Introduction

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Colovesical fistula (CVF) is the pathologic communication between the sigmoid colon and the urinary bladder, the most common cause of which tends to be diverticular disease, accounting for 50-88% of cases. However, it can also present in other diseases, such as colon cancer (10-12%), inflammatory bowel disease (5-8%), non-Hodgkin lymphoma and AIDS, as well as resulting from radiotherapy sequelae, trauma lesions, and iatrogenic lesions during pelvic surgery (4-13%), with resolution requiring surgical management [1].

The frequency of CVF in complicated diverticular disease has been estimated at 2-6%, with a range of 2-23%. That is especially true in older adult patients, in whom risk factors for chronic-degenerative diseases tend to condition morbidity in 16-35% of patients [1-5] with a worldwide mortality rate of 0.51±0.31/100.000 and a range of 0.11-1.75 [6-8].

Surgical treatment consists of resecting the affected sigmoid colon, with primary anastomosis and closure of the lesion in the bladder wall, and should be performed as an elective procedure [9-11]. The anastomosis should be protected through ileostomy, if the surgeon feels there is the possibility of anastomotic dehiscence due to suture tension or technical difficulties during the surgery [12,13]. Conventional and laparoscopic are the chosen options, and Robotic assistance has recently been successfully introduced, but given its lack of availability and high cost, is only performed at national referral centers [14-21].

The results of surgical treatment are satisfactory in the majority of patients, but 2-23% tend to present with Clavien-Dindo III-V complications. Anastomotic dehiscence is the main complication, making reintervention necessary, and the mortality rate reported in the medical literature varies from 0 to 4,5%, especially when the disease is associated with advanced age and general risk factors [22].

In Mexico in 2007, it was published a 5-year experience regarding the management of cases treated at the Hospital General de México “Eduardo Liceaga” that underwent sigmoidectomy, with good results and no deaths and in Latin America, there are no reports on the results of surgical management of CVF, which is why we consider the present study to be important [23].

Materials and Method

A retrospective, descriptive, comparative study on a cohort of cases was conducted.

Study universe: Patients diagnosed with diverticular disease, complicated by colovesical fistula (CVF), treated at the UMAE No. 14 of the Centro Médico Nacional “Adolfo Ruiz Cortines” of the Instituto Mexicano del Seguro Social in Veracruz, within the time frame of 2017-2021.

Inclusion criteria: Adult subjects with CVF.

Exclusion criteria: Adult subjects with CVF whose medical records were incomplete.

Elimination criteria: Patients that did not accept surgical treatment.

Protocol design: Patients were clinically evaluated and routine laboratory studies, colonoscopy, double contrast CT and cardiopulmonary assessment were performed. All of them underwent mechanical cleansing through liquid diet and osmotic laxatives (Macrogol 105.00 gr. in 4 takes), the day before the intervention. Sigmoidectomy was performed, with primary anastomosis and bladder wall closure. In 3 cases (6.82%), defunctionalization was carried out through ileostomy, and hysterectomy was performed in the same surgical act in 8 cases (18.18%). The conventional and laparoscopic surgical approaches were performed. In the two approaches, two staplers were employed: a 60 mm linear stapler for the proximal closure of the rectal stump and a 29 or 33 mm stapler for the anastomosis. Bladder wall repair was carried out with continuous suturing, using synthetic absorbable 0 polyglycolic acid sutures, and finally underwent testing for anastomotic leakage, by insufflating pressurized air and compressing the proximal segment to verify its integrity. A simple Penrose drain, as well as a bladder catheter, were placed in 100% of the cases. The patients received a postoperative antimicrobial regimen, consisting of cefotaxime (n = 20; 45.45%), ciprofloxacin (n = 13; 29.55%), or ceftriaxone (n = 11; 25.00%), together with metronidazole, in all cases.

Variables analyzed

Age, sex, progression time of the condition, risk factors, surgical approach, type of surgery performed, days of hospital stay, complications, and mortality.

Statistical analysis

The results were analyzed, using the descriptive statistics of measures of central tendency and dispersion for the quantitative variables and the Student’s t test for the continuous variables. The IBM-SPSS, version 25.0, software for Windows, was employed for the analysis.

