Diagnosis and management of colovesical fistulae; six-year experience of 90 consecutive cases

Laparoscopic management of colovesical fistula in different clinical scenarios

INTRODUCTION

Colovesical fistula (CVF) is a condition with various aetiologies and presentations. Surgical treatment is necessary in most cases. Due to its complexity, open approach is preferred. However, laparoscopic approach is reported in the management of CVF due to diverticular disease. The aim of this study was to analyse the management and outcome of patients with CVF of different aetiologies treated with laparoscopic approach.

PATIENTS AND METHODS

This was a retrospective study. We retrospectively reviewed all patients undergoing elective laparoscopic management of CVF from March 2015 to December 2019.

STATISTICAL ANALYSIS USED

None.

RESULTS

Nine patients underwent laparoscopic management of CVF. There were no intraoperative complications or conversions to open surgery. A sigmoidectomy was performed in eight cases. In one patient, a fistulectomy with sigmoid and bladder defect closure was performed. In two cases of locally advanced colorectal cancer with bladder invasion, a multi-stage procedure with temporary colostomy was chosen. In three cases, with no intraoperative leakage, we did not perform bladder suture. Four Clavien I-II complications were recorded. Two fragile patients died in the post-operative period. No patients required re-operation. At a median follow-up of 21 months (interquartile range: 6-47), none of the patients had recurrence of fistula.

CONCLUSIONS

CVF can be managed with laparoscopic approach by skilled laparoscopic surgeons in different clinical scenarios. Bladder suture is not necessary if leakage is absent. Informed counselling to the patient must be guaranteed concerning the risk of major complications and mortality in case of CVF due to malignant disease.

Shifting paradigms: a pivotal study on laparoscopic resection for colovesical fistulas in diverticular disease

Background

Colovesical fistulas (CVFs) pose a challenge in diverticulitis, affecting 4% to 20% of sigmoid colon cases. Complicated diverticular disease contributes significantly, accounting for 60%-70% of all CVFs. Existing studies on laparoscopic CVF management lack clarity on its effectiveness in diverticular cases compared to open surgery. This study redefines paradigms by assessing the potentiality, adequacy, and utility of laparoscopy in treating CVFs due to complicated diverticular disease, marking a paradigm shift in surgical approaches.

Methods

Conducting a retrospective analysis at Ospedale Monaldi A.O.R.N dei Colli and University Federico II, Naples, Italy, patients undergoing surgery for CVF secondary to diverticular disease between 2010 and 2020 were examined. Comprehensive data, including demographics, clinical parameters, preoperative diagnoses, operative and postoperative details, and histopathological examination, were meticulously recorded. Patients were classified into open surgery (Group A) and laparoscopy (Group B). Statistical analysis used IBM SPSS Statistic 19.0.

Results

From January 2010 to December 2020, 76 patients underwent surgery for colovesical fistula secondary to diverticular disease. Laparoscopic surgery (Group B, n = 40) and open surgery (Group A, n = 36) showed no statistically significant differences in operative time, bladder suture, or associated procedures. Laparoscopy demonstrated advantages, including lower intraoperative blood loss, reduced postoperative primary ileus, and a significantly shorter length of stay. Postoperative morbidity differed significantly between groups. Mortality occurred in Group A but was unrelated to surgical complications. No reoperations were observed. Two-year follow-up revealed no fistula recurrence.

Conclusion

This pivotal study marks a paradigm shift by emphasizing laparoscopic resection and primary anastomosis as a safe and feasible option for managing CVF secondary to diverticular disease. Comparable conversion, morbidity, and mortality rates to the open approach underscore the transformative potential of these findings. The study's emphasis on patient selection and surgeon experience challenges existing paradigms, offering a progressive shift toward minimally invasive solutions.

An unusual cause of small bowel obstruction: Migration of Foley catheter through enterovesicular fistula into the small bowel

Migration of a Foley catheter through an enterovesicular fistula is an extremely rare cause of small bowel obstruction. We present such a case in a 59-year-old female who presented to the emergency department with abdominal pain.

Endoscopic Treatment Using the Padlock Clip System for Rectourethral Fistula After Prostatectomy

We present a case of a 68-year-old man with a rectourethral fistula (RUF) successfully treated with a unique endoscopic approach using the Padlock Clip system (Steris, Basingstoke, UK). This is a complex case of a patient who, after radical prostatectomy, continued to show several complications, including fistulas and relapses. Our work aims to enhance the literature with our technique and to help the scientific community in future RUF cases. Our case stands out because this therapeutic approach has not yet been described in the literature as a possible endoscopic treatment of RUF. Therefore, our topic description is essential to assist future similar cases.

Short Term Outcomes of Open and Minimally Invasive Approaches to Segmental Colectomy for Benign Colovesical Fistula

Background. We speculated that a minimally invasive (MIS) colectomy for colovesical fistula is associated with less morbidity compared to an open colectomy. Methods. Multivariate analysis using logistic regression was used to investigate the outcomes of patients who underwent colectomy for benign colovesical fistula during 2012–2017 by surgical approach using the NSQIP database. Results. We identified 748 patients underwent partial colectomy for benign colovesical fistula during 2012–2017. Surgeons used the MIS approach in 72.7% of operations, with a conversion rate of 13.1%. The MIS approach was associated with lower morbidity (27.4% vs. 43.1%, AOR: 0.46, $P=0.02$ ) compared to the open approach. The mean operation duration was longer in MIS operations compared to open (225 min vs. 201 min, $P<0.01$ ). The robotic approach to colectomy showed no significant difference in morbidity (28.4% vs. 27.2%, $P=0.77$ ) but a decrease in conversion rate (8.1% vs. 13.8%, $P<0.01$ ) and an increase in operation length (249 min vs. 222 min, mean difference: 27 min, $P<0.01$ ) compared to a laparoscopic approach. There was no significant difference in the anastomotic leak rate between MIS and open approaches (3.7% vs. 5.4%, $P=0.14$ ) and between laparoscopic and robotic approaches (2.8% vs. 3.8%, $P=0.99$ ). Conclusions. We found a 72.7% utilization rate of MIS approach to colectomy for benign colovesical fistula in the NSQIP hospitals with a 13.6% conversion rate. Patients with MIS approach had significantly lower morbidity compared to open. A robotic approach to partial colectomy has the same morbidity risk with a decreased conversion rate compared to laparoscopic approach.

