Nella maggior parte dei casi le fistole colovescicali rappresentano una complicanza della malattia diverticolare e sono la tipologia più comune di fistola colodigestiva; meno comuni sono le fistole colovaginali, colocutanee, coloenteriche e colouterine. Nel presente lavoro abbiamo effettuato una review della letteratura riguardante le fistole colovescicali in chirurgia colorettale per diverticolite del sigma. Decriviamo anche due casi che hanno richiesto un trattamento chirurgico, in uno in elezione e nell’altro in urgenza. In entrambi i casi abbiamo eseguito una resezione colica con anastomosi primaria e minimaresezione vesvicale con posizionamento di catetere di Foley in media per 10 giorni

Cirocchi, R.

Covarelli, P.

Di Patrizi, M.S.

Farinella, E.

La Mura, F.

Milani, D.

Napolitano, V.

Sciannameo, F.

Trastulli, S.

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G Chir Vol. 30 - n. 11/12 - pp. 490-492Novembre-Dicembre 2009490IntroductionColovesical fistulae are the most common type of ve-sicointestinal fistula and the most prevalent of these arevesicosigmoid fistulae. In most cases, they are compli-cation of diverticular disease (about 50% of all vesicalfistulae) and so they can be associated with  previous hi-story of diverticulitis-like symptoms. The incidence of these fistulae due to complicateddiverticulitis is not always homogeneous and it can varyaccording to the different causes, which can be, thou-gh less commonly, locally advanced pelvis neoplasms,Crohn’s disease, radiotherapy effects, penetrating pelvictrauma and iatrogenic surgical lesions (1, 2). Case reports   We report the clinical cases of two patients with colovesical fi-stulae that we observed in our Surgery Division at the Ospedale Ci-vile “S. Maria” in Terni, Italy.Case 1 A 65-year-old man was admitted with a history of recurring cy-stitis in the previous 6 months and recent fever and pneumaturia.The patient was also affected by type II diabetes mellitus and theurine culture test was positive for Gram-negative bacteria (Escheri-chia Coli and Klebsiella).A cystoscopy was carried out and did not show the presence ofa fistula, but obey cystitis. The abdominal and pelvic ultrasound scanunderlined the presence of an adherence plate in the Douglas, whi-ch involved the sigmoid colon and the vesical wall. A barium ene-ma was performed and showed a sigmoid diverticular disease butnot the presence of a colovesical fistula. A pelvic CT did not seemSUMMARY: Colovesical fistulae in the sigmoid diverticulitis.R. CIROCCHI, F. LA MURA, E. FARINELLA, V, NAPOLITANO, D. MILANI, M.S. DI PATRIZI, S. TRASTULLI, P. COVARELLI, F. SCIANNAMEOIn most cases Colovesical fistulae are complications of diverticulardisease and representing the most common kind of colodigestive fistula;less common are colovaginal, colocutaneous, coloenteric and colouteri-ne fistula. In this article we review the literature concerning colovesical fistu-lae in colorectal surgery for sigmoid diverticulitis and report on two ca-ses that required a surgical treatment, one elective and the other in emer-gency. In both cases we performed a sigmoid resection with a primaryanastomosis and small vesical window-ectomy placing a Foley catheterfor about 10 days.RIASSUNTO: Le fistole colovescicali nella diverticolite del sigma.R. CIROCCHI, F. LA MURA, E. FARINELLA, V, NAPOLITANO, D. MILANI, M.S. DI PATRIZI, S. TRASTULLI, P. COVARELLI, F. SCIANNAMEONella maggior parte dei casi le fistole colovescicali rappresentano unacomplicanza della malattia diverticolare e sono la tipologia più comu-ne di fistola colodigestiva; meno comuni sono le fistole colovaginali, co-locutanee, coloenteriche e colouterine.Nel presente lavoro abbiamo effettuato una review della letteratu-ra riguardante le fistole colovescicali in chirurgia colorettale per diver-ticolite del