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Langbour C, Mahmoud S, Coustillères F, Lartigue MF, René J. Aerococcus urinae infection of the pubic symphysis: A rare case report. IDCases 2023; 34:e01911. [PMID: 37928817 PMCID: PMC10622683 DOI: 10.1016/j.idcr.2023.e01911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 11/07/2023] Open
Abstract
Aerococcus urinae is a Gram-positive, catalase-negative coccus, rarely responsible for urinary tract infections and seldom described for musculoskeletal infections like spondylodiscitis. An 86-year-old man presented to our hospital for groin pain without fever. Pelvic CT-guided biopsy revealed an A. urinae pubic symphysis osteomyelitis. He received a treatment by amoxicillin per os for six weeks, and did not need any surgery. An eight -month- follow-up showed a favorable evolution. Pubic symphysis infection can be induced by a wide variety of pathogens, and may have very different clinical presentations. Some authors recommend systematic surgery, but in case of susceptible pathogen associated with a low level of joint destruction, medical treatment alone should be sufficient to cure and make surgery unnecessary.
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Affiliation(s)
- Camille Langbour
- CHU Tours, Service Rhumatologie, 37170 Chambray-les-Tours, France
| | - Sara Mahmoud
- CHU Tours, Service Rhumatologie, 37170 Chambray-les-Tours, France
| | | | - Marie-Frédérique Lartigue
- CHU Tours, Service de Bactériologie-Virologie-Hygiène, F-37044 Tours, France
- ISP, UMR1282, Université de Tours, INRAE, F-37032 Tours, France
| | - Jessica René
- CHU Tours, Service Rhumatologie, 37170 Chambray-les-Tours, France
- Université François Rabelais de Tours, 37000 Tours, France
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Moring N, Barrett S, Peterson AC, Inouye BM. Pelvic Extirpative Surgery for the "End-Stage Irradiated Bladder". Cancers (Basel) 2023; 15:4238. [PMID: 37686515 PMCID: PMC10486644 DOI: 10.3390/cancers15174238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/08/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Men with prostate cancer have the daunting task of selecting from multiple modalities of treatment. The long-term effects of radiation therapy are only now being recognized. For both patients and surgeons, the end-stage irradiated bladder poses numerous problems and challenges. Specifically, irradiated bladders with urosymphyseal fistula, radiation cystitis, and rectourethral fistula are challenging to manage and treat. This review outlines the presentation, workup, and management including cystectomy for these three devastating late complications of radiation therapy. There are special considerations when performing benign cystectomy that are not typically considered during oncologic cystectomy. We discuss an overview of the current literature regarding the "end-stage bladder" resulting from radiation therapy and the important considerations that must be acknowledged when managing these patients. It is shown that many of the less invasive and conservative options ultimately lead to cystectomy. Indeed, our review concludes that cystectomy with urinary diversion is a safe and viable option in select irradiated patients with the goal to improve quality of life.
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Affiliation(s)
- Nikolas Moring
- Department of Urology, Albany Medical Center, Albany, NY 12208, USA; (N.M.); (S.B.)
| | - Seamus Barrett
- Department of Urology, Albany Medical Center, Albany, NY 12208, USA; (N.M.); (S.B.)
| | | | - Brian M. Inouye
- Department of Urology, Albany Medical Center, Albany, NY 12208, USA; (N.M.); (S.B.)
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Patel N, Mehawed G, Dunglison N, Esler R, Navaratnam A, Yaxley J, Chung E, Tse V, Roberts MJ. Uro-symphyseal Fistula: A Systematic Review to Inform a Contemporary, Evidence-based Management Framework. Urology 2023; 178:1-8. [PMID: 37182647 DOI: 10.1016/j.urology.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/26/2023] [Accepted: 05/03/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To collate available data via systematic review considering etiology, presentation, and treatment of Uro-Symphyseal Fistula (USF) in order to inform a contemporary management framework. MATERIALS AND METHODS A systematic review was performed according to the Cochrane Handbook and registered in PROSPERO (CRD42021232954). MEDLINE and CENTRAL databases were searched for manuscripts considering USF published between 2000 and 2022. Full text manuscripts were reviewed for clinical data. Univariate statistical analysis was performed where possible. RESULTS A total of 31 manuscripts, comprising 248 USF cases, met inclusion criteria. Suprapubic pain and difficulty ambulating were common symptoms. MRI confirmed the diagnosis in 95% of cases. Radiotherapy for prostate cancer was the most common predisposing factor (93%). Among these patients, prior endoscopic bladder outlet surgery was common (83%; bladder neck incision/urethral dilatation n = 59, TURP/GLL PVP n = 34). In those with prior prostatic radiation, conservative management failed in 96% of cases. Cystectomy with urinary diversion (86% n = 184) was favored over bladder-sparing techniques (14% (n = 30) after prior radiation. In radiation naïve patients, conservative management failed in 72% of patients, resulting in either open fistula repair with flap (62%) or radical prostatectomy (28%). CONCLUSION Prior radiotherapy is a significant risk factor for USF and almost always requires definitive major surgery (debridement, cystectomy, and urinary diversion). On the basis of the findings within this systematic review, we present management principles that may assist clinicians with these complex cases. Further research into pathogenesis, prevention, and optimal treatment approach is required.