Burden of Colovesical Fistula and Changing Treatment Pathways: A Systematic Literature Review

PURPOSE

Colovesical fistula (CVF) is a rare complication of sigmoid diverticulitis causing significant morbidity and quality of life impairment. Aim of this study was to analyze contemporary literature data to appraise the current standard of care and changes of treatment algorithms over time.

MATERIALS AND METHODS

A systematic review of the literature on surgical management of CVF was conducted through PUBMED, EMBASE, and COCHRANE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement guidelines.

RESULTS

Fourteen papers published between 2014 and 2020 and including 1061 patients were analyzed. One-stage colonic resection with primary anastomosis, with or without loop ileostomy, was the most common surgical procedure. A laparoscopic or robotic approach was attempted in 39.5% of patients, and conversion rate to open surgery was 7.8%. Clavien-Dindo grade ≥3 complication rate, 30-day mortality, and recurrence rate were 7.4%, 1.5%, and 0.5%, respectively.

CONCLUSIONS

Minimally invasive sigmoidectomy with primary anastomosis is safe and should be the first-choice approach for CVF. Bladder repair is not necessary after a negative intraoperative leak test. A standardized perioperative care can improve clinical outcomes and reduce the length of hospital stay and the duration of Foley catheterization.

Appendico-vesicocolonic fistula: A case report and review of literature

BACKGROUND

Appendico-vesicocolonic fistulas and appendiceal-colonic fistulas are two kinds of intestinal and bladder diseases that are rarely seen in the clinic. To our knowledge, no more than 4 cases of appendico-vesicocolonic fistulas have been publicly reported throughout the world, and no more than 100 cases of appendiceal-colonic fistulas have been reported. Although the overall incidence is low, an early diagnosis is difficult due to their atypical initial symptoms, but these diseases still require our attention.

CASE SUMMARY

Here, we report a case of a 77-year-old male patient diagnosed with an appendico-vesicocolonic fistula combined with an appendiceal-colonic fistula. The main manifestations were diarrhea and urine that contained fecal material. The diagnosis was confirmed by multiple laboratory and imaging examinations. A routine urinalysis showed red blood cells and white blood cells. Abdominal and pelvic computed tomography scans showed close adhesions between the bowels and the bladder, and fistulas could be seen. Colonoscopy and cystoscopy and some other imaging examinations clearly showed fistulas. The preoperative diagnoses were a colovesical fistula and an appendiceal-colonic fistula. The fistulas were repaired by laparoscopic surgical treatment. The diseased bowel and part of the bladder wall were removed, followed by a protective ileostomy. The postoperative diagnosis was an appendico-vesicocolonic fistula combined with an appendiceal-colonic fistula, and the pathology suggested inflammatory changes. The patient recovered well after surgery, and all his symptoms resolved.

CONCLUSION

The final diagnosis in this case was a double fistula consisting of an appendico-vesicocolonic fistula combined with an appendiceal-colonic fistula.

Colovesical Fistulae: The Varying Aetiologies

The most common presenting symptoms of colovesical fistulae (CVF) are pneumaturia and fecaluria. The most important aspect remains not only to investigate the aetiology, and the degree of both severity and complexity, but also the subsequent influence of this on overall management. In a younger population, management usually consists of curative surgery. However, this may not be possible in older patients where surgical candidacy is a genuine concern and a clinical challenge arises relating to pursuing a conservative strategy. We attempted to briefly outline how two patients were managed with a similar non-surgical approach due to frailty. These cases attempt to highlight the importance of multi-disciplinary specialty input, with a view to optimising patient care.

Regenerative medicine for digestive fistulae therapy: Benefits, challenges and promises of stem/stromal cells and emergent perspectives via their extracellular vesicles

Despite current management strategies, digestive fistulae remain extremely debilitating complications associated with significant morbidity and mortality, generating a need to develop innovative therapies in these indications. A number of clinical trials and experimental studies have thus investigated the potential of stem/stromal cells (SCs) or SC-derived extracellular vesicles (EVs) administration for post-surgical and Crohn's-associated fistulae. This review summarizes the physiopathology and current standards-of-care for digestive fistulae, along with relevant evidence from animal and clinical studies regarding SC or EV treatment for post-surgical digestive fistulae. Additionally, existing preclinical models of fistulizing Crohn's disease and results of SC therapy trials in this indication will be presented. The optimal formulation and administration protocol of SC therapy products for gastrointestinal fistula treatment and the challenges for a widespread use of darvadstrocel (Alofisel) in clinical practice will be discussed. Finally, the potential advantages of EV therapy and the obstacles towards their clinical translation will be introduced.

Management of colovesical fistula: a systematic review

INTRODUCTION

Colovesical fistulas (CVFs) account for approximately 95% enterovesical fistulas (EVFs). About 2/3 CVF cases are diverticular in origin. It mainly presents with urological signs such as pneumaturia and fecaluria. Diagnostic investigations aim at confirming the presence of a fistula. Although conservative management can be chosen for selected individuals, most patients are mainly treated through surgical interventions. CVF represents a challenging condition, which records high rates of morbidity and mortality. Our systematic review aimed at achieving deeper knowledge of both indications, in addition to short- and long-term outcomes related to CVF management.

EVIDENCE ACQUISITION

We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. Pubmed/MEDLINE, Embase, Scopus, Cochrane Library and Web of Science databases were used to search all related literature.

