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CASE REPORT
Year : 2014  |  Volume : 41  |  Issue : 3  |  Page : 208-210

Colovesical fistula managed with single staged corrective surgery


1 Department of Urology, KLES Kidney Foundation, KLES, Dr. Prabhakar Kore Hospital and MRC, Belgaum, Karnataka, India
2 Department of General Surgery, KLE University's JN Medical College, KLES, Dr. Prabhakar Kore Hospital and MRC, Belgaum, Karnataka, India

Date of Web Publication19-Sep-2014

Correspondence Address:
Rajendra B Nerli
Department of Urology, KLES Kidney Foundation, KLE University's JN Medical College, KLES Dr. Prabhakar Kore Hospital and MRC, Belgaum - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.141244

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  Abstract 

Colovesical fistulae are most commonly associated with diverticulitis. We report a case of colovesical fistula in a 55-year-old male patient presenting with pneumaturia and fecaluria. Patient was treated with single stage resection of fistula, colocolostomy and closure of bladder.

Keywords: Bladder, colovesical, diverticulitis, fistula


How to cite this article:
Nerli RB, Abhijeet SM, Patne PB, Patil RA, Togale M, Hiremath MB. Colovesical fistula managed with single staged corrective surgery. J Sci Soc 2014;41:208-10

How to cite this URL:
Nerli RB, Abhijeet SM, Patne PB, Patil RA, Togale M, Hiremath MB. Colovesical fistula managed with single staged corrective surgery. J Sci Soc [serial online] 2014 [cited 2020 Mar 28];41:208-10. Available from: http://www.jscisociety.com/text.asp?2014/41/3/208/141244


  Introduction Top


Colovesical fistula is the most common type of fistula associated with diverticular disease of the colon and it occurs in 2-22% of patients with known diverticular disease. [1],[2],[3],[4] The first description of a colovesical fistula is attributed to Rufus of Ephesus in AD 200, [5] but it was not until 1888 that Cripps produced his classic monograph on the subject. [6] In the literature diverticular disease accounts for the majority of cases (56.3%), although fistula formation (2%) is an uncommon complication of this condition. [7] Carcinoma of the colon (20.1%), Crohn's disease (9.1%), surgical trauma (3.2%) and radiotherapy (3%) follow in incidence, with carcinoma of the cervix, carcinoma of the bladder and appendicitis accounting for the remainder. The condition is less common in females and some authors attribute this to the interposition of the reproductive organs; [8] although prior hysterectomy has been reported overall in only 14.8% of women and in our series, only 3%.

The earliest treatment for colovesical fistula was defunctioning colostomy, proposed by Barbier de Melle in 1843. [9] However, it is rare for the fistula to close following this procedure alone [10] and it is therefore reserved now for patients with a poor prognosis. Local measures such as a division of the tract with over-sewing of the colon and bladder with or without the interposition of omentum is not generally recommended as the diseased tissues heal poorly and recurrence is common, although one report does advocate this procedure for selected cases of diverticular fistulae. [11] We report a case of colovesical fistula secondary to diverticular disease.


  Case report Top


This paper reports a case of a 55-year-old male patient presented with a history of pneumaturia and fecaluria of 4 months duration. Prior to this thepatient had an episode of fever, chills, frequency and passage of turbid urine. Urine examination revealed pyuria and bacteria. Ultrasonography appeared normal. Computed tomography revealed the fistulous communication between the bladder and sigmoid colon [Figure 1]a and b]. Cystoscopic examination revealed a small fistulous opening on the left lateral aspect of the dome of the bladder. It was not possible to insert a guidewire/ureteric catheter into the fistulous opening. Sigmoidocolonoscopy revealed diverticular disease of the sigmoid colon. No tumors or suspicious lesions were identified. Patient was prepared for surgical exploration with bowel washes, pre-operative antibiotics and reservation of blood. The patient was explored through an infra-umbilical midline incision. The site of colovesical fistula was identified [Figure 2]a]. The bladder was separated from the sigmoid colon using the blunt and sharp dissection. A limited colonic resection and end to end anastomosis was done. The rent in the bladder was identified, the margins freshened and the bladder closed in layers [Figure 2]b]. Post-operative period was uneventful and the patient was discharged after 1 week.
Figure 1: (a) Computed tomography (CT) scan sagi�� al view of fi stula. (b) CT scan transverse view showing adherence of the colon to the le�� wall of bladder with a pocket of air seen at the site of colovesical fi stula

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Figure 2: (a) Intra operative image showing the a�� achment of sigmoid to bladder. (b) Bladder closure done in two layers

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  Discussion Top


Diverticular diseases are uncommon in the Indian population. Although the majority of the cases are asymptomatic over their lifetime, the disease becomes symptomatic when complications occur. These complications are bleeding, diverticulitis, peri-diverticular abscess, perforation, stricture and fistula formation. [3],[12] Colovesical fistula occur when the diverticula between the colon and the bladder gets perforated and forms a fistula. The most common symptom associated with colovesical fistula is pneumaturia (77-90.1%) followed by dysuria (45%), fecaluria (36%), hematuria (22%), orchitis (10%), abdominal pain and diarrhea. [13],[14],[15] Pneumaturia should raise the suspicion of entero-vesical fistula and is often associated with a persistent urinary tract infection. In our patient, the main symptoms were diarrhea and abdominal pain. Several diagnostic methods have been used to diagnose colovesical fistulas. In a review of 66 patients with colovesical fistula, 41 patients underwent sigmoidoscopy and fistula was found in only three of them. In 56 patients, abdominal X-ray was performed and revealed air-fluid levels in the urinary bladder in 16 patients. On the other hand, fistula was detected in only 17% of patients with barium enema. [3] Nadir et al. [16] reported that virtual colonoscopy may be the most appropriate alternative diagnostic tool when other techniques fail. Furthermore, it is a non-invasive procedure and comfortable for the patient.