Ethical aspects

The present study was conducted according to the principles stated in the Declaration of Helsinki, the NOM-012-SSA3-2012, and the General Health Law for Health Research, article 17, which stipulates that the execution of research projects on humans must result in no risk for the study participants and that the data collected be completely confidential and anonymous. The protocol was approved by the Bioethics and Research Committee of the UMAE No 14 of the IMSS and the School of Medicine of the Universidad Veracruzana, Veracruz-Boca del Río.

Financial disclosure

The study was performed with resources from the participating institutions. There was no external funding.

Conflict of interest

All authors declare that there are no conflicts of interest.

Results

A total of 52 patients were studied. Seven of them were excluded due to incomplete medical records and 1 was eliminated for not accepting the surgical procedure, leaving a study group total of 44, graph 1.

The anthropometric characteristics of the entire study group were: mean age of 62,}.12±12,25 years (range 34-98), a predominance of women (n = 25; 56.82%) over men (n = 19; 43.18%), and a mean body mass index (BMI) of 31.82±5,89 kg/ m2 (range 18-38).

Progression time from disease onset to the performance of the intervention was 15.00±5.02 weeks (range 8-48). Thirty-nine cases (88.64%) presented associated comorbidities, and the ASA general anesthesia/surgery risks were: grade I and II in most of cases, table 1.

Figure 1

Table 1

The patients were divided into two groups: group A) patients that underwent the conventional approach with open surgery (n = 38; 86.36%) and group B) patients that underwent the laparoscopic approach (n = 6; 13.64%).

Anesthesia/surgery duration

In group A, duration was 220.08±44.7 minutes (range 140-310), whereas in group B, it was 340,.23±14.3 minutes (range 140-310) (p=0,001).

Intraoperative bleeding

In group A, blood loss was estimated at 332.45±14.3 ml (rango100-500), and 1 patient required 2 units of packed red blood cells, whereas in group B, blood loss was 168.1±12.8 ml (range100-350) (p=0.006).

Conversion rate

There was no need for conversion to open surgery

Defunctionalization

In group A, the surgeon decided on prophylactic defunctionalization in 3 cases (7.89%), whereas in group B it was not performed on any of the cases (p=0.183).

Oral diet resumption

In group A, oral diet was resumed at 48.71±8.9 postoperative hours (range 24-72), whereas in group B, it was resumed at 45.62±4,7 postoperative hours (range 24-72) (p=0.235).

Hospital stay

In group A, the mean duration of hospital stay was 9.92±19,7 days (range 4-6), whereas in group B, it was 4.42±0,5 days (range 7-81) (p=0.228).

Bladder catheter removal

In group A, the catheter was removed on postoperative day 32.63±5,8, whereas in group B, removal was on postoperative day 31.4±3.5 (p=0.037).

Progression Length of follow-up

In group A, follow-up lasted 14.94±13.6 months, and in group B, it lasted 13.82±4,3 months (p=0.235).

Complications

In group A, 10 cases (26.32%) presented with complications. In 5 of those cases (11.66%), they were mild Clavien-Dindo grade I complications, which included surgical wound infection (n = 4; 10.52%), seroma (n = 3; 7.89%), and anastomotic stricture (n = 1; 2.63%), all of which were resolved through conservative management. Two cases (5.26%) presented with Clavien-Dindo grade III complications, that included anastomotic leak and wall eventration, and required reintervention in the immediate postoperative period. In group B, there were only 2 ClavienDindo grade I complications: one case of seroma and one case of stricture (16.67%, respectively), which were resolved through conservative management. There was no grade III or grade IV complications (p=0.082) [1].

Reintervention

In Group A, 5 cases (13.16%) underwent reintervention, 2 of which (5.26%) were performed in the immediate postoperative period. One of the cases (2.63%) of reintervention was due to anastomotic dehiscence, and ileostomy was carried out, and the other case was due to abdominal wall eventration. In the remaining 3 cases (7.89%) elective reintervention was performed six weeks after ileostomy closure. In group B, there were no reinterventions (p=0.068), table 2.

Mortality

There were no perioperative or postoperative deaths in either of the two groups.