EVIDENCE SYNTHESIS

The 22 included articles covered an approximately 37 years-study period (1982-2019), with a total 1,365 patient population. CVF etiology was colonic diverticulitis in most cases (87.9%). Pneumaturia (50.1%), fecaluria (40.9%) and urinary tract infections (46.6%) were the most common symptoms. Abdomen computed tomography (CT) scan (80.5%), colonoscopy (74.5%) and cystoscopy (55.9%) were the most frequently performed diagnostic methods. Most CVF patients underwent surgery (97.1%) with open approach (63.3%). Almost all patients had colorectal resection with primary anastomosis with or without ostomy and 53.2% patients underwent primary repair or partial/total cystectomy. 4% anastomotic leak, 1.8% bladder leak and 3.1% reoperations rates were identified. In an average 5-68 month follow-up, overall morbidity, overall mortality and recurrences rates recorded were 8%-49%, 0%-63% and 1.2%, respectively.

CONCLUSIONS

CVF mainly affects males and has diverticular origin in almost all cases. Pneumaturia, fecaluria and urinary tract infections are the most characteristic symptoms. Endoscopic tests and imaging are critical tools for diagnostic completion. Management of CVFs depends on the underlying disease. Surgical treatment represents the final approach and consists of resection and re-anastomosis of offending intestinal segment, with or without bladder closure. In many cases, a single-stage surgical strategy is selected. Perioperative and long-term outcomes prove good.

A case report: Use of FT-IR analysis to improve Colovesical fistula diagnosis

Colovesical fistula (CVF) is an abnormal connection between the colon and the urinary bladder. Faecaluria, reported in 40–70% of cases, is virtually pathognomonic for CVF. During the 5th day of recovery in an 84 years old subject, the passage of cloudy, malodorous urine with visible debris was observed. According to the pathognomonic character of faecaluria, the sample was signed to the laboratory for biochemical and microbiological investigation, able to define the type and origin of materials. Following clinical requirements, both biochemical pathways and instrumental procedures able to confirm or exclude the presence of faecal components in urine were considered. No biochemical compound or component addressing faecal compounds in urine results available between laboratory tests. The brown powder component of the pellet was identified as Keratin, with 90% overlapping with the reference spectrum of the compound. FT-IR analysis on urine pellet can be proposed as a simple, non-invasive, and fast method to improve the diagnostic course of CVF.

A Curious Case of Rectal Ejaculation

Rectal-prostate fistulas are uncommon anatomical connections between the prostatic urethra and rectum that are typically iatrogenic but can also result from other underlying pathology. Here, we present a unique case of a rectal-prostate fistula causing the rectal passage of sperm.

A 33-year-old male with a history of illicit drug use presented with five days of testicular pain and a substantial amount of sperm passage from his rectum with ejaculation for the past two years. Computed tomography and voiding cystourethrogram (VCUG) of the pelvis revealed evidence of a rectal-prostate fistula. He was treated with piperacillin-tazobactam, and a surgical fistula repair was performed. Further investigation divulged a three-week comatose state due to cocaine and phencyclidine intoxication two years prior with documentation suggesting a traumatic Foley catheter placement and strong suspicion for premature balloon dilation in the prostatic urethra. Repeat VCUG revealed resolution of the fistula with mildly reduced antegrade ejaculatory volume.

Cases secondary to Foley catheter placement have not been previously reported in the literature. Even though urethral catheters have been shown to be effective tools in healthcare, it is crucial for clinicians to recognize the numerous potential complications that oftentimes become an afterthought to many providers. This case not only highlights a rare complication of catheter use but also emphasizes the importance of provider mindfulness when utilizing seemingly benign therapies such as Foley catheters.

Indications and outcomes of enterovesical and colovesical fistulas: systematic review of the literature and meta-analysis of prevalence

BACKGROUND

Entero-colovesical fistula is a rare complication of various benign and malignant diseases. The diagnosis is prominently based on clinical symptoms; imaging studies are necessary not only to confirm the presence of the fistula, but more importantly to demonstrate the extent and the nature of the fistula. There is still a lack of consensus regarding the if, when and how to repair the fistula. The aim of the study is to review the different surgical treatment options, focus on surgical indications, and explore cumulative recurrence, morbidity, and mortality rates of entero-vesical and colo-vesical fistula patients.

METHODS

A systematic review of the literature was conducted according to PRISMA guidelines. Random effects meta-analyses of proportions were developed to assess primary and secondary endpoints. I2 statistic and Cochran's Q test were computed to assess inter-studies' heterogeneity.

RESULTS

Twenty-two studies were included in the analysis with a total of 861 patients. Meta-analyses of proportions pointed out 5, 22.2, and 4.9% rates for recurrence, complications, and mortality respectively. A single-stage procedure was performed in 75.5% of the cases, whereas a multi-stage operation in 15.5% of patients. Palliative surgery was performed in 6.2% of the cases. In 2.3% of the cases, the surgical procedure was not specified. Simple and advanced repair of the bladder was performed in 84.3% and 15.6% of the cases respectively.

CONCLUSIONS

Although burdened by a non-negligible rate of complications, surgical repair of entero-colovesical fistula leads to excellent results in terms of primary healing. Our review offers opportunities for significant further research in this field. Level of Evidence Level III according to ELIS (SR/MA with up to two negative criteria).

Ultrasound in the Diagnosis of Malignant Pelvic Fistulas: Sonographic Findings in Correlation with Computed Tomography Imaging

Even though ultrasound is an extensively used imaging modality, it has not been effectively utilized in the evaluation and diagnosis of malignant pelvic fistulas. In this study, we tried to correlate the accuracy of sonographic findings in identifying malignant fistulas with that of computed tomography (CT) imaging. Thirty-five patients with advanced pelvic malignancies were examined over a period of 2 y. Patients underwent CT of the abdomen and pelvis with intravenous and oral/rectal contrast followed by ultrasound of the abdomen. Sonographic examinations were performed using a standardized protocol with a full bladder. Real-time ultrasound images of the abdomen and pelvis in multiple planes were acquired and stored as both image files and audio-video interleaves (AVIs). On ultrasound, the majority of the fistulas were visualized either as a continuous hyper-echoic tract within a hypo-echoic neoplastic mass ("air contrast sign") or as multiple discontinuous hyper-echoic foci with "ring down" artifacts. The sensitivity and specificity of ultrasound in the detection of malignant fistulas were 72% (confidence interval [CI]: 52%-87%) and 66% (CI: 22%-95%), respectively. We also reviewed the literature and compared the sensitivities of ultrasound in the detection of various types of pelvic fistulas obtained in previous studies with those in the present study. Results suggest that although ultrasound cannot be used as a primary imaging modality for the detection of fistulas, it can provide the earliest clue to the presence of a malignant fistula.

