Enterovesical Fistula Research Articles

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.

Case Report: A unique case of a retroperitoneal abscess during pregnancy complicated with an ileo-sigmoid-vesical fistula in a patient with active Crohn’s disease

The enterovesical fistula is an uncommon condition resulting from complications of inflammatory diseases such as Crohn’s disease. While erosion of an abscess can result in the formation of enterovesical fistula, early diagnosis of abscesses is crucial in order to avoid complications. This case is a retrospective analysis of the unusual combination of events that contributed to the misdiagnosis, further complications in a pregnant 28-year-old female diagnosed with Crohn’s disease. The patient presented a retroperitoneal abscess, which went undiagnosed and complicated with an ileo-sigmoid-vesical fistula during pregnancy. She complained of right sciatica, cruralgia, and a complete inability to lift her right leg as well as recurrent urinary infections, which were treated by multiple courses of antibiotics. The chronic situation led to the restricted growth of the fetus, which made the fetus not tolerate the labor. Emergency C-section was done due to fetal distress, but baby did well and did not need NICU. None of the gynecological examinations, ultrasound, X-ray, CT-scan, cystography, and colonoscopy performed before, during and after pregnancy were able to explain her symptoms. Fecaluria is the symptom that ultimately directed toward the presence of an eventual fistula five months after delivery. The MRI diagnosed the retroperitoneal abscess and an ileo-sigmoid-vesical fistula, which were treated by total parenteral nutrition followed by ileo-colo resection. An ileostomy was maintained for four months before anastomosis. Sciatic pain and psoasitis in a context of Crohn’s disease should alert physicians to the possible presence of a retroperitoneal abscess, which should be monitored by MRI. In addition, recurrent urinary infections during pregnancy in a context of Crohn’s disease can be sign of a formed enterovesical fistula. The multiple antibiotic courses, while allowing the continuity of the pregnancy, also contributed to further delay of diagnosis by decreasing inflammation.

Enterovesical Fistula: A Serious Complication of Crohn Disease

Due to the anatomical proximity of the last ileal loop and the bladder, Crohn’s disease can affect the urinary tract by the formation of an Enterovesical Fistula (EVF). Although rare, it represents a complication with a potential impact on the patient’s quality of life and it is often difficult to manage. In addition to the Computed Tomographic (CT) findings, several other examinations can contribute to the diagnosis of EVF, which calls for adequate management based on disconnection of the digestive tract from the bladder and maintenance of medical treatment. Despite therapeutic advances in the context of Crohn’s disease, the EVF remains a surgical indication. The present case reported is of a successfully managed EVF which was revealed by fecaluria aiming to emphasise the clinical aspects and various diagnostic tools with a special mention of the key role of medical imaging in the diagnostic process and the surgical management.

A Case of Enterovesical Fistula due to Ileal Diverticulitis Treated by Reduced Port Surgery

A Case of Enterovesical Fistula due to Ileal Diverticulitis Treated by Reduced Port Surgery

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

BackgroundEnterovesical 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.MethodsFifty-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.ResultsThe 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.ConclusionsThese 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.

Clinical characteristics and outcome of fistulizing Crohn's disease: One single‐center experience in Taiwan

Crohn's disease (CD) is characterized by chronic and/or relapsing immune activation and inflammation within the gastrointestinal tract. Approximately 35% of patients with CD are complicated by fistulae. However, little is known about the incidence and natural history of fistulizing CD in Asia, especially enterocutaneous fistulae (ECF). In this study, we aimed to investigate the clinical course and outcomes of patients with fistulizing CD. We performed a retrospective analysis using the database of Chang Gung Memorial Hospital to analysis the clinical characteristics, clinical course of CD, gender, age, medical and surgical treatment, complications, and long‐term outcomes. From January 1989 to November 2016, 97 patients were enrolled (73 males and 24 females) with a median age at diagnosis of CD of 32 years (average 36.28 ± 15.84 years). All of the patients were classified by Montreal classification. Montreal classifications A2 (age 16‐40 years; n = 56, 57.7%), L3 (ileocolonic type; n = 47, 48.5%), and B1 (nonstricturing and nonpenetrating type; n = 43, 44.3%) were the most common phenotypes. ECF occurred in five patients (5.1%), enterovaginal fistula in three patients (3.1%), and enterovesical fistula in two patients (2.0%). The duration of CD before the onset of ECF was 3.9 years, enterovaginal fistula was 2.5 years, and enterovesical fistula was 5 years, and most of the patients complicated with a fistula required surgical treatment.