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Affiliation(s)
- Nishal Patel
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Georges Mehawed
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Urology, Redcliffe Hospital, Queensland, Australia
| | - Nigel Dunglison
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Rachel Esler
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Wesley Urology Clinic, The Wesley Hospital, Brisbane, Queensland, Australia
| | - Anojan Navaratnam
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - John Yaxley
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Wesley Urology Clinic, The Wesley Hospital, Brisbane, Queensland, Australia
| | - Eric Chung
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Urology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Vincent Tse
- Department of Urology, Macquarie University Hospital, Sydney, Queensland, Australia; Department of Urology, Concord Hospital, Sydney, Queensland, Australia
| | - Matthew J Roberts
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Urology, Redcliffe Hospital, Queensland, Australia; Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.
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Simultaneous treatment of a pubovesical fistula and lymph node metastasis secondary to multimodal treatment for prostate cancer: Case report and review of the literature. Open Med (Wars) 2022; 17:1715-1723. [DOI: 10.1515/med-2022-0577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/22/2022] [Accepted: 09/06/2022] [Indexed: 11/05/2022] Open
Abstract
Abstract
Pubovesical fistula (PVF) is a rare complication of radical treatments for prostate cancer (PCa), especially when a multimodal approach is performed. We present a case of PVF with extensive communication between the bladder and the pubic bones, and lymph node metastases of PCa treated by cystectomy and salvage lymphadenectomy. We describe a case of a 65-year old male patient who, after radical prostatectomy and adjuvant radiation therapy, suffered from suprapubic and perineal pain, ambulation difficulties and recurrent urinary tract infections. Cystoscopy, cystography and contrast-enhanced magnetic resonance imaging diagnosed a PVF. Choline positron emission tomography/computed tomography scan demonstrated PCa lymph node metastases. After the failure of conservative treatment, open radical cystectomy with ureterocutaneostomy diversion and salvage lymphadenectomy were performed with resolution of symptoms. At 3-month follow-up, the pelvic and perineal pain was completely regressed and 1-year later the patient was still asymptomatic. This clinical case shows efficacy and safety of combined salvage lymphadenectomy and cystectomy with urinary diversion for the treatment of late PCa node metastasis and PVF.
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Vasdev R, DeWitt-Foy M, Elliott SP. Sacral Insufficiency Fractures After Total Pubectomy for Osteomyelitis: A Case Series. Urology 2022; 170:203-208. [PMID: 36115424 DOI: 10.1016/j.urology.2022.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/14/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To document the incidence, risk factors, and prevalence of sacral insufficiency fractures (SIF) among patients who have undergone total pubectomy for osteomyelitis. METHODS A retrospective chart review was performed of patients undergoing total pubectomy for osteomyelitis at a single institution from 2016 to 2021. Descriptive statistics and univariate analysis were performed using the Wilcoxon rank-sum test and Fisher exact test as appropriate. RESULTS Sixteen patients underwent total pubectomy for osteomyelitis. The median age was 68 years. 12/16 (75%) had previously received pelvic radiotherapy. The median BMI was 27.8 kg/m2. Eleven (68.75%) had postoperative pelvic imaging, of which 3 (27.3%) had a new SIF. One other patient had a SIF 3 days before pubectomy. Three SIFs were detected via MRI and one by CT scan. The median BMI of patients with SIF was significantly lower than those without SIF (22.4 v 30.5, p = 0.004). All patients with SIF presented with new pelvic or perineal pain without radiculopathy. Symptoms resolved for three patients with non-opioid analgesics, physical therapy, and/or a brief trial of opioids. CONCLUSIONS Sacral insufficiency fracture is a rare sequela of total pubectomy for osteomyelitis. Lower BMI is significantly associated with SIF perhaps due to reduced muscle mass or poor bone condition and, as a result, baseline pelvic instability. Medical management should be first-line therapy.