The colovescical fistula in diverticular disease: Laparoscopic approach in two different cases

•

The colovescical fistula is one of the complications of diverticular disease.

•

It can cause typical symptoms like pneumaturia and fecaluria affecting the quality of life and sometimes leading to death, usually secondary to sepsis.

•

We studied two patients with clinical, radiological and endoscopic diagnosis of colovescical fistula as a consequence of diverticular disease.

•

We performed a totally laparoscopic treatment with colonic resection and closure of the fistula with intracorporeal sutures.

•

The presence of a colovescical fistula significantly increases the difficult of the laparoscopic colonic resection.

Introduction

The colovescical fistula is one of the complications of diverticular disease. It can cause significant symptoms like pneumaturia and fecaluria affecting the quality of life and sometimes leading to death, usually secondary to sepsis. We describe two cases of colovescical fistula treated by laparoscopic approach in patients with diagnosis of complicated acute diverticulitis.

Case report

We studied two patients with clinical, radiological and endoscopic diagnosis of colovescical fistula as a consequence of diverticular disease. We performed a totally laparoscopic treatment with colonic resection and colo-proctoanastomosis after the closure of the fistula with intracorporeal sutures.

Discussion

Colovescical fistula should be suspected in patients who present fever with persistent dysuria, pneumaturia or fecaluria. The diagnosis is confirmed by a CT abdominal scan, a colonoscopy in order to rule out a colon cancer and a cystoscopy to assess the grade of bladder involvement.

Conclusion

Although colovescical fistulas caused by diverticular disease were once considered a contraindication to laparoscopic resection, nowadays they are increasingly treated by experienced surgeons using laparoscopic techniques. Compared with laparoscopic surgery for uncomplicated diverticulitis the mini-invasive treatment of colovescical fistulas requires a longer operative time and advanced surgical skills.

A Very Rare Case of Colosalpingeal Fistula Secondary to Diverticulitis: An Overview of Development, Clinical Features and Management

BACKGROUND

Colosalpingeal fistula is a rare complication secondary to diverticular disease. The pathogenesis is still not clearly understood. We present the case of a colosalpingeal fistula and a review of the management of this pathology.

CASE REPORT

A 69-year-old patient with uncomplicated diverticular disease was referred to our department for recurrent vaginal discharge. The clinical examination was unremarkable, hysteroscopy revealed the presence of air in the uterine cavity in the absence of a uterine fistula. A preliminary diagnosis of colosalpingeal fistula was made and was confirmed by computed tomography (CT) scan and hysterosalpingography. A one-stage surgery via laparotomy was successfully performed with remission of the symptoms.

CONCLUSION

Colotubal fistula is a rare complication resulting from intestinal diverticular disease. The purpose of this paper was to emphasize the presence of a rare, but serious complication occurring in diverticular disease with atypical symptoms and one-stage surgery treatment.

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

AIM

The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons.

METHODS

The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements.

RESULTS

This guideline contains 38 evidence based consensus statements on the management of diverticular disease.

CONCLUSION

This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement

Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice. They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes. As the incidence of complicated diverticular disease and colorectal malignancy increases, so too does the extent of fistulous connections between the gastrointestinal and urinary systems. These complex problems will be more common as a factor of an aging population with increased life expectancy. Diverticular disease is the most commonly encountered aetiology, accounting for up to 80% of cases, followed by colorectal malignancy in up to 20%. A high index of suspicion is required in order to make the diagnosis, with ever improving imaging techniques playing an important role in the diagnostic algorithm. Management strategies vary, with most surgeons now advocating for a single-stage approach to enterovesical fistulae, particularly in the elective setting. Concomitant bladder management techniques are also disputed. Traditionally, open techniques were the standard; however, increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management. Unfortunately, due to the relative rarity of these entities, no randomised studies have been performed to ascertain the most appropriate management strategy. Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer. With radiotherapy being a major contributing factor in the development of these complex fistulae, optimum surgical approach and exposure has changed accordingly to optimise their management. Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling, macerated tissues or associated co-morbidities. One may plan for definitive surgical intervention at a later stage. Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available. An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described. In low lying fistulae, a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts. According to recent literature, it offers a high success rate in complex cases.

Acute diverticulitis: Key features for guiding clinical management

Diverticular disease of the colon and small bowel is an important cause of pathology leading to emergency department visits and urgent gastrointestinal surgery. CT is a highly sensitive and specific modality for the diagnosis of acute diverticulitis and its complications as well as for the exclusion of alternate causes of pathology. Ultrasound, MRI and virtual CT colonoscopy have important adjunct roles for screening and workup of complications in specific patient populations. While diverticular disease most commonly involves the descending and sigmoid colon, it can also affect the proximal colon and small bowel. Acute diverticulitis may be categorized as uncomplicated or complicated according to the degree of inflammatory changes and related complications it induces, although some degree of overlap exists in clinical practice. Uncomplicated diverticulitis is classically characterized by localized inflammation surrounding a diverticulum ranging from wall thickening and phlegmonous change to the development of small, localized pericolic abscesses. Complicated forms of disease manifest with larger pericolic and distant abscesses, fistulae to adjacent organs, perforation, and peritonitis. Recurrent episodes of diverticulitis may lead to muscular hypertrophy of the bowel wall and luminal narrowing, potentially leading to bowel obstruction. Several imaging features may help to differentiate diverticulitis from colonic malignancy, however this remains a diagnostic imaging challenge that often requires further evaluation with colonoscopy. In this review, we discuss the pathophysiology and key imaging features of acute diverticulitis and its complications. We explore both common and uncommon presentations of the disease involving the colon and small bowel, acute and chronic manifestations of disease, and pitfalls to recognize when imaging alone may be insufficient to distinguish benign from malignant.

