Enterovesical fistula caused by a bladder squamous cell carcinoma

Insights into renal and urological complications of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic condition characterized by immune-mediated inflammation in the gastrointestinal tract, which follows a relapsing and remitting course. Apart from affecting the gastrointestinal tract, IBD also has extra-intestinal manifestations (EIMs). While the etiology of extraintestinal manifestation remains unclear, it is theorized to be based on immunological responses influenced by genetic factors. Renal involvement is one of the EIMs observed in ulcerative colitis and Crohn's disease. The renal manifestations in IBD patients encompass a range of conditions including nephrolithiasis, amyloidosis, tubulointerstitial nephritis, glomerulonephritis (GN), obstructive pathologies, and chronic kidney disease (CKD). The incidence of CKD in IBD patients varies from 5%-15%. The decline in renal function can stem from various factors such as direct inflammatory damage to the kidneys leading to glomerular or tubular injury, or from complications like recurrent stones, amyloidosis, or GN. Additionally, nephrotoxic medications used in treating IBD, such as TNF-α inhibitors, calcineurin inhibitors, and aminosalicylates, can exacerbate the decline in renal function. Currently, there is a lack of consensus regarding these patients' screening and renal function monitoring. This review aims to assess the existing literature on the different renal complications among individuals with IBD, shedding light on their pathophysiology and management.

Minimally Invasive Management of Post-treatment Rectovesical Fistulae

Objective: The aim of this study is to report our experience in minimally invasive management of rectovesical fistulae (RVFs). Materials and Methods: Between 2004 and 2021, 24 patients who underwent minimally invasive RVF repair by a single surgeon at 3 international institutions were retrospectively reviewed. Baseline demographic characteristics and perioperative and postoperative variables were collected. Complications were reported using the modified Clavien-Dindo Classification System and the European Association of Urology Complication Guidelines Panel Assessment and Recommendations. Fistula repair was defined as confirmation of fistula closure by imaging and complete resolution of fistula-related symptoms at the 12-month follow-up. Continuous variables are reported as medians and quartiles, whereas categorical variables are reported as frequencies and percentages. Results: Twenty-four patients with RVFs were treated: 22 males (91.7%) and 2 females with a median age of 66 (64.2-68) years. Twenty cases (83.3%) occurred postsurgery, three cases (12.5%) after surgery with combined radiotherapy, and one case (4.1%) after a combination of energy treatments. A robotic approach was performed in 19 patients (79%) and laparoscopic approach in 5 patients (21%). Ninety-six percent of patients had previous fecal diversions. No intraoperative complications were recorded. The median operative time was 180 (140-282) minutes, estimated blood loss was 50 (40-125) mL, and length of hospital stay was 2 (2-3) days. There were two Grade II complications and one Grade IIIb complication. All patients met criteria for repair. Conclusions: Minimally invasive management of RVFs is feasible. More studies are needed to assess the role of this approach among all RVF management options.

Novel Endoscopic Management of Colovesical Fistula Secondary to Colonic Diverticular Disease

Colovesical fistula (CVF) is an abnormal communication between bowel and urinary bladder. Most common cause is complicated colonic diverticular disease. The treatment of choice for CVF is surgery. Conservative treatment is reserved for highly selected patients who are unfit for definitive surgery. We report the case of an 86-year-old gentleman with multiple comorbidities, who presented with pneumaturia, fecaluria, and recurrent urinary tract infection. He was diagnosed to have sigmoid colonic diverticulosis with a CVF and was successfully managed with the novel combined endoscopic approach (a simultaneous cystoscopy and flexible colonoscopy), which could be the first to be reported from India.

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

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

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

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

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

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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.

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.

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.

Enterovesical Fistula Secondary to Transitional Cell Carcinoma of the Bladder

Although fistulae between the urinary bladder and the gastrointestinal tract are not uncommon, those caused by carcinoma of the urinary bladder are rare. This report describes the case of an 85 years old male who was diagnosed with a mass involving the small bowel and the urinary bladder during the course of investigation for recurrent urinary tract infections. At laparotomy, the presence of an enterovesical fistula involving the ileum and bladder was confirmed. Histopathological examination of the resected mass showed poorly differentiated urothelial carcinoma. No early postoperative complications were encountered and postoperative cystography showed healing of the bladder without evidence of leakage. Due to the patient's age and comorbidities, no further oncological treatment was offered. Three months later the patient was readmitted to hospital with a severe pneumonia to which he succumbed.

Rectourethral Fistula Secondary to Transurethral Resection of the Prostate

An 82-year-old male with benign prostatic hyperplasia (BPH) who underwent transurethral resection of the prostate (TURP) presented to the hospital with suprapubic pain, abdominal distension, and diarrhea. The physical examination was remarkable for an indwelling Foley's catheter. Diagnostic imaging confirmed the diagnosis of a rectourethral fistula (RUF). The most common presenting symptoms of RUF are pneumaturia, fecaluria, and urine leakage from the rectum, which may present similarly to diarrhea. He lacked the common features of RUF such as pneumaturia and fecaluria, which may be explained by a blockage of the catheter with fecal material. This case represents a rare outcome following a TURP, and it is significant due to the high morbidity associated with RUF. As such, clinicians must suspect a RUF in a post-TURP patient with diarrhea and no other obvious etiology due to the morbidity associated with RUF.

