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Pubo-urethral Fistula Repair

A pubo-urethral fistula is an abnormal hole that connects the pubic bone and the urethra. Because the fistula can also connect from the pubic bone to the prostate or the bladder, it can also be known as a pubo-prostatic or pubo-vesical fistula. This allows urine to leak onto the pubic bone, leading to infection of the bone (known as osteomyelitis).  

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Antibiotics can make the pain better and keep the infection under reasonable control; but, antibiotics cannot cure the osteomyelitis (bone infection). The only cure for the infection is surgery to fix the fistula and stop the urine from leaking onto the bone. Without surgery this infection will progress until the bone becomes destroyed; the infection can even be fatal. 

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Click here to learn more about what a pubo-urethral fistula is. Or read on to learn about surgery for pubo-urethral fistula. 

Rectum

Small Hole and Healthy Bladder = Repair Hole without removing bladder

Some criteria that suggest we can save the bladder and repair the hole are:

  • small hole (<2cm)

  • healthy bladder (it is not worth saving the bladder if it is very unhealthy from radiation)

  • not leaking urine from the penis (i.e., no incontinence)

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We are able to do this technique for only 10-20% of all pubo-urethral/pubo-prostatic fistulas because so many of them do not meet these criteria. 

Two Examples of small hole (fistulas that can be repaired without removing the bladder. One example with the prostate still in place and the other after the prostate was previously removed for cancer.

Fistula from prostate to pubic bone

Destruction of pubic bone from infection

Small Pubo-Prostatic Fistula

Small Pubo-Urethral Fistula

Prostate removed for prostate cancer. Urethra and bladder reconnected with stitches

Fistula from urethra to pubic bone

Both of these examples would be repaired in the same way as each other. Below, we just show the example of the one with the prostate still in place. 

Step 1: Remove the fistula and any infected bone

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Step 2: Patch the fistula hole in the prostate with a disc of buccal mucosa graft (in pink). This is a skin graft taken from the inside of the cheek. 

Destruction of pubic bone from infection

Abdominal (rectus) muscle.

Also known as the "abs"

Buccal mucosa graft patched onto fistula opening to close it

Step 3: Rotate the rectus ("ab") muscle into the pelvis. It serves several purposes:

  • separate the fistula from the bone so that the fistula does not recur

  • it fills the empty space. Nature abhors a vacuum. So the muscle keeps the empty space from filling with infection

  • the graft is sewn to the muscle and this keeps the graft alive

  • it brings healthy blood flow and oxygen to the bone to help it recover from the infection

Big Hole, Large Cavity and Unhealthy Bladder = Bladder removal

Some criteria that suggest we should remove the bladder to treat the fistula:

  • large hole (>2cm)

  • large cavity where the prostate used to be. This can occur either after prostate removal for cancer or in cases where the prostate is still in place but has been radiated. In both cases, there is so much tissue descrution from the radiation that there is a large cavity where the prostate is or where it should be. This cavity is filled with infection and "dead" tissue. 

  • unhealthy bladder from radiation including small bladder capacity or frequent blood in the urine

  • leaking urine from the penis (i.e., incontinence). It may not be worth fixing the hole and saving the bladder if the man will still be incontinent afterwards

Below is an example of a large fistula with a large dead tissue cavity and an unhealthy bladder from radiation. This example is best fixed with bladder removal. The tissue is too unhealthy to repair the fistula with the bladder in place. 

Radiation Cystitis: Radiation damage leads to small bladder, bladder pain and blood in the urine with clots

Large cavity of dead tissue (outlined in green): Radiation leads to tissue destruction in the area of the prostate (or where it used to be). This dead space fills with infection. 

Significant destruction of the pubic bone

Urine leakage (incontinence) may sway us to recommend bladder removal

Step 1: Remove Bladder

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Step 2: Clean out the dead space. 

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Step 3: Remove infected pubic bone

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Step 4: Rotate the rectus ("ab") muscle down into the pelvis

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Step 5: Secure the rectus muscle to the pubic bone and the edges of the dead space to help fight the infection. 

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Step 6: Now that the bladder is out, we need to create a new way for the urine to exit the body safely. Perform a urinary diversion. This is almost always an ileal conduit urinary diversion. Occassionally it may be an Indiana pouch urinary diversion. 

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