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Colovesical Fistula: Unexpected Complication 7 Years After Augmentation Ileocystoplasty
Pediatric Case Report Colovesical Fistula: Unexpected Complication 7 Years After Augmentation Ileocystoplasty Ahmed Abdelhalim and Ashraf T. Hafez 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. UROLOGY 82: 1153e1155, 2013. 2013 Elsevier Inc.
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he ability to augment the capacity of the bladder with a reconfigured bowel segment has dramatically altered our ability to form a compliant urinary reservoir that protects the integrity of the upper urinary tract and promotes urinary continence. Despite the functional success of enterocystoplasty, clinical experience has demonstrated that numerous complications can result from the incorporation of small and large bowel and their associated heterotopic epithelium into the urinary tract. Altered growth, recurrent infections, stone formation, renal function deterioration, secondary malignancy, electrolyte, and acid-base disturbances are some of the long-term complications.1-3 In this article, we report the incidence of a colovesical fistula as a delayed complication (Clavian grade IIIb) after augmentation ileocystoplasty.
CASE REPORT A 16-year-old boy was born with classic bladder exstrophy. Staged repair was used to reconstruct the bladder. Bladder neck reconstruction was done at the age of 4 years, but it failed to achieve urinary continence. Thus, bladder neck closure, augmentation ileocystoplasty, and Mitrofanoff catheterizable stoma were done at the age of 9 years to increase the bladder capacity and to keep the patient dry. Since then, clean intermittent selfcatheterization was instituted using 12-Fr catheter through the continent cutaneous stoma. In the subsequent follow-up, the patient was dry at day and night. The upper tract was preserved. Gravity cystogram showed Financial Disclosure: The authors declare that they have no relevant financial interests. From the Urology and Nephrology Center, Mansoura University, Egypt Reprint requests: Ahmed Abdelhalim, M.Sc., M.R.C.S., Urology and Nephrology Center, Mansoura University, Gomhoria Street, 35516 Egypt. E-mail: [email protected] Submitted: March 23, 2013, accepted (with revisions): April 23, 2013
ª 2013 Elsevier Inc. All Rights Reserved
that the augmented bladder had a reasonable capacity without obvious fistulous communications. No serious metabolic complications were reported throughout the follow-up period. Over the past 2 years, the patient has been suffering from chronic intermittent diarrhea with the passage of loose watery stool. The patient denied febrile episodes, abdominal pain, cramping, vomiting, or bleeding per rectum. The patient did not report a family history of inflammatory bowel diseases or malabsorption syndromes. On examination, the patient had no signs of dehydration, malnutrition, or systemic illness. Abdominal and rectal examinations were unremarkable. Lower gastrointestinal tract endoscopy was done to diagnose the cause of diarrhea. A fistulous tract was identified in the sigmoid colon 30 cm from the anal verge. A contrast material was instilled during colonoscopy. Surprisingly, the augmented bladder was opacified, which denoted the presence of a colovesical fistula (Fig. 1). Cystoscopy was performed using the pediatric cystoscope through the cutaneous outlet. The augmented bladder was full of fecal matter. A hyperemic area with shreddy mucosa was seen in the posterior wall of the bladder just below the attachment of the outlet. Cold cup biopsies excluded the possibility of malignancy. On exploration, the sigmoid colon was adherent to the bladder. The anterior wall of the bladder was opened. The fistulous tract was identified. A 6-Fr catheter was successfully passed through the tract to the colon (Figs. 2 and 3). The fistulous tract was excised with the related part of the colon. The continuity of the colon was reestablished by interrupted seromuscular sutures and the augmented bladder was closed. The postoperative convalescence was free of complications. The bladder was drained by outlet and suprapubic catheters for 3 weeks. Intermittent catheterization was then resumed and continence was maintained. 0090-4295/13/$36.00 http://dx.doi.org/10.1016/j.urology.2013.04.033
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Figure 2. Intraoperative image showing a catheter (black arrow) passing through the fistulous tract between the bladder (A) and sigmoid colon (B). White arrows at the top point to the direction of the head of the patient. (Color version available online.)
Figure 1. The augmented bladder was opacified when contrast material was injected at colonoscopy, indicating the presence of a fistulous communication between the bowel and the bladder.