sigma. Decriviamo anche due casi che hanno richiesto untrattamento chirurgico, in uno in elezione e nell’altro in urgenza. Inentrambi i casi abbiamo eseguito una resezione colica con anastomosiprimaria e minimaresezione vesvicale con posizionamento di catetere diFoley in media per 10 giorni.Università degli Studi di Perugia Ospedale S. Maria di Terni Chirurgia Generale e d’UrgenzaScuola di Specializzazione in Chirurgia Generale© Copyright 2009, CIC  Edizioni Internazionali, RomaColovesical fistulae in the sigmoid diverticulitisR. CIROCCHI, F. LA MURA, E. FARINELLA, V, NAPOLITANO, D. MILANI, M.S. DI PATRIZI, S. TRASTULLI, P. COVARELLI, F. SCIANNAMEOKEY WORDS: Colovesical fistula - Diverticular disease - Surgery.Fistola colovescicale - Malattia diverticolare - Chirurgia.491Colovesical fistulae in the sigmoid diverticulitisto be necessary, while a cystography was carried out and showed thepresence of a colovesical fistula. The patient underwent a left hemicolectomy associated with asmall vesical window-ectomy, in order to have enough healthy wallfor the later reconstruction with Vicryl stiches. A vesical two-waycatheter and a drainage were placed and the Foley catheter was re-moved on the 10th postoperative day after a negative cystography.Case 2 A 72-year-old woman was treated in emergency for acute ab-dominal pain and septic conditions with dysuria, ileus since 5 daysand neutrophilia (84%). The ultrasound scan was positive for a Dou-glas abscess and the patient underwent surgery for a suspected ap-pendicitis with peritonitis. We found a large volume of pus in the pelvic pouch (but no si-gn of appendix inflammation), and several adherences involving thegreat epiploon, the sigmoid intestine and the bladder. So we carriedout adherence lysis, pus drainage and we removed the inflamed stret-ch of the large epiploon, the sigmoid tract involved in the inflam-matory process and a small part of the vesical wall adherent to thecolon. A Knight-Griffen  terminal-lateral rectocolic anastomosis wasperformed and a vesical wall reconstruction with Vicryl stiches wascarried out. Also in this case we placed a vesical two-way catheter which wasremoved on 10th postoperative day after a negative cystography. Discussion  Colovesical fistulae from diverticulitis are the mostcommon vesical fistula and they can be due to two dif-ferent mechanisms: direct extension and rupture of a di-verticular abscess into the bladder (most common) ordirect perforation of the diverticulum which adheres tothe bladder (more rare). The signs of colovesical fistulas can be vague and noteasily identified, but in nearly all cases, a “pre-fistula syn-drome” is present: pain in the lower abdomen, dysuria,and vesical tenesmus. The correct diagnostic approachin case of clinical suspect of  colovesical fistula has beenalways discussed but even the guidelines for sigmoid di-verticulitis proposed by the American Society of Colon andRectal Surgeons’ Task Force hasn’t established the most sui-table method for diagnosis of colovesical fistula (4) . So-me authors suggest a colic type investigation (recto-sig-moidoscopy and barium enema) (5, 6). Most urologi-sts propose intravenous pyelography, cystography andcystoscopy (7, 8). Most of the authors emphasize the useof CT with contrast medium (9, 10). This allows thecorrect diagnosis in 92-100% of the cases. Direct eva-luation with a spiral CT of the fistula can be obtainedin a minority of cases, while most signs are indirect: blad-der opacification with contrast (70-80%), gas in the ve-sical lumen (95%), adjacent colon diverticula and  fo-cal thickening of the vesical wall or abscess between co-lon and bladder. Garcea et al. in their study of 90 con-secutive cases of colovesical fistulae state that barium ene-ma, colonic endoscopy and CT should be routine in theinvestigation of colovesical fistulae (6).Surgery is the only possible treatment for colovesi-cal fistulae. According to Garcea et al. resection and pri-mary anastomosis should be the treatment of choice, withan acceptable risk of anastomotic leak and mortality (6).In the Clinical Decision Making in Colorectal Surgery,Wexner and Texeira suggest  placing  ureteral stents inthe immediate pre-operatory time to avoid iatrogenic le-sions due to adhesiolysis (11).  