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Primary Repair (No Tissue Interposition) for USF

This page considers closure of a urosymphyseal fistula without vascularized tissue interposition. Terminology varies: the TURNS study used “primary repair” for bladder-preserving closure or urethroplasty with or without a flap. It is therefore incorrect to identify every published primary repair as a no-flap operation.[1]

For the treatment decision, see USF / PPF Bladder-Sparing Approaches. The flap-based alternative is organ-sparing repair with interposition.

Clinical Role​

USF often combines a urinary leak, infected pubic bone and radiation-damaged tissue. Reconstruction must address the urinary source, infected or nonviable tissue, drainage and any distal obstruction. Flap coverage can separate the urinary repair from the bone bed and fill dead space; expert series commonly advocate it. Evidence does not establish that every repair without a flap inevitably fails, or that a fixed recurrence percentage applies to an individual patient.[1][2]

A small, closable defect in viable tissue is different from a contracted irradiated bladder with cavitation or an unsalvageable outlet. If a safe, functional reconstruction cannot be achieved, omitting a flap does not make local closure an adequate substitute for more extensive source control. Reconstruction and diversion options require specialist assessment.[1][2]

Escandón 2026 — Comparative Evidence and Its Limits​

This retrospective 56-patient study included 11 primary repairs, 34 omental reconstructions and 11 VRAM reconstructions, with at least three months of follow-up. The abstract reports 90-day sepsis rates of 18%, 3% and 27%, respectively, and lower recurrence with omentum. Its adjusted association for recurrence at 90 days was OR 0.012 versus primary repair; it did not establish superiority over VRAM.[3]

These groups included different underlying operations: patients with obstruction, radiation cystitis or a nonviable sphincter underwent anterior exenteration and flap transfer. This is not a randomized comparison of otherwise identical bladder-preserving closures. The abstract's reported 30% primary-repair recurrence does not specify an evaluable denominator; it should not become a universal counseling estimate. The odds ratio does not prove a 98.8% causal reduction in recurrence risk.[3]

Operative and Postoperative Principles​

The surgical plan should specify debridement of infected bone and soft tissue, management of the fistula and urinary defect, whether the bladder and outlet are preservable, and the reason any interposition is omitted. The incision, catheter and closure layers are tailored to the anatomy and urinary repair; omission of a flap does not define a standardized operative protocol.[1][2]

Obtain operative bone/tissue cultures where debridement is performed. In Andrews' 25 irradiated patients, urine and bone cultures differed in 21/22 paired samples; the figure describes that cohort, not the accuracy of every patient's urine culture. Antimicrobial selection, route and duration should follow the organisms, source control and infectious-disease assessment. Catheter removal and imaging depend on the urinary reconstruction and healing.[4][2]

New pelvic pain, fever, recurrent drainage or deteriorating mobility warrants reassessment for infection, persistent leakage or recurrent fistula. Successful initial closure does not ensure a functional bladder outlet.[1][4]

Conservative Care Is a Separate Decision​

Catheter drainage and antibiotics are not synonymous with surgical primary repair. A 2023 systematic review of published USF cases reported failure of conservative care in 96% after radiation and 72% without radiation; these are selected, heterogeneous reports rather than prospective individual-risk estimates. Conservative or palliative care can still be appropriate when major surgery is unsuitable or declined, with explicit goals and monitoring.[5][2]

For sepsis or poor physiological reserve, prioritize stabilization and appropriate drainage/source control. There is no established evidence for deliberately performing an inadequate no-flap closure as a routine bridge to a later flap operation. Likewise, successful glue treatment of other urinary fistulas does not establish treatment of USF-associated bone infection.

References​

1. 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

2. 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

3. 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

4. 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

5. 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