Urethrocutaneous fistula after use of Tegress bulking agent: Case report and review of the literature

Abstract

We report a case of a 68-year-old man who presented with a urethrocutaneous fistula after off-label use of Tegress (C. R. Bard, Inc., Murray Hill, NJ) Urethral Implant for post-prostatectomy incontinence. He was treated for prostate cancer with an open radical retropubic prostatectomy and adjuvant external beam radiation therapy. He was treated unsuccessfully for stress incontinence with a Tegress Urethral Implant and presented to our clinic initially with extrusion of the material urethrally. Four years later he re-presented with a large bullous skin lesion on his suprapubic area. Contrast-enhanced magnetic resonance imaging and retrograde urethral cystogram demonstrated a urethrocutaneous fistula. Subsequent cystoscopy revealed the calcified extruded material in the same location as the site of Tegress injection. The patient underwent simple cystectomy with ileal diversion. He recovered well postoperatively. This appears to be the first reported case of urethrocutaneous fistula after use of a Tegress Urethral Implant for post-prostatectomy stress urinary incontinence. Case reportA 68-year-old man initially presented with a 4-year history of persistent stress urinary incontinence (SUI) requiring diapers, severe perineal pain, and recurrent occasional urinary retention requiring catheterization. He had a history of prostate cancer treated in 2003 with open radical retropubic prostatectomy (RRP) and adjuvant external beam radiation therapy.He had no open surgical procedures for incontinence, but had 2 Tegress (C. R. Bard, Inc., Murray Hill, NJ) Urethral Implant injections in 2006 to treat his incontinence, which had no effect. After the injections he developed painful urination, increased frequency and urgency, blood in his urine, perineal pain and penile discharge described as "a solid substance, gravel-like." He then presented at our institution in 2007 where, on physical examination, he had significant urinary leakage from the urethral meatus and tenderness to deep palpation of the perineal area. The scrotum, testes, and epididymis were normal. Urinalysis showed +2 leukocytes, positive nitrites, trace protein, and 50 heme. Urine cytology was negative for neoplasm. Cystoscopy was performed and showed material at both the 12 (anterior) and 6 o'clock (posterior) position, with only the 6 o'clock position showing material extrusion. The patient was then followed for several years by our clinic with 9 separate cystourethroscopies to debride the extruding Tegress material from the 6 o'clock position since the anterior position was epithelialized. These were performed utilizing a resectoscope with a cold loop. He was also found to have an acquired bladder neck contracture, which was dilated during these procedures. He was started on a trial of solifenacin 10 mg to manage his urinary incontinence. The severe, chronic perineal pain was managed initially with ibuprofen 800 mg twice a day and then duloxetine 60 mg once a day when he complained of being unable to "sit for more than an hour" without significant pai...