A cystoscopy or cystography might also be helpful in these cases. Cystoscopy was found to be the most accurate test to detect fistulas (44-46.2%) followed by barium enema (20.1%). [13],[17] Surgical treatment for many years favored three stage resection, but as prophesized by Charles Mayo in 1950, single stage procedures have gradually gained ground and are becoming standard of care. [18] Preliminary defunctioning colostomy is recommended when intestinal obstruction or abscess formation arc present, or where there has been previous radiotherapy, but the majority of cases can be treated by a single procedure wherefore reducing both morbidity and duration of hospital stay. [19]

 
  References Top

1.Vasilevsky CA, Belliveau P, Trudel JL, Stein BL, Gordon PH. Fistulas complicating diverticulitis. Int J Colorectal Dis 1998;13:57-60.  Back to cited text no. 1
    
2.Woods RJ, Lavery IC, Fazio VW, Jagelman DG, Weakley FL. Internal fistulas in diverticular disease. Dis Colon Rectum 1988;31:591-6.  Back to cited text no. 2
    
3.Pollard SG, Macfarlane R, Greatorex R, Everett WG, Hartfall WG. Colovesical fistula. Ann R Coll Surg Engl 1987;69:163-5.  Back to cited text no. 3
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4.Mileski WJ, Joehl RJ, Rege RV, Nahrwold DL. One-stage resection and anastomosis in the management of colovesical fistula. Am J Surg 1987;153:75-9.  Back to cited text no. 4
[PUBMED]    
5.Kellogg WA. Vesico-enteric fistula. Am J Surg 1938;41:136.  Back to cited text no. 5
    
6.Cripps H. Passage of air and faeces from the urethra. Lancet 1888;2:619.  Back to cited text no. 6
    
7.Ward JN, Lavengood RW Jr, Nay HR, Draper JW. Diagnosis and treatment of colovesical fistulas. Surg Gynecol Obstet 1970;130:1082-90.  Back to cited text no. 7
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8.Kovalcik PJ, Veidenheimer MC, Corman ML, Coller JA. Colovesical fistula. Dis Colon Rectum 1976;19:425-7.  Back to cited text no. 8
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9.Lindstedt E. Intestino-vesical fistula. Scand J Urol Nephrol 1967;1:253-8.  Back to cited text no. 9
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10.Pugh JI. On the pathology and behaviour of acquired non-traumatic vesico-intestinal fistula. Br J Surg 1964;51:644-57.  Back to cited text no. 10
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11.Lewis SL, Abercrombie GF. Conservative surgery for vesicocolic fistula. J R Soc Med 1984;77:102-4.  Back to cited text no. 11
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12.West AB, Losada M. The pathology of diverticulosis coli. J Clin Gastroenterol 2004;38:S11-6.  Back to cited text no. 12
    
13.Garcea G, Majid I, Sutton CD, Pattenden CJ, Thomas WM. Diagnosis and management of colovesical fistulae; six-year experience of 90 consecutive cases. Colorectal Dis 2006;8:347-52.  Back to cited text no. 13
    
14.Wig JD, Kochhar R, Goenka MK, Singh SK, Nagi B, Suri S, et al. Colovesical fistula complicating colonic diverticulosis. Indian J Gastroenterol 1995;14:73-4.  Back to cited text no. 14
    
15.Najjar SF, Jamal MK, Savas JF, Miller TA. The spectrum of colovesical fistula and diagnostic paradigm. Am J Surg 2004;188:617-21.  Back to cited text no. 15
    
16.Nadır I, Ozın Y, Kiliç ZM, Oğuz D, Ulker A, Arda K. Colovesical fistula as a complication of colonic diverticulosis: Diagnosis with virtual colonoscopy. Turk J Gastroenterol 2011;22:86-8.  Back to cited text no. 16
    
17.Driver CP, Anderson DN, Findlay K, Keenan RA, Davidson AI. Vesico-colic fistulae in the Grampian region: Presentation, assessment, management and outcome. J R Coll Surg Edinb 1997;42:182-5.  Back to cited text no. 17
    
18.Mayo CW, Blunt CP. Vesicosigmoidal fistulas complicating diverticulitis. Surg Gynecol Obstet 1950;91:612-6.  Back to cited text no. 18
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19.McConnell DB, Sasaki TM, Vetto RM. Experience with colovesical fistula. Am J Surg 1980;140:80-4.  Back to cited text no. 19
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