatment burdenSingle-modality radiationMultiple sequential energy sources (EBRT + brachy + cryo/HIFU)[5]
Tissue qualityAdequate for primary closureSeverely fibrotic, devascularized[3][8]

Key principles: urodynamic assessment of detrusor function is critical, particularly in patients with preexisting frequency / urgency / urge incontinence. If the external sphincter is destroyed (common after radiation + multiple endoscopic procedures), per-urethral voiding is not feasible — bladder-sparing reconstruction then requires bladder-neck closure + continent catheterizable stoma rather than vesicourethral anastomosis.[3][7]

In Bugeja 2016, reconstruction was possible in 7 of 15 patients (47%) — all via salvage RP with substitution / augmentation cystoplasty.[8]

Approach 1 — Salvage Radical Prostatectomy + Augmentation Cystoplasty + Continent Catheterizable Stoma​

The most well-described bladder-sparing approach for USF in irradiated patients with a prostate in situ. Pioneered by Pisters & Westney (MD Anderson).

Surgical technique​

  1. Salvage radical prostatectomy — retropubic approach simultaneously excises the fistula origin and removes the diseased prostatic urethra. Technically demanding due to radiation-induced fibrosis and obliterated tissue planes.[7][9]
  2. Complete bladder-neck closure — rather than vesicourethral anastomosis (very high incontinence in salvage setting), the bladder neck is closed primarily. An intestinal segment (ileocecal patch, sigmoid, or ileal) is interposed at the closure to reinforce healing and prevent recanalization.[10]
  3. Augmentation cystoplasty — ileal augmentation increases capacity reduced by radiation; addresses preexisting storage symptoms; eliminates need for postoperative anticholinergics in many patients.[3][11]
  4. Continent catheterizable stoma:
    • Appendicovesicostomy (Mitrofanoff) — preferred when appendix is available
    • Monti ileovesicostomy — reconfigured ileal segment
    • Spiral Monti — for longer channel requirements[11]
  5. Pubic-symphysis debridement / pubectomy — concurrent resection of infected symphyseal bone.[8][12]
  6. Omentoplasty — omental flap fills dead space and interposes between the reconstruction and the debrided symphysis.[8]

Outcomes​

  • Continence — at mean 61 mo: 83.3% (10/12) dry with CIC every 3–8 h[11]
  • Patient satisfaction — 86% would choose to undergo surgery again[11]
  • Stomal revision rate — 33% at mean 39 mo (stenosis or relocation)[11]
  • Incontinence Symptom Index — severity 1.86, bother 1.0 (minimal symptoms)[11]
  • Vs salvage RP with standard VUA (incontinence rates 40–60%): superior continence because the bladder neck is closed and voiding occurs via CIC[3][7]

Specific complications​

  • Stomal stenosis requiring revision ~ 27–33%[3][11]
  • Augmented bladder rupture (rare, 1 reported case)[10]
  • Small-bowel anastomotic leak (1 death in original series of 13)[7]
  • No intraoperative complications or surgical deaths in the augmentation series[11]

Approach 2 — Organ-Sparing Fistula Repair with Rectus Abdominis Flap (No Prostatectomy / Diversion)​

Described by Kaufman & Vanni — avoids both prostatectomy and urinary diversion entirely.

Surgical technique[6]​

  1. Midline lower abdominal incision — enter the retropubic space
  2. Pubic-symphysis debridement — resect all infected / necrotic bone using rongeurs and curettes until healthy bleeding bone is encountered
  3. Fistula tract excision and closure — identify and excise the fistulous communication between prostatic urethra / bladder neck and symphysis; close the urinary-tract defect primarily in multiple layers
  4. Rectus abdominis (VRAM) muscle flap interposition — pedicled flap based on the inferior epigastric artery, mobilized and transposed into the retropubic space between the urinary-tract closure and the debrided symphysis — provides well-vascularized tissue in an irradiated field[6][13]

Outcomes​

  • Kaufman / Vanni series (n = 4): all fistulas closed with a single procedure at median 27 mo[6]
  • All patients avoided prostatectomy and urinary diversion
  • Best suited for localized anterior fistula with adequate bladder function and no severe radiation cystitis