Laparoscopic surgery for diverticular colovesical fistula: single-center experience of 11 cases

Objective

Laparoscopic surgery for diverticular colovesical fistula (CVF) is technically challenging, and the incidence of conversion to open surgery (COS) is high. This study aimed to review our experience with laparoscopic surgery for diverticular CVF and identify preoperative risk factors for COS.

Results

This was a single institution, retrospective, observational study of 11 patients (10 males and 1 female) who underwent laparoscopic sigmoid colon resection with fistula resection for diverticular CVF from 2014 to 2019. Preoperative magnetic resonance imaging (MRI) was performed to evaluate the fistula location in the bladder, patency of the rectovesical pouch (i.e., the destination of dissection procedure between sigmoid colon and bladder) and estimate the contact area between the sigmoid colon and bladder. The relationship between preoperative variables and COS incidence was analyzed between completed laparoscopy and COS groups. The overall incidence of postoperative morbidity (Clavien–Dindo classification Grade II or higher) was 36% (4/11). Severe morbidity, reoperation, and mortality were not observed. The incidence of COS was 27% (3/11). Posterior bladder fistulas were significantly associated with COS. CVFs located on the posterior bladder appears to be a risk factor for COS. Identifying risk factors for COS preoperatively could help guide the intraoperative course.

Low diagnostic sensitivity of cystoscopy and cystography of surgically confirmed vesicoenteric fistulae

PURPOSE

The objective of this study was to assess the accuracy of cystoscopy and cystography, as compared to other diagnostic studies, in identifying vesicoenteric fistulae (VEF) in a contemporary series of patients with surgically confirmed VEF.

METHODS

With institutional review board approval, we performed a single-center retrospective review of surgically confirmed VEF between 2002 and 2018. Demographic data, comorbidities, symptoms, and diagnostic evaluation were reviewed. The sensitivity, specificity, and accuracy of cystoscopy in diagnosis of VEF were compared to cross-sectional imaging.

RESULTS

The study cohort consisted of 51 patients with surgically confirmed VEF secondary to diverticular disease. Diagnostic evaluation included cross-sectional imaging with CT (94%), colonoscopy (82%), cystoscopy (75%), cystography (53%), and barium enema (26%). Cystoscopic evaluation definitively demonstrated evidence of VEF in 34% of patients, while 55% of patients had nonspecific urothelial changes on cystoscopy without definitively demonstrating VEF. Comparatively, the sensitivity of VEF was 25% for cystography and 84% for CT.

CONCLUSIONS

In clinical practice, the diagnostic work-up of VEF is variable. In the modern era of managed care, inclusion of cystoscopy and cystography in the evaluation of VEF does not contribute a substantial additive benefit over standard cross-sectional imaging. Cystoscopy and cystography could potentially be eliminated from the diagnostic evaluation of VEF, in the absence of a concern for malignancy, in an effort to minimize unnecessary invasive testing as well as health care expenditures.

Colovesical Fistula: Applicability of the Laparoscopic Approach and Results According to Etiology

INTRODUCTION

Colovesical fistulae have significant morbidity. The aim of our study was to describe a case series of benign and malignant colovesical fistulae, focusing on the viability of the laparoscopic approach.

METHODS

We reviewed the characteristics of 34 patients with diverticular and colon adenocarcinoma-related colovesical fistulae treated surgically from January 2001 to March 2018, 28 with elective surgery and 6 by urgent surgery. The diagnosis was established by abdominal CT scan, colonoscopy and cystoscopy. Clinically stable patients, with no retroperitoneal or bladder trigone invasion, were approached laparoscopically.

RESULTS

There were 13 benign cases (all of them approached by sigmoidectomy), 9 performed by laparoscopy with 3 conversions. Partial cystectomy was done in 11 cases, and in two cases conservative management with urinary catheter. Five laparoscopic approaches were performed in 21 patients diagnosed with malignant colovesical fistula, with 3 conversions and 16 laparotomies. The procedures were sigmoidectomy, left colectomy, anterior resection and pelvic exenteration. All of them required partial or total cystectomy. Sixteen patients had complications, most of which were minor (Clavien-Dindo classificationI-II) and with laparotomy approach.

CONCLUSIONS

The laparoscopic approach can be feasible in well-selected and stable patients, but we have to take into consideration that the conversion rate can be high and this surgery should be performed by experienced surgeons.

Perioperative Management of Patients with Colovesical Fistula

BACKGROUND

Colovesical fistula (CVF) is an uncommon complication of diverticulitis. Substantial heterogeneity exists in the perioperative management of this condition. We seek to evaluate the role of bladder leak testing, closed suction drainage, prolonged bladder catheter usage, and routine postoperative cystogram in the management of CVF.

STUDY DESIGN

This is a retrospective study from a single academic health center investigation patients undergoing operation for diverticular CVF from 2005 to 2015 (n = 89).

RESULTS

Patients undergoing operative repair for diverticular CVF resection had a mortality of 4% and overall morbidity of 46%. Intraoperative bladder leak test was performed in 36 patients (40%) and demonstrated a leak in 4 patients (11%). No patients with a negative intraoperative bladder leak test developed a urinary leak. Overall, five (6%) patients developed postoperative bladder leak. Three were identified by elevated drain creatinine and two by cystogram. The diagnostic yield of routine cystogram was 3%. All bladder leaks were diagnosed between postoperative day 3 and 7. Of patients with a postoperative bladder leak, none required reoperation and all resolved within 2 months.

CONCLUSIONS

There is significant variability in the management of patients undergoing operation for CVF. Routine intraoperative bladder leak test should be performed. Cystogram may add cost and is low yield for routine evaluation for bladder leak after operation for CVF. Urinary catheter removal before postoperative day 7 should be considered.