Selective use of cystogram following segmental bowel resection in patients with enterovesical fistula.

Patients undergoing resectional surgery for enterovesical fistulas generally have an indwelling urinary catheter postoperatively to prevent a recurrent fistula. The aim of this study was to assess the role of a cystogram as part of the postoperative follow-up of such surgery, when it should be performed and for how long the bladder should be drained after surgery. A retrospective single-centre study of all patients undergoing ileocaecal or sigmoid resection for surgery for enterovesical fistula with the primary end-point of recurrent urinary fistula. Between 1994 and 2015, 46 patients (23 male; mean age 55.4±18.3years) underwent surgery [23 (50%) for diverticular disease, 16 (34.8%) for Crohn's disease, five (10.9%) for malignancy and two (4.3%) for previous radiotherapy]. Closure of the bladder fistula was by simple suture in 21 (46%) patients and with an omental pedicle in 16 (36%). Overall median duration of urinary drainage was 10.5 [interquartile range (IQR): 7.3-14.0] days. A postoperative cystogram was performed in 26 (57%) patients after a median of 10.0 (IQR: 8.0-13.0) days. This demonstrated persistent leakage in three patients, of whom two had undergone surgical closure of the bladder. This group required prolonged drainage (7, 19 and 40days). One patient who had undergone surgery following radiotherapy for urothelial cancer developed a recurrent malignant fistula at 9months, even though the postoperative cystogram had been negative. This study suggests that a routine postoperative cystogram after surgery for enterovesical fistula may not be necessary for all patients if the bladder is drained for 1-2weeks after bowel resection.

Prenatal Diagnosis of Enterolithiasis in 20 Cases

Background: Enterolithiasis is a sonographic sign defined by hyperechogenic foci within the – often distended – fetal bowel. Objectives: We report on a series of 20 cases with enterolithiasis diagnosed prenatally and illustrate the spectrum of associated malformations. Method: This was a retrospective study involving 20 fetuses with enterolithiasis at two large tertiary referral centers in Germany over a 17-year period (2000–2017). Results: Median diagnosis was made with ultrasound at 18+2 weeks of gestation (IQR_25,75: 14+5, 26+5). Additional malformations included urogenital malformations (cloacal malformation in 7/20 fetuses [35%] and kidney defects in 7/20 fetuses [35%]), cardiac malformations (3/20 fetuses [15%]), and vertebral malformations (5/20 fetuses [25%]). Of 20 fetuses, 14 could be attributed to the anorectal malformation spectrum, 3/20 fetuses presented with caudal regression syndrome, and 1 fetus with bilateral kidney agenesis, congenital diaphragmatic aplasia, and enterovesical fistula, respectively. Conclusion: Enterolithiasis is a rare prenatal sonographic feature. Because of the frequent occurrence of uro-recto-genital malformations, thorough prenatal counseling should be performed.

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.

Augmentation Enterocystoplasty for Patients with Ketamine-induced Cystitis

Purpose: Ketamine abuse has been a worldwide issue recently. Ketamine-induced cystitis (KC) is an annoying urinary tract symptom secondary to long-term ketamine abuse. The aim of our study is to review clinical outcomes of bladder augmentation enterocystoplasty (AE) for the patients with KC. Materials and Methods: We performed bladder AE for eight patients with refractory symptoms of KC (severe bladder pain, micturition pain, urgency, frequency, and contracted bladder). All the patients received conservative treatment at clinics or referred from other hospital. Results: Between 2007 and 2015, eight patients (seven males and one female), aged 26–48 years (mean 32.7 years), underwent AE as indicated. The duration of ketamine abuse ranged from 2 to 15 years (mean 6.8 years). Contracted bladder was noted in all patients, hydronephrosis in two and hydroureter in one under intravenous pyelography. Postoperative hospitalization ranged from 12 to 47 days (mean 22.4 days). Significant increases in estimated glomerular filtration rate (86.43 ± 21.47 vs. 103.14 ± 29.32 ml/min/1.73 m2,P < 0.05), functional bladder capacity (47.75 ± 10.07 vs. 273.13 ± 54.96 ml,P < 0.0001), and pain visual analog score (6.0 ± 1.2 vs. 1.75 ± 0.89,P < 0.0001) were noted after AE. Surgical complications included adhesion ileus, progressive impaired renal function, and enterovesical fistula. All the patients were satisfied with the outcomes of the surgery, based on their responses to the self-report questionnaires. All patients reported marked improvement in micturition pain and urinary frequency, which greatly elevated life quality. Most patients were followed up at the outpatient department within 1 year or were lost to follow-up after surgery. Conclusion: This case series demonstrated that for surgical management of refractory bladder pain and low bladder capacity resulting from KC, AE might be effective. However, cessation of ketamine use is the most important to prevent recurrence of the above symptoms.