Limitations​

  • Very small case series (n = 4); long-term durability uncertain
  • Requires urinary-tract defect amenable to primary closure
  • Does not address the underlying radiation-damaged prostatic urethra — may be prone to recurrent stricture or fistulization

Approach 3 — Primary Fistula Repair (TURNS Multicenter Data)​

The TURNS (Trauma and Urologic Reconstruction Network of Surgeons) multicenter study compared cystectomy (n = 19) vs bladder-sparing fistula repair (n = 12) in 31 patients with radiation-induced anterior urinary fistula.[14]

Outcomes​

  • Both approaches highly successful — 84% overall pain resolution at 6 mo
  • Only 1 fistula recurrence in the bladder-sparing group, subsequently managed with cystectomy
  • 30- and 90-day major complications (≥ Grade 3) limited to 4 and 2 patients respectively across both groups
  • No significant differences in complication rates between approaches (study underpowered for this comparison)

Where it fits​

TURNS provides multicenter evidence that bladder-sparing fistula repair is a defensible primary option in selected patients with radiation-induced anterior urinary fistula, particularly when the bladder is functional and the fistula tract is amenable to local repair with vascularized tissue interposition. Most bladder-sparing repairs in this cohort used rectus abdominis interposition (Approach 2).

Persistent Bladder-Outlet Dysfunction Caveat​

Even when the fistula is successfully closed, bladder-outlet dysfunction frequently persists. In Raup 2016, 90% of irradiated patients undergoing fistula repair developed subsequent bladder-neck contracture or SUI, vs only 14% of non-irradiated patients.[15] Counsel patients preoperatively that eventual urinary diversion may be required even after an initially successful bladder-sparing surgery.

Key Takeaways​

  • Bladder-sparing is feasible in only ~14% of irradiated USF / PPF — strict patient-selection.
  • Salvage RP + augmentation + continent catheterizable stoma (Pisters / Westney): 83% continent at 5 yr with CIC; 86% would choose surgery again; 27–33% stomal revision rate.
  • Organ-sparing fistula repair + rectus abdominis (VRAM) flap (Kaufman / Vanni): 100% closure in 4 patients at 27 mo without prostatectomy or diversion — best for localized anterior fistula with intact bladder function.
  • TURNS primary fistula repair: 84% pain resolution at 6 mo in n = 12; 1 recurrence salvaged with cystectomy.
  • Bladder-outlet dysfunction persists in 90% of irradiated patients after fistula repair — eventual diversion may still be required.

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. Moring N, Barrett S, Peterson AC, Inouye BM. "Pelvic extirpative surgery for the 'end-stage irradiated bladder'." Cancers. 2023;15(17):4238. doi:10.3390/cancers15174238

3. De E, Pisters LL, Pettaway CA, Scott S, Westney OL. "Salvage prostatectomy with bladder neck closure, continent catheterizable stoma and bladder augmentation: feasibility and patient reported continence outcomes at 32 months." J Urol. 2007;177(6):2200–2204. doi:10.1016/j.juro.2007.01.151

4. Campbell JG, Vanni AJ. "Complex lower genitourinary fistula repair: rectourethral fistula and puboprostatic fistula." Urol Clin North Am. 2022;49(3):553–565. doi:10.1016/j.ucl.2022.04.012

5. Mundy AR, Andrich DE. "Urorectal fistulae following the treatment of prostate cancer." BJU Int. 2011;107(8):1298–1303. doi:10.1111/j.1464-410X.2010.09686.x

6. 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

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. 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

9. Leibovici D, Spiess PE, Heller L, et al. "Salvage surgery for locally recurrent prostate cancer after radiation therapy: tricks of the trade." Urol Oncol. 2008;26(1):9–16. doi:10.1016/j.urolonc.2006.12.016

10. 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

11. 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

12. 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

13. Robertson CN, Riefkohl R, Webster GD. "Use of the rectus abdominis muscle flap in urological reconstructive procedures." J Urol. 1986;135(5):963–965. doi:10.1016/s0022-5347(17)45938-6

14. 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

15. 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