Is suturing of the bladder defect in benign Enterovesical fistula necessary?

BACKGROUND

Enterovesical fistula (EVF) is a abnormal connection between the intestine and the bladder. The aim of the study was to analyze whether closure of the defect in the bladder wall during surgery is always necessary.

METHODS

Fifty-nine patients with benign EVF undergoing surgical treatment were enrolled. A one-stage surgical procedure was performed in all patients. After the separation of the diseased bowel segment, methylene blue was introduced. Through a catheter into the bladder. Only patients with urinary bladder leakage were sutured.

RESULTS

The most common intestinal fistula involving the urinary bladder was colovesical fistula, observed in 53% of cases. Two-thirds of patients had diverticular disease as the underlying pathology. There was no relationship between suturing of the bladder and perioperative complications. Recurrent EVF was observed in one patient with bladder suturing and in two patients without suture.

CONCLUSIONS

These findings suggest that closure of the bladder defect is not necessary in cases where a leak is not demonstrated from the bladder intraoperatively. This study is limited by its retrospective design and small numbers and a randomized controlled trial is recommended to answer this question definitively.

An Unexpected Passage: A Complex Enterovesicular Fistula

Enterovesicular fistulas (EVFs) are abnormal connections between the colon and the urinary bladder. They are estimated to account for one in every 3,000 surgical hospital admissions and are rarely associated with long-standing Crohn's colitis. We present an interesting case of a 93-year-old man with a long-standing history of Crohn's colitis on mesalamine, whose mechanical fall at home lead to the discovery of a colovesicular fistula with invading urothelium concerning for squamous cell carcinoma.

Over 1-Year Followup of Laparoscopic Treatment of Enterovesical Fistula

Background and Objective:

Entero vesical fistulas (EVFs) are an uncommon complication mainly of diverticular disease (70%) and less commonly of Crohn's disease (10%). Only about 10% are caused by malignancies. At this time, it is unclear whether the laparoscopic approach can be routinely proposed as a safe procedure for patients with EVF. The aim of this study was to assess the feasibility and safety of laparoscopic surgery in the treatment of EVFs in patients with complicated diverticular and Crohn's disease.

Methods:

All patients with the diagnosis of EVF who underwent laparoscopic surgery were identified from prospective collected data based in two institutions between 2007 and 2017. Patients with malignancy were excluded. Recorded parameters included operative time, conversion to open surgery, the presence of a protective loop ileostomy, perioperative complications, number of units of blood transfused, postoperative course, and histologic findings.

Results:

Seventeen patients were included in the study: 10 patients with a colo-vesical fistula due to diverticular disease, and 7 patients with an ileo-vesical fistula due to Crohn's disease. There were no conversions to open surgery and none of the patients needed a protective ileostomy. The bladder was sutured in 12 patients (70%). No intra-operative complications were met, and no blood transfusions were needed; there were no anastomotic leaks, nor mortality in both groups.

Conclusions:

The laparoscopic approach for benign EVF in selected patients is both feasible and safe in the hands of experienced surgeons with extensive expertise in laparoscopic surgery.

Sonographic Diagnosis of a Colovesical Fistula Due to Sigmoid Colon Cancer

Based on sonographic findings, colovesical fistula was diagnosed in a 71-year-old man with sigmoid colon cancer. Gray-scale sonography revealed an irregular thickening of the sigmoid colon wall abutting the urinary bladder which also showed thickening in the region of contact. Color Doppler sonography showed a twinkling artifact within the thickened bladder wall. Contrast-enhanced computed tomography scan showed luminal communication between the sigmoid colon and the bladder in the region of thickening.

Diverticular colovesical fistula: What should we really be doing?

BACKGROUND

Colovesical fistula secondary to diverticular disease is increasing in incidence. Presentation and severity may differ, but a common management strategy may be applied. The aim of this study is to evaluate the characteristics and perioperative management of patients with colovesical fistulae and determine optimal management.

METHODS

From 2003 to 2012, all charts of surgical patients with diverticular colovesical fistulae at two different institutions were reviewed. Patient and presentation characteristics and perioperative management and outcomes were recorded. Patient groups with early and late catheter removal (< 8 and ≥ 8 days) were compared with significance level set at p < 0.05.

RESULTS

Seventy-eight patient charts were reviewed. The mean duration of symptoms was 7.5 months. Laparoscopic assisted surgery was carried out in 35% of patients. Complex bladder repair was performed in 27%. Mean length of stay was 8 days. Mean urinary catheter duration was 13 days. Seventy percent of patients underwent postoperative cystogram, with 4% positive for extravasation. Patients with early catheter removal were significantly older, more likely to have received intraoperative methylene blue instillation, and less likely to have had a complex bladder repair (p < 0.05). Complication rate, length of stay, postoperative cystography, and stent use were similar for both catheter removal groups.

CONCLUSIONS

Intraoperative methylene blue bladder instillation should be utilized to limit unnecessary bladder repairs. In the setting of negative methylene blue extravasation, surgeons may confidently remove urinary catheters in 7 days or less, in some cases as early as 48 h. In complex bladder repairs, cystogram is still an important adjunct, with those patients with negative studies benefiting from catheter removal at 7 days or less.

Laparoscopic approaches to complicated diverticulitis

BACKGROUND

The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis.

PURPOSE

The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis.

CONCLUSIONS

New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.

Colovesical Fistula: An Unusual Complication of Cytomegalovirus Colitis

Cytomegalovirus (CMV) is a double-stranded DNA virus that is associated with clinically significant disease in patients with advanced immunosuppression, particularly those with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). End-organ disease with CMV is classically associated with a CD4 cell count less than 50 cells/microliter. CMV colitis is the second most common manifestation of end-organ disease in this patient population. CMV-associated enteric fistula is a rare complication that has been described in only a few case reports in the literature. These cases describe gastrocolic, enterocutaneous, enterocolic, rectovaginal, and colocutaneous fistulae. However, colovesical fistula has not been described previously. Here, we report the first case of CMV-associated colovesical fistula in a patient with HIV infection and AIDS.

