Enterovesical Fistula Research Articles

The Respective Role of Medical and Surgical Therapy for Enterovesical Fistula in Crohn’s Disease

There are very few reports available on the role of medical and surgical therapy for enterovesical fistula (EVF) in Crohn's disease (CD). The goal of this study was to investigate the respective role of medical and surgical therapy. Thirty-seven patients with EVF in CD, who were consecutively admitted to our institution between 2004 and 2011, underwent initial medical treatment. Medical records were abstracted from our prospective CD database. We performed a univariate analysis of risk factors for surgery. The origin of EVF was ileal (ileovesical fistula, 78.4%) and sigmoidal (sigmoidovesical and ileosigmoidovesical fistula, 21.6%). After medical therapy (antibiotics, azathioprine, steroids, infliximab, or a combination), 13/37 (35.1%) patients achieved long-term remission over a mean period of 4.7 years and avoided surgery. Surgery was performed in 24/37 (64.9%) patients presenting with intractable disease. Univariate analysis showed that the significant risk factors for surgery included sigmoid-originated EVF (P=0.019) and concurrent CD complications (P=0.001), such as small bowel obstruction, abscess formation, enterocutaneous fistula, enteroenteric fistula, and persistent ureteral obstruction or urinary tract infection. For patients with ileovesical fistula alone, medical therapy is the first choice. For patients with ileovesical fistula accompanied by other CD complications, surgical intervention will most likely be needed. Patients with sigmoidovesical or ileosigmoidovesical fistula are more likely to require surgery than an uncomplicated ileovesical fistula.

Royal College surgical objectives of urologic training: A survey of faculty members from Canadian training programs

According to the Royal College objectives of training in urology, urologic surgical procedures are divided as category A, B and C. We wanted to determine the level of proficiency required and achieved by urology training faculty for Royal College accreditation. We conducted a survey that was sent electronically to all Canadian urology training faculty. Questions focused on demographics (i.e., years of practice, geographic location, subspecialty, access to robotic surgery), operating room contact with residents, opinion on the level of proficiency required from a list of 54 surgical procedures, and whether their most recent graduates attained category A proficiency in these procedures. The response rate was 43.7% (95/217). Among respondents, 92.6% were full timers, 21.1% practiced urology for less than 5 years and 3.2% for more than 30 years. Responses from Quebec and Ontario formed 69.4% (34.7% each). Of the respondents, 37.9% were uro-oncologists and 75.7% reported having access to robotic surgery. Sixty percent of faculty members operate with R5 residents between 2 to 5 days per month. When respondents were asked which categories should be listed as category A, only 8 procedures received 100% agreement. Also, results varied significantly when analyzed by sub-specialty. For example, almost 50% or more of uro-oncologists believed that radical cystectomy, anterior pelvic exenteration and extended pelvic lymphadenectomy should not be category A. The following procedures had significant disagreement suggesting the need for re-classification: glanular hypospadias repair, boari flap, entero-vesical and vesicovaginal fistulae repair. Overall, more than 80% of faculty reported that their recent graduating residents had achieved category A proficiency, in a subset of procedures. However, more than 50% of all faculty either disagreed or were ambivalent that all of their graduating residents were Category A proficient in several procedures. There is sufficient disagreement among Canadian urology faculty to suggest another revision of the current Royal College list of category A procedures.

Report of successful use of ustekinumab in Crohn’s disease refractory to three anti-TNF therapies