Table 2

Discussion

The standardized treatment of FVC is surgical resection of the sigmoid and suture of the vesical wall, which should be performed electively after the acute episode has been controlled. The open surgery approach can be carried out, although traditional, handassisted, or robotic-assisted laparoscopy can be performed at high-volume referral centers by experienced coloproctology surgeons. The laparoscopic techniques have shown results equal to those of the conventional approach, with less intraoperative blood loss, and significantly reduced morbidity, surgical site infections, and length of hospital stay. However, the use of laparoscopy has been the subject of debate due to the elevated conversion rate caused by the firm pelvic adhesions resulting from the inflammatory process [12-21].

The results of our cohort of cases were compared with eleven studies published over the past fifteen years, in which 401 patients that underwent surgical interventions (155 open surgeries [38.65%] and 246 laparoscopies [61,35%]) were analyzed [15, 21-30], table 4.

In the majority of the case series evaluated, the mean age was 68 years (range 28-84), whereas it was slightly lower, at 62.12±12.21 years (range 34-98), in our study. In general, male sex predominated (54-63%), whereas female sex predominated in our analysis (56.82%), with a BMI of 31.82±5.89 (range 18- 38). The comorbidities associated with complicated diverticular disease were frequent in all the case series. In our study, they presented in 88,26% of the patients, with the majority having one or two complications. The most frequent comorbidities were obesity, diabetes mellitus, and high blood pressure and the ASA risk was grade I and II in 90.91% of our patients, similar to that reported by different authors [26- 32].

Surgery duration in our study was a mean 220.08±44.7 minutes for open surgery, whereas it was 340.23± 14.3 minutes for the laparoscopic approach. The difference was statistically significant (p=0.001), similar to that published with a mean of 150 to 350 minutes for complicated diverticular disease, with longer times in cases of colovesical fistula [29-33].

Intraoperative blood loss was higher during open surgery, at 332.45±14.33 ml (range 100-500), with only one case requiring blood transfusion, whereas for the laparoscopic procedure, blood loss was only 168.1±12 ml, resulting in a statistically significant difference (p=0.001), higher than reported by other aurors of 75-125 ml [24,25,30] The use of preventive ileostomy is usually left up to the criterion and experience of the surgeon and is recommended in cases in which there is a possibility of anastomotic dehiscence, whether due to deficient tissue irrigation or suture line tension, we prefer the performance of the ileostomy as a defunctionalization procedure because its closure is simpler and with less morbidity than the transverse colostomy The results published by different authors is 9.47%, especially regarding open surgery, and is similar to the 7.89% of our open surgery cases (p=0.183) [9,12,14,15,21,24- 30]. The conversion rate to open surgery found in the literature is 21.95%, ranging from 0 to 40%, but in our case series, there was no need for conversion in any of the patients.

Immediate postoperative management was satisfactory in the majority of our patients. They all received an antimicrobial regimen made up of the combination of metronidazole with cefotaxime in 45.45%, ciprofloxacin in 29.55%, or ceftriaxone in 25,00%. There were no statistically significant differences, with respect to oral diet resumption, which took place at 48.71±8.9 hours after the open surgery and at 45.62±4.7 hours after the laparoscopic surgery (p=0.165), to the number of days of hospital stay, which was 9.92±19.7 days in the open surgery patients and 4.42±0.5 days in the laparoscopy patients (p=0.228), or to bladder catheter removal, which was on postoperative day 32.6±5.8 for open surgery and day 31.4±3.5 for the laparoscopic procedure (p=0.037).

The length of postoperative follow-up was similar in groups A and B (14.94±136 days and 13.82±4.3 days, respectively) (p=0.235). Complications presented in 10 cases (26.32%) in the open surgery group, 2 (5.26%) of which were Clavien-Dindo III (anastomotic leak and abdominal wall eventration) that required reintervention in the immediate postoperative period. In the laparoscopy group there were 2 minor complications (seroma and stricture) and no serious ones (p=0.082), similar to that reported in the universal literature (7.23%; range 0-23). The mortality rate was low in all the case series (0-2.3%) and there were no deaths in our study patients [9,12,14,15,21,24-30].

Table 3

Conclusions

Sigmoidectomy with closure of bladder perforation is the recommended treatment in patients with colovesical fistula, which should be performed electively.

In our series as published by various authors we obtained good results with low morbidity and no mortality, so we consider it safe and reliable

Laparoscopic surgery has advantages over the conventional approach and is recommended to be performed in high-volume hospitals and by experienced surgeons.

References

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