A colovesical fistula with a persistent descending mesocolon due to partial situs inversus: A case report

•

Colovesical fistula was occered in the extremely rare condition: partial situs inversus with persistent descending mesocolon (PDM).

•

Distinctive features of PDM were shortening adhesions noted at the dorsal aspect of the descending and sigmoid mesocolon without marginal vessel.

•

In this case, these congenital abnormalities might help the suture failure during the operation of sigmoid colectomy.

Introduction

Situs inversus viscerum, a congenital condition in which the visceral organs are a mirror image of their normal physiological positions, could be total or partial. Persistent descending mesocolon (PDM) is a congenital anomaly that is asymptomatic because of its short length. PDM causing intestinal obstruction is a known clinical complication.

Presentation of case

A 74-year-old woman presented with pneumaturia and enteruria for two months, and recurrent cystitis for a month. An enhanced computed tomography (CT) showed air in the bladder along with sigmoid colonic diverticula adherent to it, suspecting a fistula. The CT also showed partial situs inversus with the common hepatic artery, and left colic artery arising abnormally from the superior mesenteric artery (SMA). Minimally invasive endoscopic closure using the over-the-scope clipping system was difficult because of thickening and scar tissue due to chronic inflammation from diverticulitis. Thus, a sigmoidectomy was performed to close the fistula. Intraoperatively, we noted an abnormally fixed descending mesocolon. An emergency reoperation was performed on the sixth postoperative day owing to an anastomotic leak. Suture failure was attributed to these congenital abnormalities due to insufficient blood flow from an absent marginal vessel and a high endocolonic pressure by adhesions. Sigmoid colon re-resection and maturation of an ileostomy was performed. The patient had no specific postoperative complications, and the ileostomy was closed after three months.

Conclusion

We report an extremely rare case of colovesical fistula due to a PDM in a patient having partial situs inversus with abnormal branches originating from the SMA.

Laparoscopic surgery of benign entero-vesical or entero-vaginal fistulae

PURPOSE

Entero-vesical or entero-vaginal fistulae (EVF) are an uncommon septic complication mainly of diverticular disease. The fistulae are usually situated within extensive and dense inflammatory masses occluding the entrance of the pelvis. There are still some controversies regarding laparoscopic feasibility and treatment modalities of this disorder.

METHODS

A retrospective chart review of all patients with EVF operated at our department since 2008. Patients were identified by use of the computerized hospital information system.

RESULTS

In nineteen patients (ten males), median age 68 years, 13 patients had entero-vesical fistulae, and 6 patients had entero-vaginal fistulae. The fistulae were caused by complicated diverticular disease in 16 patients (84 %), Crohn's disease (two patients), and ulcerative colitis (one patient). All cases were attempted laparoscopically. Operative treatment involved separation of the inflammatory mass and resection of the affected colorectal segment. There were three conversions (16 %), all three requiring bladder repair considered too extensive for laparoscopic means. In two further patients small bladder defects were sutured laparoscopically, the remaining patients required no bladder repair. The inferior mesentric artery (IMA) was preserved in all cases. Median operative time was 180 min. Two patients received a protective ileostomy: one converted patient and one cachectic patient with Crohn's disease under immune-modulating therapy. Both ileostomies were closed. Altogether, there were five complications in five patients (26 %), four of them were minor (Clavien grade I and II). The cachectic patient with Crohn's disease suffered a major (grade IIIb) complication (stoma prolapse, treated by early closure of the ileostomy). There was no anastomotic leakage and no mortality. Median hospital stay was 12 days.

CONCLUSIONS

The laparoscopic approach is a safe option for the treatment of EVF of benign inflammatory origin. In most cases it offers all the advantages pertaining to minimally invasive surgery. For a definite and causal approach, the disorder belongs primarily within the therapeutic domain of the visceral surgeon. Following the separation of the inflammatory colon, most of the bladder lesions caused by EVF will heal without further surgical measures.

Management of diverticular disease

Diverticular disease is a common condition in Western countries and the incidence and prevalence of the disease is increasing. The pathogenetic factors involved include structural changes in the gut that increase with age, a diet low in fibre and rich in meat, changes in intestinal motility, the concept of enteric neuropathy and an underlying genetic background. Current treatment strategies are hampered by insufficient options to stratify patients according to individual risk. One of the main reasons is the lack of an all-encompassing classification system of diverticular disease. In response, the German Society for Gastroenterology and Digestive Diseases (DGVS) has proposed a classification system as part of its new guideline for the diagnosis and management of diverticular disease. The classification system includes five main types of disease: asymptomatic diverticulosis, acute uncomplicated and complicated diverticulitis, as well as chronic diverticular disease and diverticular bleeding. Here, we review prevention and treatment strategies stratified by these five main types of disease, from prevention of the first attack of diverticulitis to the management of chronic complications and diverticular bleeding.

Colovesical Fistula After Renal Transplantation: Case Report

Colovesical fistula is a relatively rare condition that is primarily related to diverticular disease. There are few reports of colovesical fistula after renal transplantation. We report of a 53-year-old man who was diagnosed with colovesical fistula after recurrent urinary tract infection, 5 months after undergoing cadaveric renal transplantation. Laparoscopic partial resection of the sigmoid colon with the use of the Hartmann procedure was performed. Six months after that surgery, there was no evidence of recurrent urinary tract infection and the patient's renal graft function was preserved. Physicians should keep colovesical fistula in mind as a cause of recurrent urinary tract infection in renal transplant recipients, especially in those with a history of diverticular disease.

Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral surgery

BACKGROUND

Diverticular disease is one of the most common disorders of the gastrointestinal tract. 28-45% of the population develop colonic diverticula, while about 25% suffer symptoms and about 5% complications.

AIM

To create formal guidelines for diagnosis and management.