COMMENT Different segments of the alimentary tract have been widely used to increase the bladder capacity and create continent reservoirs in patients with small, poorly compliant bladders. Augmentation ileocystoplasty, with or without the creation of continent cutaneous stoma, has proved to be a successful treatment option when other treatment measures fail. It has revolutionalized the treatment of patients with neuropathic lower urinary tract dysfunction, exstrophy-epispadias complex, valve bladder syndrome, cloacal anomalies, and irreversible bladder damage. These procedures have helped to achieve continence, improve body image, and quality of life and prevent renal function deterioration.4 However, this procedure is not without its complications. Patients subjected to enterocystoplasty are at risk of a number of short- and long-term complications, various metabolic consequences, and unknown late sequelae. Recurrent infections, stone formation, upper tract deterioration, gastrointestinal complications, growth 1154
affection, stomal complications, secondary malignancy, electrolyte, and acid-base disturbance are some of the possible long-term complications.2 So far, we are still exploring the long-term consequences of incorporating bowel segments into the urinary tract. Moreover, onethird of patients will require further surgery after augmentation cystoplasty. Thus, a lifelong dedication from the patient, family, and health care providers is required for prevention, early detection, and management of possible complications.5,6 Fistula formation after augmentation enterocystoplasty has been reported in the immediate postoperative period.7 However, this report has shown that colovesical fistula might occur several years after successful augmentation enterocystoplasty. A review of published data has revealed a single case report of a delayed postoperative ileal-ileocystoplasty fistula presented with chronic intermittent diarrhea.8 To our knowledge, the occurrence of colo-vesical fistula as a delayed complication of augmentation enterocystoplasty has never been reported. Although the possible mechanism of fistula formation is unknown, traumatic catheterization might be the underlying mechanism. In retrospect, the possibility of enterovesical fistula should be taken into consideration for patients with chronic diarrhea after enterocystoplasty. Cystoscopy might be helpful for the diagnosis of enterovesical fistula; however, the findings on cystoscopy are often nonspecific. Contrast radiography might be helpful for diagnosis; however, negative results, as in this case, are not UROLOGY 82 (5), 2013
ocystoplasty. Thus, Austen and Kälble11 recommended annual endoscopic surveillance that starts in the third postoperative year for patients with any form of urinary diversion for early detection of secondary malignancies.
CONCLUSION Colovesical fistula might occur several years after augmentation enterocystoplasty. Traumatic catheterization might be the presumed possible mechanism. Exclusion of malignancy comes in the first place. Other long-term complication of enterocystoplasty might be revealed by the test of time. References
Figure 3. Intraoperative image showing a catheter passing through the fistulous tract (black arrows) between the ileal patch used for augmentation (A) and the sigmoid colon (B). The native bladder plate (C) is seen at the bottom. The close relation of the fistula to the attachment of the cutaneous outlet (black asterisk) can be easily noticed. White arrow at the top points to the direction of the head of the patient. (Color version available online.)
conclusive.9 Computerized axial tomography is now gaining popularity as the imaging modality of choice for diagnosis of colovesical fistula.10 Biochemical analysis of the liquid fecal matter might have helped to narrow the differential diagnosis. Before commencing treatment, the presence of malignancy should be ruled out. Although secondary malignancy is usually diagnosed 10-20 years after incorporation of intestinal segments into the urinary tract, it might occur as early as 2 years after enter-
UROLOGY 82 (5), 2013
1. Hautmann RE, Abol-Enein H, Hafez K, et al. Urinary diversion. Urology. 2007;69(suppl 1):17-49. 2. Scales CD Jr, Wiener JS. Evaluating outcomes of enterocystoplasty in patients with spina bifida: a review of the literature. J Urol. 2008; 180:2323-2329. 3. Baradaran N, Stec A, Wang MH, et al. Urinary diversion in early childhood: indications and outcomes in the exstrophy patients. Urology. 2012;80:191-195. 4. Rubenwolf PC, Beissert A, Gerharz EW, et al. 15 years of continent urinary diversion and enterocystoplasty in children and adolescents: the Wurzburg experience. BJU Int. 2010;105:698-705. 5. Metcalfe PD, Cain MP, Kaefer M, et al. What is the need for additional bladder surgery after bladder augmentation in childhood? J Urol. 2006;176(4 Pt 2):1801-1805; discussion 5. 6. Elshal AM, Abol-Enein H, Sarhan O, et al. Catheterizable serous lined urinary outlet in children and adolescents: a choice when other treatments fail. J Urol. 2011;185:1083-1087. 7. Bunyaratavej P, La-ornual S, Kongkanand A, et al. Ten years’ experience with enterocystoplasty. J Med Assoc Thai. 1993;76: 327-333. 8. Lin S, Hagger RW, Renani SM, et al. Delayed ileal-ileocystoplasty fistula formation: an unusual complication of augmentation enterocystoplasty. J Pediatr Urol. 2012;8:e16-e18. 9. Pontari MA, McMillen MA, Garvey RH, et al. Diagnosis and treatment of enterovesical fistulae. Am Surg. 1992;58:258-263. 10. Leicht W, Thomas C, Thuroff J, et al. Colovesical fistula caused by diverticulitis of the sigmoid colon: diagnosis and treatment. Urologe A. 2012;51:971-974. 11. Austen M, Kalble T. Secondary malignancies in different forms of urinary diversion using isolated gut. J Urol. 2004;172:831-838.
