Introduction: Urosymphyseal fistula (USF) is defined as a direct fistula from the urinary tract into the pubic symphysis resulting in progressive and treatment-refractory osteomyelitis (1). USF is a rare complication causing chronic pelvic pain months to years after surgery, radiation, or ablative therapies in the pelvis. It can also rarely be precipitated by urethral or prostatic instrumentation (1,2). Initial management consists of pain management and antibiotics (3). Surgical management is required for definitive treatment (2). This video presents a rare case of USF following transurethral resection of the prostate (TURP). Methods: This case presents an 80 year old man who underwent two TURPs complicated by a symptomatic USF. The surgery began by reflecting the bladder off the anterior abdominal wall. A portion of the bladder was strongly adherent to the pubic symphysis. Once freed, the prostate was identified and dissected away from the surrounding tissue. A Y-shaped incision was made on the bladder neck revealing an approximately 3cm fistula tract at the 12 o’clock position. Next, a midline cautery incision was made into the symphyseal cartilage. Debridement of the cartilage and bone fragments was continued until healthy appearing tissue was reached. Next, attention was turned to the complex bladder neck reconstruction, which was done in a YV-plasty configuration. The reconstruction was done using 9 inch 3-0 V lock suture starting at the midpoint of the fistula tract. A running single layer closure was performed on each side and eventually the edges were pulled together. Prior to complete closure, a final 20F silicone catheter was inserted. The bladder was then backfilled with 120cc of sterile saline and the anastomosis was water tight. Finally, attention was turned to the omental flap interposition. The omentum was identified and was easily brought between the pubic symphysis and bladder neck. Using 2-0 V lock sutures it was anchored to the symphysis and secured in place. Results: The operative recovery was uncomplicated. Intraoperative tissue cultures grew Pseudomonas prompting treatment with Cefepime. The patient was discharged home on postoperative day 3 with a foley catheter. Conclusions: This video presents the surgical management of a USF following TURP. Although rare, clinicians should consider USF in patients who present with pelvic pain or pain with walking after prostatic instrumentation. SOURCE OF Funding: None.