Diagnosis and Surgical Management of Enterovesical Fistulas in Crohn’s Disease in the Biologic Era: A Multi-Institutional Analysis

McKenna, Nicholas P. MD; Mathis, Kellie L. MD; Habermann, Elizabeth B. PhD, MPH; Lightner, Amy L. MD Author Information

Entero-vesical fistula revealed by recurrent urinary tract infection

Entero-vesical fistula revealed by recurrent urinary tract infection

An elderly man with fecal materials in the Foley catheter

A 70-year-old man presented to the emergency department with a 2-week history of watery diarrhea. Fecal materials were found in the Foley catheter. A computed tomography of the abdomen and pelvis revealed chronic diverticulitis with enterovesical fistula. The patient was treated with broad-spectrum antibiotics and underwent an urgent surgery with a transverse loop colostomy. The presence of fecaluria should raise the clinical suspicion of enterovesical fistula. Computed tomography is the choice of diagnostic modality.

Conservative Management of Intraperitoneal Urinary Bladder Perforation with Enterovesical Fistula

Conservative Management of Intraperitoneal Urinary Bladder Perforation with Enterovesical Fistula

Tuberculosis of Intestine with Concurrent Complex Enterovesical and Enterocutaneous Fistula

Tuberculosis of Intestine with Concurrent Complex Enterovesical and Enterocutaneous Fistula

Successful treatment of an enterovesical fistula due to Crohn's disease with stem cell transplantation: a case report.

Successful treatment of an enterovesical fistula due to Crohn's disease with stem cell transplantation: a case report.

Double peritoneal fat flap in the treatment of an enterovesical fistula.

Double peritoneal fat flap in the treatment of an enterovesical fistula.

Inflammatory Bowel Diseases: focus on epidemiology

Abstract The worldwide incidence and prevalence of Inflammatory Bowel Diseases (IBD) continues to increase, recent studies showing a future global spread of Inflammatory Bowel Diseases. Epidemiological data coming for Romania are scarce. The aim is to describe epidemiological features of Inflammatory Bowel Diseases in an adult population in the South-East side of Romania. The retrospective and descriptive study included 128 patients: group 1=Crohn’s Disease (CD) (79), group 2=Ulcerative Colitis (UC) (46) and group 3=Unclassified Colitis (Unclassified C) (3). We calculated the prevalence of Inflammatory Bowel Diseases in Constanţa in 2016. The phenotypic distribution was: 62% with Crohn’s Disease, 36% with Ulcerative Colitis and 3 patients with Unclassified Colitis. Crohn’s Disease: The prevalence was 0.11/100000 inhabitants. 51% were female and 49% were male. The age distribution showed a uniform model of the frequency of Crohn’s Disease in patients aged between 21 and 50 years. According to Montreal Classification, ileo-colonic involvement L3 was the most frequent in 47% and 60% patients presented inflammatory phenotype B1. 44% had intestinal complications. 9% had extraintestinal complications. 16.4% required surgical interventions. Ulcerative Colitis: The prevalence was 0.06/100000 inhabitants. We noticed a slight male predominance: 57% were male and 43% female. The age distribution showed a bimodal peak of incidence in patients aged between 21-30 years and 41-50 years. The most common disease extension was left colitis E2 in 47% cases. One patient had an enterovesical fistula. Extraintestinal complications were not reported in this group. No patient required surgical intervention. Unclassified Colitis: 3 male patients with ages between 31-50 years were diagnosed with Unclassified Colitis. Complications or need for surgery were not reported in this group. We noticed the predominance of Crohn’s Disease in our region while in other parts of Romania Ulcerative Colitis is predominant. We suppose that the predominance of Crohn’s Disease in Dobrogea can be due to environmental factors, diet or ethnics, but additional epidemiological studies to define better the association with environmental factors and risk factors for Crohn Disease or Ulcerative Colitis in our region are needed.