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Complex Lower Genitourinary Fistula Repair. Urol Clin North Am 2022; 49:553-565. [DOI: 10.1016/j.ucl.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Resection of Pubic Symphysis and Cystectomy Significantly Improves Short-Term Patient-Reported Physical Functioning among Patients with Pubovesical Fistula and Pubic Bone Osteomyelitis. Urology 2022; 167:218-223. [DOI: 10.1016/j.urology.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 05/05/2022] [Accepted: 05/10/2022] [Indexed: 11/19/2022]
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Anele UA, Wood HM, Angermeier KW. Management of Urosymphyseal Fistula and Pelvic Osteomyelitis: A Comprehensive Institutional Experience and Improvements in Pain Control. Eur Urol Focus 2021; 8:1110-1116. [PMID: 34479839 DOI: 10.1016/j.euf.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/18/2021] [Accepted: 08/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Urosymphyseal fistula (USF) is an uncommon but painful and devastating condition typically occurring after radiotherapy for pelvic malignancy, with a delayed diagnosis and a risk of opioid dependence. OBJECTIVE To characterize our institutional experience and determine the impact of intervention for USF on pain control and opioid use. DESIGN, SETTING, AND PARTICIPANTS We evaluated data for 33 adult patients diagnosed with USF and managed at a quaternary institution between 2009 and 2021. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We assessed chronic opioid use, pain scores, prior therapy for pelvic malignancy, prior endoscopic procedures, microbiology and histology congruence, and postoperative complications. For comparative analyses we used a χ2 test or Fisher's exact test for categorical variables and a Wilcoxon signed-rank test for continuous variables. RESULTS AND LIMITATIONS Nearly 94% of the patients had received prior pelvic radiotherapy and >80% occurred in 2016-2021 but were not diagnosed until a median of 10 mo (interquartile range [IQR] 3.5-19.5) following endoscopic procedure(s). Osteomyelitis was suspected in 78.8% of imaging reports and nearly 70% had a positive preoperative urine culture. Over 90% of patients underwent cystectomy, pubic bone debridement or resection, and a soft-tissue pedicle flap. Preoperative urine cultures were concordant with 60% of intraoperative tissue/bone cultures. Histologic osteomyelitis was identified in 85% and concordant with 80% of preoperative imaging. Clavien-Dindo grade ≥3 complications occurred in 15.6%. The median pain score decreased from 4 (IQR 0-8) preoperatively to 0 (IQR 0) postoperatively (p < 0.001). Chronic opioid use decreased from 39.4% to 21.2% (p = 0.02). CONCLUSIONS Pelvic osteomyelitis may complicate USF and commonly manifests with severe, persistent pain. USF incidence may be increasing or at least increasingly recognized, but diagnosis is delayed. Definitive management results in significant improvements in pain perception and a decrease in chronic opioid use. PATIENT SUMMARY We examined features of urinary fistulas, which are abnormal openings or connections between part of the urinary tract and another structure. Patients with a urinary fistula involving the pelvic bones can present with severe pain, but diagnosis of the condition is often delayed. Removal of some pelvic bone with bladder removal or repair can result in a decrease in long-term pain and in the use of opioid drugs for pain relief.
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Affiliation(s)
- Uzoma A Anele
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Hadley M Wood
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kenneth W Angermeier
- Center for Genitourinary Reconstruction, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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9
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Hoeh B, Müller SC, Kluth LA, Wenzel M. Management of Medium and Long Term Complications Following Prostate Cancer Treatment Resulting in Urinary Diversion - A Narrative Review. Front Surg 2021; 8:688394. [PMID: 34434956 PMCID: PMC8381645 DOI: 10.3389/fsurg.2021.688394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/09/2021] [Indexed: 12/24/2022] Open
Abstract
The purpose of this narrative review is to discuss and highlight recently published studies regarding the surgical management of patients suffering from prostate cancer treatment complications. Focus will be put on the recalcitrant and more complex cases which might lead to urinary diversion as a definite, last resort treatment. It is in the nature of every treatment, that complications will occur and be bothersome for both patients and physicians. A small percentage of patients following prostate cancer treatment (radical prostatectomy, radiation therapy, or other focal therapies) will suffer side effects and thus, will experience a loss of quality of life. These side effects can persist for months and even years. Often, conservative management strategies fail resulting in recalcitrant recurrences. Prostate cancer patients with "end-stage bladder," "devastated outlet," or a history of multiple failed interventions, are fortunately rare, but can be highly challenging for both patients and Urologists. In a state of multiple previous surgical procedures and an immense psychological strain for the patient, urinary diversion can offer a definite, last resort surgical solution for this small group of patients. Ideally, they should be transferred to centers with experience in this field and a careful patient selection is needed. As these cases are highly complex, a multidisciplinary approach is often necessary in order to guarantee an improvement of quality of life.