Radical cystectomy and en-bloc resection of enterovesical fistula from bladder cancer

Enterovesical fistulae secondary to benign or malignant bowel disease are not uncommonly reported in the literature. However, bladder malignancy as the primary pathology is exceedingly rare. We report a case of muscle invasive urothelial carcinoma of bladder with an enterovesical fistula to a loop of small bowel. The patient first presented with signs and symptoms of per rectal bleeding, haematuria, pneumaturia, faecaluria and rectal micturition. Her initial biochemistry test revealed significant metabolic acidosis with normal anion gap and hypokalemia. A computed tomography abdomen/pelvis with rectal contrast demonstrated an enterovesical fistula from the dome of bladder to a loop of small bowel. The patient underwent radical cystectomy with en-bloc resection of a loop of involved ileum and sigmoid colon due to the intraoperative findings of the sigmoid colon adherent to the tumour. The published literature is reviewed, focusing on the incidence, diagnostic modality and treatment strategies available for this rare condition.

Concealed enterovesical fistula associated with forgotten intra-abdominal haemostat and intravesical towel

Introduction. Enterovesical fistula is rare and is often caused by bowel inflammatory diseases and tumours in the urinary bladder or the intestine with local infiltration of bowel or bladder, respectively. The fistula usually presents with lower urinary tract symptoms, pneumaturia, and faecaluria or with food particles in the urine. Intra-abdominal retained surgical foreign bodies have also been reported as causes. Case Presentation. A case of atypical presentation in a woman with enterovesical fistula following abdominal hysterectomy. Investigations confirmed the presence of surgical towel in the urinary bladder and a pair of artery forceps in the abdomen. The towel was removed at cystoscopy after which she presented with food particles in the urine. She later had laparatomy to remove the haemostat and to repair the fistula. Discussion. A typical presentation of enterovesical fistula delayed the diagnosis and treatment in this patient. Conclusion. Managing patients with recurrent urinary tract infection after abdominal operation should include appropriate imaging of the abdomen with emphasis on pelvic organs. Also, surgical operation should always be given the best shot the first time and strict operation room standards and guidelines should always be followed.

Enterovesical fistulae: aetiology, imaging, and management

Background and Study Objectives. Enterovesical fistula (EVF) is a devastating complication of a variety of inflammatory and neoplastic diseases. Radiological imaging plays a vital role in the diagnosis of EVF and is indispensable to gastroenterologists and surgeons for choosing the correct therapeutic option. This paper provides an overview of the diagnosis of enterovesical fistulae. The treatment of fistulae is also briefly discussed. Material and Methods. We performed a literature review by searching the Medline database for articles published from its inception until September 2013 based on clinical relevance. Electronic searches were limited to the keywords: "enterovesical fistula," "colovesical fistula" (CVF), "pelvic fistula", and "urinary fistula". Results. EVF is a rare pathology. Diverticulitis is the commonest aetiology. Over two-thirds of affected patients describe pathognomonic features of pneumaturia, fecaluria, and recurrent urinary tract infections. Computed tomography is the modality of choice for the diagnosis of enterovesical fistulae as not only does it detect a fistula, but it also provides information about the surrounding anatomical structures. Conclusions. In the vast majority of cases, this condition is diagnosed because of unremitting urinary symptoms after gastroenterologist follow-up procedures for a diverticulitis or bowel inflammatory disease. Computed tomography is the most sensitive test for enterovesical fistula.

Rectovesical fistula related to transurethral resection of a bladder lesion

A rectovesical fistula (RVF) is an uncommon complication of urooncologic surgery. Although several RVFs have been reported, our case is the first reported RVF in the literature that iatrogenically occurred after transurethral resection of the bladder. A single-stage primary repair with omental flap interposition without a colostomy was successfully performed because of the persistence of the fistula during followup. After 6 months of followup, no fistula or bladder mass was detected.

Enterovesical fistulas: diagnosis and management

Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. It represents a rare complication of inflammatory or neoplastic disease, and traumatic or iatrogenic injuries. The most common aetiologies are diverticular disease and colorectal carcinoma. Over 75% of affected patients describe pathognomonic features of pneumaturia, faecaluria and recurrent urinary tract infections. The diagnosis of EVF can be challenging, and frequently patients are monitored for months before the condition is recognised and treated effectively. Diagnostic tools include laboratory tests, imaging studies and endoscopic procedures. Although conservative management can be attempted in selected patients, in most cases, the treatment is mainly based on surgical interventions. Recently, the laparoscopic approach to EVF has been shown to be safe and effective. Although it is a rare condition in a general surgery setting, EVF is a challenging condition leading to high morbidity and mortality rates.