Prostatosymphyseal Fistula After Photoselective Vaporization of the Prostate: A Very Rare Complication of a Transurethral Surgery

Abstract

Prostatosymphyseal fistula (PSF) is a very rare complication described after transurethral surgery of the prostate including photoselective vaporization of the prostate (PVP) with GreenLight^ΤΜ laser (Boston Scientific, Marlborough, MA). Sporadic cases have also been reported in the literature as side effects of pelvic radiation therapy. We present a 65-year-old male patient who underwent PVP as an elective procedure for the treatment of severe lower urinary tract symptoms. The primary management after the diagnosis of the fistula was conservative but as this did not result in an expected improvement, the patient underwent radical prostatectomy as a last resort. PSF formation is the result of the communication between the anterior capsule of the prostate and the bladder neck via pubic symphysis and the surrounding tissues. This condition often leads to either urinoma formation or osteitis pubis. In the majority of cases, treatment options are complex surgical reconstruction using flaps or grafts, radical prostatectomy or urinary diversion as an ultimate solution. The rarity of the complication and the accompanied atypical signs and symptoms warrant a low threshold for suspicion so as to diagnose the event early and provide the appropriate treatment.

Keywords: greenlight laser; photoselective vaporization; prostatosymphyseal fistula; radical prostatectomy.

Figure 1. Soft tissue ultrasound scan: collection of fluid within the left adductor muscle and early cellulitis.

Figure 2. (A) MRI image shows fluid signal which appears to communicate from the bladder neck via the pubic symphysis inferolaterally into the left adductor collection with an adductor aponeurosis cleft sign noted. (B) Another MRI image shows a left-sided intramuscular collection with a maximally 6.5-cm transverse dimension and a 2.3-cm depth fluid collection noted centred upon the left adductor magnus muscle in the proximal thigh with marked surrounding oedema also involving the adductor brevis muscle.

Figure 3. Coronal MRI image shows that the previously visualized fluid collection within the left adductor muscle compartment has partially resolved two months post-catherization. There remains however significant oedema within the muscle fibres. The ongoing communication from the bladder neck into the pubic symphysis is evident.