METHODS

Six working groups with 44 participants analyzed key questions in subject areas assigned to them. Following a systematic literature search, 451 publications were included. Consensus was obtained by agreement within the working groups, two Delphi processes and a guideline conference.

RESULTS

Targeted management of diverticular disease requires a classificatory diagnosis. A new classification was created. In addition to the clinical examination, intestinal ultrasound or computed tomography is the determining factor. Interval colonoscopy is recommended to exclude comorbidities. A low-fiber diet, obesity, lack of exercise, smoking and immunosuppression have an adverse impact on diverticulosis. This can lead to diverticulitis. Antibiotics are no longer recommended in uncomplicated diverticulitis if no risk factors such as immunosuppression are present. If close monitoring is ensured, uncomplicated diverticulitis can be treated on an outpatient basis. Complicated diverticulitis should be treated in hospital, involving broad-spectrum antibiotic therapy, where necessary abscess drainage, and surgery, if possible laparoscopically. In the case of chronic relapsing diverticulitis, the risk of perforation decreases with each episode, so that surgery is no longer recommended after the second episode but only following individual assessment.

CONCLUSIONS

New findings on diverticular disease call into question the overuse of antibiotics and excessive indications for surgery. Targeted treatment requires a precise diagnosis and intensive interdisciplinary cooperation.

Accuracy of preoperative urinary symptoms, urinalysis, computed tomography and cystoscopic findings for the diagnosis of urinary bladder invasion in patients with colorectal cancer

BACKGROUND

To determine the accuracy of preoperative urinary symptoms, urinalysis, computed tomography (CT) and cystoscopic findings for the diagnosis of urinary bladder invasion in patients with colorectal cancer.

MATERIALS AND METHODS

Records of patients with colorectal cancer and a suspicion of bladder invasion, who underwent tumor resection with partial or total cystectomy between 2002 and 2013 at the Faculty of Medicine Siriraj Hospital, were reviewed. Correlations between preoperative urinary symptoms, urinalysis, cystoscopic finding, CT imaging and final pathological reports were analyzed.

RESULTS

This study included 90 eligible cases (71% male). The most common site of primary colorectal cancer was the sigmoid colon (44%), followed by the rectum (33%). Final pathological reports showed definite bladder invasion in 53 cases (59%). Significant features for predicting definite tumor invasion were gross hematuria (OR 13.6, sensitivity 39%, specificity 73%), and visible tumor during cystoscopy (OR 5.33, sensitivity 50%, specificity 84%). Predictive signs in CT imaging were gross tumor invasion (OR 7.07, sensitivity 89%, specificity 46%), abnormal enhancing mass at bladder wall (OR 4.09, sensitivity 68%, specificity 66%), irregular bladder mucosa (OR 3.53, sensitivity 70%, specificity 60% ), and loss of perivesical fat plane (OR 3.17, sensitivity 81%, specificity 43%). However, urinary analysis and other urinary tract symptoms were poor predictors of bladder involvement.

CONCLUSIONS

The present study demonstrated that the most relevant preoperative predictors of definite bladder invasion in patients with colorectal cancer are gross hematuria, a visible tumor during cystoscopy, and abnormal CT findings.

Colovesical fistula: should it be considered a single disease?

PURPOSE

This research was conducted to compare the management and the outcome of patients with colovesical fistulae of different aetiologies.

METHODS

Retrospective data were collected from 2002 to 2012 and analyzed with SPSS ver. 17. Age, gender, aetiology, management, hospital stay, postoperative complications, and mortality were studied and compared among colovesical fistulae of different aetiologies.

RESULTS

A total of 55 patients, 46 males (84%) and 9 females (16%), with a median age of 65 years (interquartile range [IQR], 48-75 years) were studied. Diverticular disease was the most common benign cause and recto-sigmoid cancer the most common malignancy. Anterior resection and bladder repair were the most frequent operations in benign cases, as was total pelvic exenteration in the malignant group. Multiple intestinal loop involvement and subsequent resection were significantly higher in those with Crohn disease than it was in patients of colovesical fistula due to all other causes collectively (60% vs. 6%, P = 0.006). Patients with malignancy had a higher postoperative complication rate than patients who did not (12 [80%] vs. 7 [32%], P = 0.0005). Pelvic collection (11, 22%) was the most frequent early complication (predominantly in the malignant group) whereas incisional hernia (8, 22%) was the most common late complication, with a predominance in the benign group. The median hospital stay was significantly prolonged in the malignant group (32 days; IQR, 17-70 days vs. 16 days; IQR, 11-25 days; P < 0.001).

CONCLUSION

Despite their having similar clinical presentation, colovesical fistulae of various aetiologies differ significantly in management and outcome.

Elective Surgery for Sigmoid Diverticulitis - Indications, Techniques, and Results

Diverticulitis is one of the leading indications for elective colonic resections although there is an ongoing controversial discussion about classification, stage-dependent therapeutic options, and therapy settings. As there is a rising trend towards conservative therapy for diverticular disease even in patients with a complicated form of diverticulitis, we provide a compact overview of current surgical therapy principles and the remaining questions to be answered.

Laparoscopic management of diverticular colovesical fistula: experience in 15 cases and review of the literature

Colovesical fistulas secondary to diverticular disease may be considered a contraindication to the laparoscopic approach. The feasibility of laparoscopic management of complicated diverticulitis and mixed diverticular fistulas has been demonstrated. However, few studies on the laparoscopic management of diverticular colovesical fistulas exist. A retrospective analysis was performed of 15 patients with diverticular colovesical fistula, who underwent laparoscopic-assisted anterior resection and bladder repair. Median operating time was 135 minutes and median blood loss, 75 mL. Five patients were converted to an open procedure (33.3%) with an associated increase in hospital stay (P = 0.035). Median time to return of bowel function was 2 days and median length of stay, 6 days. Overall morbidity was 20% with no major complications. There was no mortality. There was no recurrence during median follow-up of 12.4 months. These results suggest that laparoscopic management of diverticular colovesical fistulas is both feasible and safe in the setting of appropriate surgical expertise.