Gene association studies highlighting the association between IL-23 receptor polymorphism and IBD [1] have stimulated much interest in targeting of Th17 signalling as part of therapy. Ustekinumab is a monoclonal antibody directed against the shared p40 subunit of IL-12 and IL-23. An initial RCT of ustekinumab in Crohn’s disease failed to definitively demonstrate effectiveness [2]. Subgroup analysis suggests that ustekinumab may be effective in patients with a raised CRP who have previously received infliximab [3]. We present the case of a 53-year-old gentleman diagnosed with Crohn’s disease in 1983. He underwent early colectomy with end-ileostomy for medically refractory disease. He experienced persistent disease activity with very significant cumulative corticosteroid use and developed progressive penetrating complications with multiple enteroenteric, enterocutaneous and enterovesical fistulae, requiring several laparotomies. He did not experience any therapeutic benefit to either azathioprine or mercaptopurine. He was a primary non-responder to infliximab and adalimumab. He remained steroid dependent to control his symptoms of abdominal pain and high-output ileostomy. He developed progression of disease in 2010 with pyloric involvement resulting in gastric outlet obstruction. His weight fell from 61 to 50 kg between February and June 2010. He was judged unsuitable for a gastrojejunostomy due to his extensive surgical history (frozen abdomen). His symptoms worsened despite use of high-dose steroids, ciclosporin and subsequently combination certolizumab and methotrexate. He also underwent five sessions of pyloric stricture dilatation and placement of two temporary metal stents with limited success. His albumin fell from 25 to 14 g/dL (normal range 35–45 g/dL) in Jan 2011. Ustekinumab was commenced as an unlicensed therapy in February 2011 (with discontinuation of methotrexate and certolizumab). He received induction at weeks 0, 1, 2, 3 at 90 mg subcutaneously (s/c) as per the Sandborn et al. [2] induction regimen. His weight increased from 49 kg (at initiation of induction) to 53 kg at end of induction. His albumin correspondingly rose from 14 to 20 g/dL with a decrease in the C-reactive protein (CRP) from 37.2 to 3.4 mg/L (normal range \ 5mg/L) during the same timeframe. A maintenance regimen of ustekinumab at 45 mg s/c every month was then initiated. Corticosteroids were then weaned gradually and eventually discontinued in May 2011. He has remained symptomatically well and has not required further steroids. The patient’s weight has continued to increase (see Fig. 1) despite steroid withdrawal. CRP remains suppressed at 3.8 g/dL. He required only three further sessions of pyloric stricture dilatation. He remains steroid free and in remission at more than 12-month follow-up. This is the first documented case of successful induction and maintenance of remission of Crohn’s disease by ustekinumab in a patient who has failed all three anti-TNF agents. Z. S. Heetun (&) D. Keegan D. O’Donoghue G. A. Doherty Centre for Colorectal Disease, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland e-mail: heetunz@gmail.com

Prise en charge de la maladie de Crohn fistulisante hors fistules ano-périnéales dans une population marocaine : à propos de 60 cas

IntroductionCrohn’s disease is an inflammatory enterocolitis, witch may be complicated by enterocutaneous, intestinal, entero-vesical and recto-vaginal fistulas.Materials and methodsThis is a retrospective study of 60 cases of fistulizing Crohn’s disease followed in the Department of Gastroenterology “B” at Ibn Sina Hospital in Rabat.ResultsOf a total of 245 cases of Crohn’s disease, 60 patients (24.5%) had a fistulizing form, excluding anoperineal fistulas. The location of fistulas was predominatly an intestinal fistulas (44%), followed by enterocutaneous fistulas (26%), enterovesical fistulas (10%) and recto-vaginal fistulas (7%). Medical treatment with immunosuppressors was prescribed in 15 cases of intestinal fistulas, 2 cases of enterocutaneous fistulas and 1 case of recto-vaginal fistula followed by a closure of fistula in 26% of the intestinal fistulas and treatment failure in the other locations. Surgical treatment was indicated immediately in 70% of the cases and after failure of medical treatment in 11.3% of the cases. Endoscopic recurrence was significantly more frequent in patients who postoperativelyreceived aminosalicylates (61.5%) compared to those treated with immunosuppressor (25%) (p <0.01). Clinical remission was also significantly associated with medical treatment with immunosuppressors (78.4%) compared with aminosalicylates (21.6%) (P = 0.04).ConclusionsSurgical treatment remains indicated in themajority of cases of fistulizing Crohn’s disease (70%). In our study, endoscopic recurrence and clinical remission were significantly associated with the type of medical treatment postoperatively.