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Affiliation(s)
- Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
| | - Stefan C Müller
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
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10
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Anele UA, Wood HM, Angermeier KW. Urosymphyseal fistulas in women: identification and characterization of a previously undescribed phenomenon. J Surg Case Rep 2021; 2021:rjab331. [PMID: 34386191 PMCID: PMC8354677 DOI: 10.1093/jscr/rjab331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/10/2021] [Accepted: 07/13/2021] [Indexed: 12/05/2022] Open
Abstract
Urosymphyseal fistula (USF) is a very uncommon but catastrophic condition which typically occurs in the setting of previous radiation treatment for prostate cancer. As a result, USF has only been described in male populations. For the first time, we characterize this phenomenon in a series consisting of four women managed at our quaternary institution. We found that most patients presented with pubic pain and all were diagnosed with USF on CT or MRI. Imaging commonly demonstrated features suggesting osteomyelitis which was confirmed on histology. Patients experienced significant decreases in peri-operative pain scores following extirpative surgery with urinary diversion, bone debridement/resection and tissue interposition. This case series highlights the rarity of USF in women in order to help promote increased recognition and timely management.
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Affiliation(s)
| | - Hadley M Wood
- Center for Genitourinary Reconstruction, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kenneth W Angermeier
- Center for Genitourinary Reconstruction, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Shu HT, Elhessy AH, Conway JD, Burnett AL, Shafiq B. Orthopedic management of pubic symphysis osteomyelitis: a case series. J Bone Jt Infect 2021; 6:273-281. [PMID: 34345575 PMCID: PMC8320518 DOI: 10.5194/jbji-6-273-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/04/2021] [Indexed: 01/21/2023] Open
Abstract
Objectives: The purpose of this case series is to describe the orthopedic
management of pubic symphysis osteomyelitis with an emphasis on the key
principles of treating bony infection. Furthermore, we sought to identify whether debridement of the pubic symphysis without subsequent internal fixation
would result in pelvic instability.
Methods: A retrospective chart review was performed to identify all cases of
pubic symphysis osteomyelitis treated at both institutions from 2011 to 2020. Objective outcomes collected included infection recurrence, change in pubic
symphysis diastasis, sacroiliac (SI) joint diastasis, and ambulatory status.
Subjective outcome measures collected included the numeric pain rating scale
(NPRS) and the 36-Item Short Form Survey (SF-36). Pubic symphysis diastasis
was measured as the distance between the two superior tips of the pubis on a
standard anterior–posterior (AP) view of the pelvis. SI joint diastasis was measured bilaterally as the joint space between the ileum and sacrum
approximately at the level of the sacral promontory on the inlet view of the
pelvis. A paired t test was utilized to compare the differences in outcome measures. An α value of 0.05 was utilized. Results: Six patients were identified, of which five were males and one was
female (16.7 %), with a mean ± standard deviation (SD) follow-up of 19 ± 12 months (range 6–37 months). Mean ± SD age was 76.2 ± 9.6 years (range 61.0–88.0 years) and body mass index (BMI) was 28.0 ± 2.9 kg/m2 (range 23.0–30.8 kg/m2). When postoperative
radiographs were compared to final follow-up radiographs, there were no
significant differences in pubic symphysis diastasis (P = 0.221) or SI
joint diastasis (right, P = 0.529 and left, P = 0.186). All patients were ambulatory without infection recurrence at final follow-up. Mean improvement
for NPRS was 5.6 ± 3.4 (P = 0.020) and mean improvement for SF-36
physical functioning was 53.0 ± 36.8 (P = 0.032).
Conclusion: This case series highlights our treatment strategy for pubic
symphysis osteomyelitis of aggressive local debridement with local
antibiotic therapy. Additionally, debridement of the pubic symphysis without
subsequent internal fixation did not result in pelvic instability, as
determined by pelvic radiographs and ability to fully weight bear postoperatively.
