Urosymphyseal fistula in the cancer survivor was first described Dr Jaspreet Sandhu’s group at Memorial Sloan Kettering Cancer Center in 2012.¹ At that time, however, the reconstructive urology community could not grasp the implications of this potentially devastating disease process. The Duke reconstructive group described the first series of patients with fistula and concomitant bone infection and proposed an algorithmic approach to obtain cure in these patients in 2015.² Subsequently, the London group, led by Professor Mundy, validated this disease process with their cohort of patients the next year.³

The evolution of our understanding of this disease process over the last decade now has established a successful treatment algorithm for this disease, which often includes bladder removal along with the majority of the pubic symphysis and superior and inferior pubic rami bone. We now have long-term follow-up data on the quality of life in patients who have undergone these massive procedures. Resection can be quite drastic and often requires bone removal all the way to the acetabular joint (see Figure). Early on, surgeons had concerns about pelvic instability and we saw reports of preemptive placement of pubic symphysis metallic hardware, bridges, and cement into the resection area as well as prophylactic posterior screw placement into the sacroiliac joint in order to stabilize the pelvic rim. However, we are now learning that despite this very radical resection the adult pelvis may not be destabilized as might be expected after removing this portion of the anterior pelvic ring.

Figure. Pelvis film showing the extent of resection of the pubic symphisis and superior and inferior pubic rami with no need for posterior fixation.

From the very beginning, our group prospectively followed the outcomes for all patients undergoing cystectomy with pubic symphysis resection for pubic bone osteomyelitis. We have learned that not only are these patients uniformly cured almost instantly of their chronic debilitating pain,⁴ but are able to return to normal functional activities after this massive operation. Additionally, many groups now have a combination of preoperative and postoperative objective and subjective data that have helped us understand the stability of the adult pelvis after these resections. These include pain scores, quality of life scores, and assessment of gait after pubic bone removal. Our group follows patient-reported pain scores obtained both pre- and postoperatively. The preoperative groups have pain scores that are significantly elevated but drop to normal (0/10) at the 1-year follow-up.⁴ Similarly, the quality of life scores as outlined in the 12-Item Short-form (SF) surveys have similar improvement. The SF-12 is a validated 12 question patient-reported outcome survey that addresses both mental functioning and physical functioning in patients.⁵ While the physical functioning score does not directly address changes in gait, it does address certain things such as being able to perform daily activities, physical activity, and strenuous exercise. We found that patients with pubic symphysis fistula and osteomyelitis had significantly impaired mental and physical functioning scores prior to surgery. Uniformly, both of these scores return to normal baseline scores at 1-year follow-up after surgery.

Recently, the orthopedic literature started publishing outcomes for these patients. Shue et al followed subjective outcomes including the Numeric Pain Rating Scale and the SF-36 survey. Objective measures were also followed postoperatively, including radiographic evaluation of the distance between the 2 superior tips of the pubis on anteroposterior x-rays as well as sacroiliac joint diastasis measured by x-ray postoperatively at various time intervals. They found that the pain scores improved significantly as well as the SF-36 scores. Most interestingly, the investigators found no difference in measurements on the follow-up radiographs when analyzed postoperatively with a mean follow-up of 19 months (range 6-37).⁶ Other groups have validated these findings as well, with a recent series from 2021 reporting on 5 patients who underwent surgical resection, all regaining the ability to be fully ambulatory without the need of walking aids by 13 months.⁷

Pubic symphysis fistula with resultant osteomyelitis of the pubic bone is a potentially devastating side effect of life-saving radiation therapy given for prostate cancer. The current curative procedure often includes complete removal of the bladder and resection of the infected bone to noninfected healthy bone along with postoperative antibiotics based on the cultures from the resected bone. Despite this very large operation, the current experience indicates that patients are able to return to a normal quality of life without the threat of destabilizing the pelvis. This reinforces that there is no need for preventive internal fixation of the pelvic rim in order to potentially prevent pelvic instability down the road.