Surgical Management in Enterovesical Fistula in Crohn Disease at a Single Medical Center

Crohn disease is a chronic, transmural, inflammatory disease of the gastrointestinal tract with unknown etiology. It can affect any part of the gastrointestinal tract and may cause fistula, stricture, or abscess formation with disease progression. The preoperative diagnosis and definite management of this rare complication are challenges for physicians, urologists, and surgeons.

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.

Theoretical and Practical Considerations in Colo-Rectal Diverticulosis Complicated with Multiple Sigmoido-Recto-Vesical Fistulas

Although there is a complete anatomical separation between urinary and digestive tract, in certain pathological conditions, the direct proximity between the bladder and the sigmoid colon allows the development of entero-vesical fistulas. Colic diverticulosis is the second leading cause of entero-vesical fistulas, after malignancy. Usually, the enterovesical fistula is unique, on a single bowel segment; rarely is multiple, involving different intestinal segments. We present the case of a 41 years old man, with a double fistula: sigmoido-vesical and recto-vesical, respectively. The diagnosis was challenging despite the clinical aspect included pneumaturia and fecaluria. A particular symptom was sexual dysfunction. CT scan and a pelvic MRI revealed the two fistula colo-vesical and recto-vesical. A recto-sigmoid resection with subperitoneal colo-rectal anastomosis and partial cystectomy were performed with uneventful postoperative recovery. Conclusion: The multiple entero-vesical fistulas developed on a single intestinal segment are extremely rare, and, to our knowledge this is the only case reported in the literature. The management is challenging, and in our opinion the resection with anastomosis and partial cystectomy is the best choice.

Imaging in gastroenterology.

Imaging in gastroenterology.

A Rare Cause of Entero-Vesical Fistula Caused by a Skewer, Multidisciplinary Management and Minimally-Invasive Surgical Correction

Entero-vesical fistulae (EVf) occurs rarely but it is a serious clinical condition often correlated with other pathologies. It accounts for 1 to 3000 hospital accesses/year. We present a patient with a sigmoid-vesical fistulae caused by the accidental ingestion of a wood skewer two years before. In literature about 6,09 % of accesses in the first aid area(FAa) are due to the ingestion of foreign bodies(FBs) but in 80-90% of them they are expelled with stools. In frequently FBs in the lower gastrointestinal tract can be the result of an orally ingested sharp object that becomes impacted. The management of this case was multidisciplinary, and the correction was a laparoscopic one time approach.

Recurrent Urinary Tract Infections, Inflammatory Mass Masquerdaing as a Bladder Mass in a Patient with Crohnʼ Disease with Enterovesical Fistula

Recurrent Urinary Tract Infections, Inflammatory Mass Masquerdaing as a Bladder Mass in a Patient with Crohnʼ Disease with Enterovesical Fistula

Enterovesical fistula and intestinal obstruction by ileal endometriosis

Enterovesical fistula and intestinal obstruction by ileal endometriosis

NASPGHAN Clinical Report on the Evaluation and Treatment of Pediatric Patients With Internal Penetrating Crohn Disease

Natural History of Pediatric Crohn Disease T he natural history of pediatric Crohn disease (CD) remains unpredictable, although some trends are observed that differentiate children from adults. Pediatric CD often presents with more severe disease and more frequent need for immunosuppressive therapy (1). Growth failure, present in 15% to 20% of patients, is a unique characteristic of pediatric CD not seen in adult-onset CD (2). Colonic disease distribution is common in patients younger than 10 years (1). The need for surgical intervention also varies, with 1 study reporting the actuarial risk of having undergone an extensive intestinal resection being 48.6% 5% in a childhood-onset group versus 14.6% 2% in the adult-onset group (P< 0.001) (1). More recently, long-term follow-up of patients enrolled in pediatric registries shows a cumulative surgical rate of 14% to 17% at 5 years and 28% at 10 years (3,4).

