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      Colovesical Fistulae: The Varying Aetiologies

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          Abstract

          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.

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

          Brian C Sutton, Zulqarnain I. Majid, Clare Pattenden … (2006)
          Colovesical fistulae are well-recognized but relatively uncommon presentation to colorectal surgery. As a result, few centres have sufficient experience in the investigation and surgical treatment of colovesical fistulae to develop clear protocols in its management. This study examines the diagnostic and treatment pathways of 90 consecutive patients with colovesical fistulae presenting to a single surgeon, over a six-year period. Using the findings from this study and previously published data, the authors suggest tentative guidelines for the diagnosis and management of such patients. Pneumaturia and faecaluria were present in 90.1% of all cases. The diagnosis of colovesical fistula is predominately a clinical one, however, cystoscopy was the most accurate test to detect fistulae (46.2%) followed by barium enema (20.1%). Barium enema was the most sensitive test to detect stricture formation (70.6%). Colonic endoscopy was the most reliable means of excluding a colonic malignancy. The most common pathology was diverticular disease (72.2%), colonic carcinoma (15.3%) and Crohn's disease (9.7%). Left sided colonic resections were undertaken in 73.6% of patients, right hemicolectomy in 4.2% and defunctioning loop colostomies in 18.5%. Of the left sided resections, primary anastomosis was achieved in 92% of cases (n = 48) with one postoperative leak and no mortality. Resection and primary anastomosis should be the treatment of choice for colovesical fistulae, with an acceptable risk of anastomotic leak and mortality. Barium enema, colonic endoscopy and CT should be routine in the investigation of colovesical fistulae.
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            Internal fistulas in diverticular disease.

            D Jagelman, V Fazio, F L Weakley … (1988)
            Internal fistulas in diverticular disease are uncommon and have a reputation of being difficult to treat. Eighty four patients treated from 1960 to April 1986, representing 20.4 percent (84 of 412) of the surgically treated diverticular disease patients, were reviewed. Eight patients had multiple fistulas. Sixty-five percent (60 to 92) of fistulas were colovesical, 25 percent (23 of 92) colovaginal, 6.5 percent (6 of 92) coloenteric, and 3 percent (3 of 92) colouterine fistulas. There were 66 percent (35 of 53) males and 34 percent (18 of 53) females with colovesical fistulas only. Hysterectomies had been performed in 50 percent (12 of 24) and 83 percent (19 of 23) of females with colovesical and colovaginal fistulas, respectively. Operative management included: resection anastomosis, resection with anastomosis and diversion, Hartmann procedure, and three-stage procedure. In the latter half of the series there was a significant decrease in staging procedures with no significant statistical difference in complications. There were three deaths (3.5 percent) in the series. Other complications included: wound infection, 21 percent (18 of 84), enterocutaneous fistula, 1 percent (4 of 84), and anastomotic dehiscence, 5 percent (4 of 84). Primary anastomosis can be performed with acceptable morbidity and mortality and today is the procedure of choice, leaving staging procedures to selected patients.
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              Laparoscopic surgery for fistulas that complicate diverticular disease.

              Konstantinos Nassiopoulos, George P. Petropoulos, Evangelos Menenakos … (2003)
              Diverticular disease is complicated by colovesical and colovaginal fistulas in 4-20% of patients. Laparoscopic surgery is usually reserved for selected cases of uncomplicated disease. The aim of this study was to assess the efficacy and effectiveness of laparoscopic surgery in the treatment of those patients. Eighteen patients, 15 with colovesical fistulas and three with colovaginal fistulas, were operated on laparoscopically. Prospectively collected data, associated with technical feasibility, short-term outcome and effectiveness, were analysed. Twelve sigmoidectomies, four extended left colectomies and two segmentectomies were performed. Fistulas were treated with simple dissection or mechanical division, and the bladder wall was repaired in two patients. Mean operating time was 237 min (range 165-330). There was one conversion (5.5%) and no post-operative death. Morbidity was 27.7% and included one major complication. Return of gastrointestinal function occurred 2.9 days post-operatively, and the mean hospital stay was 10 days after surgery. During the 5.1-year follow-up period there was one fistula recurrence (5.5%) and no recurrent diverticulitis. Laparoscopic one-stage surgery was technically feasible and safe, with low morbidity. Effectiveness appears favourable when compared with open surgery, but prospective randomized studies are necessary to support such a conclusion.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cureus
                Journal ID (iso-abbrev): Cureus
                Journal ID (issn): 2168-8184
                Title: Cureus
                Publisher: Cureus (Palo Alto (CA) )
                ISSN (Electronic): 2168-8184
                Publication date (Electronic, pub): 29 November 2021
                Publication date (Electronic, collection): November 2021
                Volume: 13
                Issue: 11
                Electronic Location Identifier: e20025
                Affiliations
                [1 ] Gastroenterology and Hepatology, and General Internal Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
                [2 ] General Internal Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
                [3 ] Internal Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
                [4 ] Radiology, Conquest Hospital, East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
                [5 ] Gastroenterology, Conquest Hospital, East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
                Author notes
                Article
                DOI: 10.7759/cureus.20025
                PMC ID: 8649672
                SO-VID: ed153e1c-2048-4aec-83a6-a04390c0a467
                Copyright © Copyright © 2021, Zafar et al.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date accepted : 29 November 2021
                Categories
                Subject: Internal Medicine
                Subject: Medical Education
                Subject: Anatomy

                Keywords: multi-disciplinary team approach,ct-abdomen & pelvis (portal venous phase),mri fast relaxation fast spin echo sequence),contrast-enhanced ct-abdomen & pelvis,colo vesical fistulae
                Data availability:
                Keywords: multi-disciplinary team approach, ct-abdomen & pelvis (portal venous phase), mri fast relaxation fast spin echo sequence), contrast-enhanced ct-abdomen & pelvis, colo vesical fistulae

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