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Affiliation(s)
- Henry T Shu
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ahmed H Elhessy
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopaedics, Sinai Hospital, Baltimore, MD, USA
| | - Janet D Conway
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopaedics, Sinai Hospital, Baltimore, MD, USA
| | - Arthur L Burnett
- Department of Urology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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12
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Complicated pubovesical fistula on PET/CT and MRI. Eur J Nucl Med Mol Imaging 2021; 48:3335-3336. [PMID: 33742237 DOI: 10.1007/s00259-021-05305-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
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13
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Andrews JR, Hebert KJ, Boswell TC, Avant RA, Boonipatt T, Kreutz-Rodrigues L, Bakri K, Houdek MT, Karnes RJ, Viers BR. Pubectomy and urinary reconstruction provides definitive treatment of urosymphyseal fistula following prostate cancer treatment. BJU Int 2021; 128:460-467. [PMID: 33403768 DOI: 10.1111/bju.15333] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To describe the natural history, reconstructive solutions, and functional outcomes of those men undergoing pubectomy and urinary reconstruction after prostate cancer treatment. PATIENTS AND METHODS This study retrospectively identified 25 patients with a diagnosis of urosymphyseal fistula (UF) following prostate cancer therapy who were treated with urinary reconstruction with pubectomy. This study describes the natural history, reconstructive solutions, and functional outcomes of this cohort. RESULTS All 25 patients had a history of pelvic radiotherapy for prostate cancer. The median (interquartile range [IQR]) time from prostate cancer treatment to diagnosis of UF was 11 (6, 16.5) years. The vast majority of men (24/25; 96%) presented with debilitating groin pain during ambulation. Posterior urethral stenosis was common (20/25; 80%), with 60% having repetitive endoscopic treatments. Culture of pubic bone specimens demonstrated active infection in 80%. Discordance between preoperative urine and intraoperative bone cultures was common, 21/22 (95.5%). After surgery, major 90-day complications (Clavien-Dindo Grade III and IV) occurred in eight (32%) patients. Pain was significantly improved, with resolution of pain (24/25; 96%) and restoration of function, the median (IQR) preoperative Eastern Cooperative Oncology Group Performance Status (ECOG PS) was 3 (2, 3) vs median postoperative ECOG PS score of 0 (0, 1). CONCLUSION Endoscopic urethral manipulation after radiation for prostate cancer is a risk factor for UF. Conservative management will not provide symptom resolution. Fistula decompression, bone resection, and urinary reconstruction effectively treats chronic infection, improves pain and ECOG PS scores.
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Affiliation(s)
- Jack R Andrews
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Kevin J Hebert
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Timothy C Boswell
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Ross A Avant
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Thanapoom Boonipatt
- Department of Plastic Surgery, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | | | - Karim Bakri
- Department of Plastic Surgery, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - R Jeffery Karnes
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Boyd R Viers
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
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14
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Kahokehr AA, Boysen WR, Schild MH, Nosé BD, Huang J, Eward W, Peterson AC. Urinary Pubic Symphysis Fistula Leads to Histopathologic Osteomyelitis in Prostate Cancer Survivors. Urology 2020; 148:297-301. [PMID: 32763316 DOI: 10.1016/j.urology.2020.07.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the histologic findings in the pubic bone resected during extirpative surgery for urinary pubic symphysis fistula (UPF). The concurrent presence of osteomyelitis and the need for bone resection at time of extirpative surgery for UPF has been debated. We hypothesized that UPF results in histopathologically confirmed osteomyelitis, underscoring the importance of bone resection at the time of surgery. METHODS An IRB-approved retrospective review of all patients undergoing surgery for UPF from 2012 to 2019 was performed. Demographic data were recorded. A single pathologist performed histopathologic examination of bone tissue in each case. Logistic regression and Fisher exact test were used to assess association of osteomyelitis with clinical factors. RESULTS We identified 36 patients who underwent major extirpative surgery for UPF with bone pathology available for review. Bone histopathology findings confirmed presence of osteomyelitis in the majority (n = 32, 88.9%). This was characterized as chronic osteomyelitis in 15 (41.7%), acute osteomyelitis only in 1 (2.8%) and combined chronic, and acute osteomyelitis in 16 (44.4%). Osteonecrosis was seen in 11 cases (33.6%). There was no correlation between presence of osteomyelitis and age, timing from radiotherapy to diagnosis of UPF, type of radiotherapy, or history of endoscopic bladder outlet procedures. CONCLUSION Osteomyelitis is present on histology of the pubic bone resected during surgery for UPF in the majority of cases (88.9%). Osteonecrosis is also common. These findings underscore the critical importance of pubic bone resection at time of UPF surgery to adequately treat the diseased bone.
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Affiliation(s)
| | - William R Boysen
- Division of Urology, Duke University Medical Center, Durham, NC.
| | | | - Brent D Nosé
- Division of Urology, Duke University Medical Center, Durham, NC
| | - Jiaoti Huang
- Division of Urology, Duke University Medical Center, Durham, NC
| | - Will Eward
- Division of Urology, Duke University Medical Center, Durham, NC
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