Colovesical Fistula: Unexpected Complication 7 Years After Augmentation Ileocystoplasty

Augmentation enterocystoplasty has been extensively used to attain high-capacity low-pressure urinary reservoirs in patients with neuropathic bladder, exstrophy-epispadias complex, valve bladder syndrome, and contracted bladder. Enterovesical fistula might occur as an early complication after enterocystoplasty. We report the case of a 16-year-old boy, who presented with chronic watery diarrhea 7 years after augmentation ileocystoplasty. A colovesical fistula was diagnosed. We discuss the clinical presentation, management plan, and operative findings.

Point-of-Care Sonographic Diagnosis of an Enterovesical Fistula

Video — Enterovesical fistula in a 73-year-old man. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Dynamic FDG PET/CT Imaging With Diuresis Demonstrates an Enterovesical Fistula in a Lymphoma Patient With Repeated Colon Diverticulitis

A 43-year-old male patient with follicular B-cell lymphoma was referred for a FDG PET/CT scan due to severe left lower abdominal pain to rule out recurrent cancer. These FDG PET/CT images and previous FDG PET/CT images 5 months ago both revealed an air bubble in the urinary bladder on the CT images. He had a recurrent urinary tract infection history for 6 months. A list-mode dynamic data acquisition with diuresis intravenous injection revealed linear FDG activity extending from the upper-left portion of the bladder to a soft tissue mass in the lower-left pelvic region. An enterovesical fistula was confirmed by surgery.

Effect of Prior Radiotherapy and Ablative Therapy on Surgical Outcomes for the Treatment of Rectourethral Fistulas

We evaluate the impact of pelvic radiation and ablative therapy on the surgical repair of rectourethral fistula. A total of 45 patients with rectourethral fistulas were identified from a prospective database. From 1998 to 2010 a total of 49 surgical reconstructive procedures were performed. Fistula formation was secondary to radiation (brachytherapy, external beam radiation) and ablative therapy (cryotherapy or high intensity focused ultrasound) in 29 patients. The approach for surgical repair and clinical outcomes were analyzed to identify the impact of radiation and ablative therapy on successful fistula repair. Median patient age was 68 years and mean followup was 42 months (IQR 7, 71). A primary repair was more frequently attempted (15 of 16 [94%] vs 6 of 29 [21%], p <0.0001) and successful in nonradiation/ablation cases (13 of 15 [87%] vs 1 of 6 [17%], p = 0.003). Patients with prior radiation/ablation were significantly more likely to require permanent colostomy (25 of 29 [86%] vs 0%, p <0.0001) and permanent urinary diversion as part of fistula management (27 of 29 [93%] vs 1 of 16 [6%], p <0.0001). Of the 6 patients with radiation/ablation induced fistula who underwent primary repair, 4 subsequently required urinary diversion for fistula recurrence, 1 is symptomatic with recurrence and 1 (who presented with a 0.5 cm fistula) has had no evidence of fistula recurrence. Unlike the repair of a rectourethral fistula after surgical intervention, which is typically amenable to primary repair, most patients with severe radiation and ablation induced fistula will require urinary diversion with or without permanent colostomy. Thus, permanent urinary diversion should be considered early in the surgical management of these cases.

Bloqueio neurolítico subaracnoideo em paciente com dor oncológica refratária: relato de caso