If peritonitis is present, Hermann and Abernathy, re-commend the lysis of the adherences between bladderand sigmoid colon, with resection and  left-side colo-stomy; the two-stage surgery is justified by the risk ofanasthomatic dehiscence in presence of a peritonitis (12).Instead, in a 9-year review about complicated diverti-cular disease, the authors state that the procedure of re-section and primary anastomosis for acute diverticuli-tis has an acceptable morbidity and mortality (13). Forhigh-risk anastomosis, a covering loop ileostomy insteadof a Hartmann’s procedure would be preferred (13). Although it is not possible to define the ideal andsafe surgical approach, according to our experience andto some literature reviews, the “golden standard” is a sig-moid resection with a primary anastomosis and a smallvesical window-ectomy, placing Foley catheter for about10 days (14).1. Covarelli P, Cirocchi R, Alemagni Pimpinelli G, Nonno S, Se-verini D, Mosci F: Fistole colovescicali nella malattia divertico-lare. Atti del convegno congiunto Società Tosco-Umbra di Chi-rurgia e Royal Society of Coloproctology, Firenze, 1995;157-58.2. Cristofani R, Bufalari A, Cirocchi R et al. Valutazione compa-rativa degli interventi per diverticolite acuta complicata. Atti del-l’XI Congresso Nazionale del Collegium Internazionale Chirur-giae Digestivae. Napoli, 1994.3. Charúa-Guindic L, Jiménez-Bobadilla B, Reveles-González A,Avendaño-Espinosa O, Charúa-Levy E [Incidence, diagnosis andtreatment of colovesical fistula.] Cir Cir. 2007 Sep-Oct;74(5):343-9.4. Task Force dell’American Society of Colon and rectal Surgeons:Practice parameters for sigmoid diverticulitis. Dis Colon Rec-tum 1995; 125-32.5. Almy TP, Nailove A. Malattia diverticolare del colon. In: Slei-senger MH, Fortran JS (eds): Trattato di Gastroenterologia. Pa-dova: Piccin Nuova Libreria 1998; 14588-75.6. Garcea G, Majid I, Sutton CD, Pattenden CJ, Thomas WM.Diagnosis and management of colovesical fistulae; six-year ex-perience of 90 consecutive cases. Colorectal Dis 2006;8(4):347-52.7. Marshall FF. Chirurgia della vescica. In: Walsh PC, Retik AB,References492R. Cirocchi et al.Vaughan ED, Wein AJ (eds): Urologia di Campbell. Roma: Ver-ducci Editore 1999; 3307-28.8. Cappèle O, Scottè M, Sibert L, Songnè B, Grise P, Ténière P.Role of complementary tests in the management of colo-vesi-cal fistulae. Prog Urol. 2001; 11(4):657-61.9. Angelelli G, Macarini L. Diverticolite. Torino, Edizioni Miner-va Medica, 107-9.10. Najjar SF, Jamal MK, Savas JF, Miller TA. The spectrum of co-lovesical fistula and diagnostic paradigm. Am J Surg 2004;188(5):617-21.11. Habr-Gama A, Teixera MG. In: Wexner SD, Vernava AM III(eds): Clinical decision making in colorectal surgery. New York,Igaku-Shoin 1995; 303-8.12. Hermann G, Abernathy C. Diverticular disease. In: Norton, Law-rence W & Ben Eiseman (eds), Saunders Co 1986: Surgical de-cision making. pp158-59.13. Bahadursingh AM, Virgo KS, Kaminski DL, Longo WE. Spec-trum of disease and outcome of complicated diverticular disea-se. Am J Surg 2003; 186(6):696-701.14. Lauro A, Alonzo Poza A, Cirocchi R et al. Laparoscopic surgeryfor colon diverticulitis. Min Chir 2002; 57(1):1-5.

Colovesical fistulae in the sigmoid diverticulitis

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Colovesical fistulae in the sigmoid diverticulitis

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