Unmasking of Urinary-pubic Symphysis Fistula After Implantation of Artificial Urinary Sphincter in Prostate Cancer Survivors—User Beware

Objective To describe the dramatic and rapid unmasking of urinary-pubic symphysis fistula (UPF) and chronic osteomyelitis after artificial urinary sphincter (AUS) implantation. This has never been reported as UPF is usually an insidious sequelae of radiotherapy or energy ablation for prostate cancer. Methods We prospectively identified men who underwent rapid clinical decline due to UPF soon after AUS implantation at our institution in the previous 24 months. Chart and imaging was reviewed to assess preoperative and postoperative factors. Results Three patients were identified. All men had undergone radiation therapy for prostate cancer and all had undergone prior manipulation of the posterior urethra for complications of radiotherapy. Radiation cystitis was present and all had a low cystometric bladder capacity before surgery. All patients declined rapidly after surgery. UPF was diagnosed in 2 men after activation of AUS at 6-7 weeks postoperatively and 1 patient presented before activation at 3 weeks postoperatively. UPF tract was demonstrated with magnetic resonance imaging in the acute phase in all 3 cases. Two patients have undergone cystectomy and loop diversion with resolution of symptoms and one patient is awaiting definitive surgery. Conclusion Unmasking of occult UPF resulted in rapid clinical decline after AUS implantation. Increased intravesical filling pressure from increased urethral resistance likely resulted in opening of occult fistula tracts. UPF should be in the differential diagnosis if there is history of radiotherapy or urethral instrumentation. An underlying and undiagnosed UPF may lead to grave consequences after AUS implantation.