JUSTIFICATIVA E OBJETIVOS: O uso de bloqueio neurolítico subaracnoideo no controle de dor tem diminuído nos últimos anos devido à introdução de novas técnicas, mas ainda tem importância no controle de dor oncológica refratária. O objetivo deste estudo foi apresentar um caso de dor oncológica, em que esta técnica foi utilizada para controle da dor. RELATO DO CASO: Paciente do sexo masculino, 45 anos, diagnosticado com carcinoma espinocelular de canal anal localmente avançado e lesão ulcerada em região perineal com presença de fístula retovesical e infecção local. O paciente apresentava dor intensa com escala verbal numérica (EVN) =10 e recebia tratamento farmacológico com doses altas de opioide e adjuvantes sem boa resposta. Foi realizado bloqueio neurolítico subaracnoideo com fenol a 5% e após realização do bloqueio houve melhora significativa do quadro doloroso, tendo paciente referindo alívio de 80% após 20 minutos do procedimento. A melhora permaneceu até o 21º dia após bloqueio quando o paciente foi a óbito devido complicações infecciosas. CONCLUSÃO: O caso ilustrou o uso do bloqueio subaracnoideo com fenol a 5% para controle de dor oncológica. Conclui-se que para casos selecionados, onde a expectativa de vida é limitada, esta técnica pode ser empregada com sucesso.

Riparazione Laparoscopica di Fistola Enterovescicale in Paziente Portatore di Megauretere sx

Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. We present the case of EVF secondary to diverticular disease in a male with congenital megaureter. A laparoscopic repair of the colon vesical fistula was performed with colon resection. With the patient in the Trendelenburg position -30° degrees on the right side, 5 trocars are positioned trans-peritoneally. The exploration of the abdominal cavity shows the sigmoid diverticular disease adhering tenaciously to the posterior wall of the bladder. The intestinal loops are medialized. The inferior mesenteric vein is isolated, clipped and divided. The mesosigma is isolated and the inferior mesenteric artery is closed 2 cm from its emergence from the aorta with EndoGIA™ 45 stapler. The left colon is isolated from its splenic flexure to the mesorectum. The peritoneum between the bladder and sigmoid colon at the site of the tenacious adhesions is incised. The left megaureter is isolated from the diverticular disease and the bladder is opened on the site of the fistula, to permit a wide resection of the fistula. The posterior wall of the bladder is then closed with double running sutures. Section of the rectum with EndoGIA™ 45 stapler. Extraction of 20 cm of sigma comprising diverticular disease by a 5 cm suprapubic laparotomy. The sigma is cut and the proximal head of the circular stapler is inserted and closed with a running suture. The left colon is put back in place into the peritoneal cavity. The laparotomy is closed and the surgery is reconverted into laparoscopy. A colorectal end-to-end anastomosis according to Knight Griffen is performed with ILS 29 circular stapler. The anastomosis is tested for leakage with hydropneumatic test: no evidence of spillage. A laminar drainage is placed close to the anastomosis and the incisions are closed. The operative time was 240 minutes. There were no intra- or post-operative complications. The bladder catheter was removed on day 7 after cystography. The patient was discharged asymptomatic on the 8th post-operative day. Laparoscopic treatment of enterovesical fistulas for benign disease is a safe and standardized procedure. It remains a difficult procedure with a conversion rate higher than laparoscopy for uncomplicated diverticulitis or malignancy. The procedure in a single session with intracorporeal bowel anastomosis is the standard.

Laparoscopic conservative surgery of colovesical fistula: is it the right way?

Enterovesical fistula is a rare disease. The standard treatment of colovesical fistula is removal of the fistula, suture of the bladder wall, and colic resection with or without temporary colostomy. The usual approach is open because the laparoscopic one has high conversion rates and morbidity. We report the first laparoscopic conservative treatment of colovesical fistula in our knowledge and its long-term results. A 69-year-old man was affected by colovesical fistula due to endoscopic exeresis of a 2 cm adenomatous polyp in the sigmoid diverticulum. We performed a laparoscopic conservative treatment of the fistula without colic resection. Operative time was 210 min and estimated blood loss was 300 ml. The catheter was removed after 10 days. Time to first flatus was 2 days and the hospital stay was 8 days. No peri- or post-operative complications occurred. At 48-month follow-up fistula did not recur. Laparoscopic conservative surgery for colovesical fistula is safe and feasible. It could be a therapeutic option in selected cases, especially if diverticular disease and inflammation are slight.

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.