1. Uro-symphyseal fistulation after prostatic irradiation – an unrecognised but important complication Introduction Chronic pain following external beam radiotherapy (EBRT) for prostate cancer is often attributed to ‘osteitis pubis’. We have become aware of another complication, namely fistulation into the pubic symphysis, which is more serious and commoner than previously thought. Methods (cont)  In some patients the fistulous track is seen to extended anteriorly and laterally up to and into the origin of the adductor muscles (figure 3). Methods  Presented 11 months to 5 years following initial treatment  Symptoms are usually investigated by plain Xray and bone scan and treated as ‘osteitis pubis’  MRI (figure 1) and urethrography (figure 2) are required to demonstrate fistulation into the pubic symphysis Aim  To recognise uro-symphyseal fistulation as a distinct complication of radiotherapy for prostate cancer  To discuss clinical presentation, diagnosis and surgical managment  To emphasise the marked improvement in chronic debilitating pain which all these patients experience, following surgical debridement and/or reconstruction Conclusion  Uro-symphyseal fistula should be considered in patients with pubic pain after radiotherapy for prostate cancer and should be positively investigated by MRI and urethrography  Reconstruction is feasible with excellent symptomatic relief but is a major surgical undertaking with an almost inevitable risk of varying degrees of sphincter weakness incontinence Figure 3a – MRI showing fistulous track through the pubic symphysis (A) extending down into the origin of the right adductor muscles (B) following a BNI for bladder neck contracture after RP and adjuvant EBRT Figure 1 – MRI showing fistulous track between a remnant prostatic cavity (A) and the pubic symphysis (B) following EBRT and salvage cryotherapy. Bugeja S, Chaudhury I, Andrich D.E, Mundy A.R Institute of Urology, University College London Hospitals, UK No. 164 Posters Proudly Supported by: Aetiology of uro-symphyseal fistula (n=7) Presentation RP and adjuvant EBRT (n=4)Severe chronic pain in all EBRT and BNI (n=1)Recurrent infections (n=2) EBRT and salvage HIFU (n=1)Haematuria (n=2) EBRT and salvage cryotherapy (n=1) Figure 2 – fistulous track (A) seen on urethrogram extending anteriorly from the prostatic urethra into the symphysis pubis following EBRT Figure 3b – urethrogram showing extensive extravasation of contrast with a track extending around the lateral aspect of the prostate towards the rectum (A) and another fistulous track to the adductor compartment of the leg on the other side (B) Results Principles of surgery Excision of the fistulous track together with the involved symphyseal bone all the way back to healthy tissue Closure of the urinary defect Salvage RP and redo-vesico-urethral anastomosis in patients not having had a prostatectomy Omental mobilisation to wrap urethral repair and cover bony surfaces Outcomes of surgery Immediate improvement of suprapubic and pelvic pain Extensive surgery with a protracted recovery Sphincter weakness incontinence may result and may require implantation of an artificial urinary sphincter at a later stage Figure 4 – the entire pubic symphysis has been excised and omentum (A) mobilised to fill the defect Figure 5 – outcome following salvage RP in the patient shown in Figure 1 Radical prostatectomy (RP); Bladder neck incision (BNI); High Intensity Focussed Ultrasound (HIFU) A A 1 2 4 5 3 3