1155
T
he ability to augment the capacity of the bladder with a reconfigured bowel segment has dramatically altered our ability to form a compliant urinary reservoir that protects the integrity of the upper urinary tract and promotes urinary continence. Despite the functional success of enterocystoplasty, clinical experience has demonstrated that numerous complications can result from the incorporation of small and large bowel and their associated heterotopic epithelium into the urinary tract. Altered growth, recurrent infections, stone formation, renal function deterioration, secondary malignancy, electrolyte, and acid-base disturbances are some of the long-term complications.1-3 In this article, we report the incidence of a colovesical fistula as a delayed complication (Clavian grade IIIb) after augmentation ileocystoplasty.
CASE REPORT A 16-year-old boy was born with classic bladder exstrophy. Staged repair was used to reconstruct the bladder. Bladder neck reconstruction was done at the age of 4 years, but it failed to achieve urinary continence. Thus, bladder neck closure, augmentation ileocystoplasty, and Mitrofanoff catheterizable stoma were done at the age of 9 years to increase the bladder capacity and to keep the patient dry. Since then, clean intermittent selfcatheterization was instituted using 12-Fr catheter through the continent cutaneous stoma. In the subsequent follow-up, the patient was dry at day and night. The upper tract was preserved. Gravity cystogram showed Financial Disclosure: The authors declare that they have no relevant financial interests. From the Urology and Nephrology Center, Mansoura University, Egypt Reprint requests: Ahmed Abdelhalim, M.Sc., M.R.C.S., Urology and Nephrology Center, Mansoura University, Gomhoria Street, 35516 Egypt. E-mail: [email protected] Submitted: March 23, 2013, accepted (with revisions): April 23, 2013
ª 2013 Elsevier Inc. All Rights Reserved
that the augmented bladder had a reasonable capacity without obvious fistulous communications. No serious metabolic complications were reported throughout the follow-up period. Over the past 2 years, the patient has been suffering from chronic intermittent diarrhea with the passage of loose watery stool. The patient denied febrile episodes, abdominal pain, cramping, vomiting, or bleeding per rectum. The patient did not report a family history of inflammatory bowel diseases or malabsorption syndromes. On examination, the patient had no signs of dehydration, malnutrition, or systemic illness. Abdominal and rectal examinations were unremarkable. Lower gastrointestinal tract endoscopy was done to diagnose the cause of diarrhea. A fistulous tract was identified in the sigmoid colon 30 cm from the anal verge. A contrast material was instilled during colonoscopy. Surprisingly, the augmented bladder was opacified, which denoted the presence of a colovesical fistula (Fig. 1). Cystoscopy was performed using the pediatric cystoscope through the cutaneous outlet. The augmented bladder was full of fecal matter. A hyperemic area with shreddy mucosa was seen in the posterior wall of the bladder just below the attachment of the outlet. Cold cup biopsies excluded the possibility of malignancy. On exploration, the sigmoid colon was adherent to the bladder. The anterior wall of the bladder was opened. The fistulous tract was identified. A 6-Fr catheter was successfully passed through the tract to the colon (Figs. 2 and 3). The fistulous tract was excised with the related part of the colon. The continuity of the colon was reestablished by interrupted seromuscular sutures and the augmented bladder was closed. The postoperative convalescence was free of complications. The bladder was drained by outlet and suprapubic catheters for 3 weeks. Intermittent catheterization was then resumed and continence was maintained. 0090-4295/13/$36.00 http://dx.doi.org/10.1016/j.urology.2013.04.033
1153
Figure 2. Intraoperative image showing a catheter (black arrow) passing through the fistulous tract between the bladder (A) and sigmoid colon (B). White arrows at the top point to the direction of the head of the patient. (Color version available online.)
Figure 1. The augmented bladder was opacified when contrast material was injected at colonoscopy, indicating the presence of a fistulous communication between the bowel and the bladder.