5-Year Outcomes of Hypofractionated Radiation Therapy With VMAT in Prostate Cancer and Analysis of Qualiy of Life

Hypofractionated radiotherapy (HR) has been suggested might be equally or more effective with a shortened overall treatment duration for prostate cancer (PC). However, the quality of life (QoL) and late toxicity is an important issue in PC treatment decisions. Our aim was to report our clinical outcomes of patients receiving HR and investigate the toxicity and QoL. Clinical data of patients with PC were retrospectively evaluated. Patients received HR with VMAT and online image-guidance using daily CBCT. Dose was 70 Gy at 2.5 Gy/fraction. 3 target volumes were contoured: 20.3% prostate only, 17.2% prostate + seminal vesicles and 52.3 % prostate + seminal vesicles + pelvic lymph nodes. Patients filled out EORTC QLQ-C30 and PC-specific QLQ-PR25 questionnaires in two measuring points of observation. Late toxicity was assessed according to RTOG/EORTC score and International Prostate Symptom Score (IPSS) at the last consultation. The analysis included 115 PC patients (52–82 years) with 25-low-, 32 intermediate- and 58 high-risk. Median Gleason score was 7 and median PSA level of 10.25 ng/mL. Neoadjuvant androgen deprivation therapy was given to 87 patients (75.6 %) and stopped in 28 patients after 6 months; in 59 patients after 2–3 years. Median follow-up was 4.3 years (maximum: 5.5 years) The median of last PSA measurement was 0.10 ng/mL. 2 patients had PSA failure (biochemical control rate was 98.4%). No patients had local, node or metastatic relapse. Late genitourinary (GU) toxicity was observed for grades 0, 1, 2, 3 and 4 in 31.3%, 28.9%, 18%, 9.4% and 1.6%, respectively; late gastrointestinal (GI) toxicity was recorded for grades 0, 1, 2 and 3 in 75%, 5.5%, 6.3% and 0.8% patients, respectively. No grade IV late gastrointestinal toxicity was reported. IPSS score after radiotherapy was 10.5 ± 8.7 (mean ± SE). No deaths from prostate cancer but 1 due to toxicity by enterovesical fistula. Relapse-free interval was 52 months. 5-year cause-specific survival was 100% and 5-year overall survival was 90%. The questionnaires of QoL were filled out in two measuring points of observation (median 40 months after radiotherapy). Patients who received HR showed a lower degree of global health status and functional scale and increase of certain symptoms of side effects. However, emotional functioning improved and constipation decreased. The second questionnaire based on PC-specific symptoms increased, however, sexual functioning improved (questions about sexual functioning were conditional). These results are comparable to the reference date on QoL of cancer patients. HR with VMAT produces excellent rates of biochemical control for low, intermediate and high-risk PC. The long term GU and GI toxicity rates were considered low and acceptable. In addition, it is a well tolerated treatment in terms of QoL and has no negative impact on functioning and everyday life.

Diagnosis and treatment of enterovesical fistulas

A fistula is an atypical connection between two epithelial surface. We studied retrospectively four male pa­tients with enterovesical fistulas treated in our departments between March 2016 - March 2017. These in­cluded colovesical, rectovesical and ileovesical fistulas. Patients presented with urinary symptoms (pneu­maturia, faecaluria and recurrent urinary tract infections). One patient had received radiotherapy after rec­tal resection for rectal carcinoma. For another of the cases the fistula was being due to periprostatic abscess. The third patient was diagnosed with bladder carcinoma with rectal invasion. The fourth patient was with direct invasion of sigmoid cancer to the bladder. The most common investigations included abdominal ul­trasound, CT scan, cystoscopy and colonoscopy. Enteral stoma was performed in all cases as a part of sur­gical treatment. All patients underwent open procedure, as a main rule enteral stoma was performed to cease the contami­nation, and primary repair of the bladder was performed. No recurrences were recorded, but there were sev­eral complications, including Clavien-Dindo gr. V. Most of the complications were treated by interventional urology. In conlusion, enteral division and primary repair of the bladder are safe approaches for treatment of enterovesical fistulas. As a rule ceasing of contamination should always be performed. Cystoscopy can manage most of the complications occurring in the early postoperative period. Scr Sci Med 2017; 49(3): 53-56