COMMENT Different segments of the alimentary tract have been widely used to increase the bladder capacity and create continent reservoirs in patients with small, poorly compliant bladders. Augmentation ileocystoplasty, with or without the creation of continent cutaneous stoma, has proved to be a successful treatment option when other treatment measures fail. It has revolutionalized the treatment of patients with neuropathic lower urinary tract dysfunction, exstrophy-epispadias complex, valve bladder syndrome, cloacal anomalies, and irreversible bladder damage. These procedures have helped to achieve continence, improve body image, and quality of life and prevent renal function deterioration.4 However, this procedure is not without its complications. Patients subjected to enterocystoplasty are at risk of a number of short- and long-term complications, various metabolic consequences, and unknown late sequelae. Recurrent infections, stone formation, upper tract deterioration, gastrointestinal complications, growth 1154
affection, stomal complications, secondary malignancy, electrolyte, and acid-base disturbance are some of the possible long-term complications.2 So far, we are still exploring the long-term consequences of incorporating bowel segments into the urinary tract. Moreover, onethird of patients will require further surgery after augmentation cystoplasty. Thus, a lifelong dedication from the patient, family, and health care providers is required for prevention, early detection, and management of possible complications.5,6 Fistula formation after augmentation enterocystoplasty has been reported in the immediate postoperative period.7 However, this report has shown that colovesical fistula might occur several years after successful augmentation enterocystoplasty. A review of published data has revealed a single case report of a delayed postoperative ileal-ileocystoplasty fistula presented with chronic intermittent diarrhea.8 To our knowledge, the occurrence of colo-vesical fistula as a delayed complication of augmentation enterocystoplasty has never been reported. Although the possible mechanism of fistula formation is unknown, traumatic catheterization might be the underlying mechanism. In retrospect, the possibility of enterovesical fistula should be taken into consideration for patients with chronic diarrhea after enterocystoplasty. Cystoscopy might be helpful for the diagnosis of enterovesical fistula; however, the findings on cystoscopy are often nonspecific. Contrast radiography might be helpful for diagnosis; however, negative results, as in this case, are not UROLOGY 82 (5), 2013
ocystoplasty. Thus, Austen and Kälble11 recommended annual endoscopic surveillance that starts in the third postoperative year for patients with any form of urinary diversion for early detection of secondary malignancies.
CONCLUSION Colovesical fistula might occur several years after augmentation enterocystoplasty. Traumatic catheterization might be the presumed possible mechanism. Exclusion of malignancy comes in the first place. Other long-term complication of enterocystoplasty might be revealed by the test of time. References
Figure 3. Intraoperative image showing a catheter passing through the fistulous tract (black arrows) between the ileal patch used for augmentation (A) and the sigmoid colon (B). The native bladder plate (C) is seen at the bottom. The close relation of the fistula to the attachment of the cutaneous outlet (black asterisk) can be easily noticed. White arrow at the top points to the direction of the head of the patient. (Color version available online.)
conclusive.9 Computerized axial tomography is now gaining popularity as the imaging modality of choice for diagnosis of colovesical fistula.10 Biochemical analysis of the liquid fecal matter might have helped to narrow the differential diagnosis. Before commencing treatment, the presence of malignancy should be ruled out. Although secondary malignancy is usually diagnosed 10-20 years after incorporation of intestinal segments into the urinary tract, it might occur as early as 2 years after enter-
UROLOGY 82 (5), 2013
1. Hautmann RE, Abol-Enein H, Hafez K, et al. Urinary diversion. Urology. 2007;69(suppl 1):17-49. 2. Scales CD Jr, Wiener JS. Evaluating outcomes of enterocystoplasty in patients with spina bifida: a review of the literature. J Urol. 2008; 180:2323-2329. 3. Baradaran N, Stec A, Wang MH, et al. Urinary diversion in early childhood: indications and outcomes in the exstrophy patients. Urology. 2012;80:191-195. 4. Rubenwolf PC, Beissert A, Gerharz EW, et al. 15 years of continent urinary diversion and enterocystoplasty in children and adolescents: the Wurzburg experience. BJU Int. 2010;105:698-705. 5. Metcalfe PD, Cain MP, Kaefer M, et al. What is the need for additional bladder surgery after bladder augmentation in childhood? J Urol. 2006;176(4 Pt 2):1801-1805; discussion 5. 6. Elshal AM, Abol-Enein H, Sarhan O, et al. Catheterizable serous lined urinary outlet in children and adolescents: a choice when other treatments fail. J Urol. 2011;185:1083-1087. 7. Bunyaratavej P, La-ornual S, Kongkanand A, et al. Ten years’ experience with enterocystoplasty. J Med Assoc Thai. 1993;76: 327-333. 8. Lin S, Hagger RW, Renani SM, et al. Delayed ileal-ileocystoplasty fistula formation: an unusual complication of augmentation enterocystoplasty. J Pediatr Urol. 2012;8:e16-e18. 9. Pontari MA, McMillen MA, Garvey RH, et al. Diagnosis and treatment of enterovesical fistulae. Am Surg. 1992;58:258-263. 10. Leicht W, Thomas C, Thuroff J, et al. Colovesical fistula caused by diverticulitis of the sigmoid colon: diagnosis and treatment. Urologe A. 2012;51:971-974. 11. Austen M, Kalble T. Secondary malignancies in different forms of urinary diversion using isolated gut. J Urol. 2004;172:831-838.
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