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Vesico-Enteric Fistulas
Symposium on Personal Preferences in Surgery
Vesico-Enteric Fistulas Clifton F. West, Jr, M.D.*
Vesico-enteric fistulas have been known to the medical profession for centuries. They were first described in detail as to etiology, pathology and treatment in the British literature in the late nineteenth century. However, it was not until more refined techniques in intestinal and urologic surgery evolved that progress was made in the complete correction of this relatively uncommon surgical problem. Collected reviews were common in the 1920's and 1930's from the Mayo Clinic and other leading medical centers in this country. Treatment consisted of an intestinal diverting procedure, usually a transverse colostomy. With our present surgical knowledge, the patient with this distressing problem, when due to benign disease, can look forward to complete correction with low morbidity and mortality. Certain basic principles must be observed. This report concerns 28 cases managed over a 10 year period.
INCIDENCE The average hospital can expect two or three cases for every 10,000 admissions. Males predominate over females in a ratio ranging from 3:1 to 5:1. Our own recent series was 19 males to 9 females. However, this included 3 patients with radiation necrosis for female pelvic cancer. The uterus is thought to protect the bladder from the intestinal disease process by its usual anatomic interposition. This may be altered by the higher incidence of hysterectomy in our present population and, indeed, some recent series show a ratio approaching 50-50.
ETIOLOGY AND PATHOLOGY In the late nineteenth century tuberculosis, amebiasis, and syphilis were the common causes in the described cases. These are almost un*Associate Surgeon, Lankenau Hospital; Assistant Professor in Surgery, Jefferson Medical College, Philadelphia, Pennsylvania
Surgical Clinics of North America- Vol. 53, No.3, June 1973
565
566
CLIFTON
F.
WEST, JR.
Figure 1. Schematic drawing of vesico-enteric fistulas: A, vesicaappendiceal; B, ileovesical; C, colovesical; D, rectovesical.
known at the present time. Diverticulitis is by far the most common underlying pathology. Cases of vesico-appendiceal fistula which have been reported have always been due to a neglected or overlooked appendicitis with rupture. There were 19 cases of diverticulitis with two cases of Crohn's disease in our series. Carcinoma of the sigmoid was present in 6 cases. Radiation necrosis associated with treatment for female pelvic malignant disease comprised 3 cases. The fistula is initiated by ulceration and inflammation of the bowel wall with subsequent perforation and extramural suppuration from whatever the underlying cause happens to be. The route is determined by the anatomic pathway available and, fortunately, is usually located on the dome of the bladder. In malignant cases, where operable, this allows for adequate bladder resection with preservation of bladder function. However, none of our 6 patients with colon carcinoma survived more than 5 years, the longest survival being 4112 years, with an average of 2 yean. This is thought to reflect the advanced stage of colonic carcinoma.
CLINICAL FEATURES Urinary symptoms predominate the picture, with recurrent cystitis the most common feature. This was present in over 50 per cent of our cases. The delay in diagnosis of the fistula in our series ranged from several weeks to 18 months.
VESICO-ENTERIC FISTULAS
567
Pneumaturia is a pathognomonic sign and was present in 21 of 28 cases. Fecaluria was present in 15 cases. The intestinal signs were silent in over half of our cases and when manifested were relatively nonspecific. Pain and alteration in bowel habit were the most common. Three with carcinoma of the sigmoid complained of bloody stools in conjunction with their urinary symptoms. There was no bleeding with the 17 cases of diverticulitis and 2 of Crohn's disease. Interestingly enough, the 2 cases of Crohn's disease were diagnosed as "spastic colitis," thought to be related to the tension of their recurrent urinary symptoms. The ages of these patients were 32 and 34. The delay in one was 18 months in spite of having seen three separate urologists. The three cases due to radiation necrosis followed cobalt therapy and also had a finding of residual tumor. Both probably contributed to this disorder.
CLINICAL INVESTIGATTON The patient with a suspected vesico-enteric fistula demands the efforts of both the urologist and surgeon. Since urological symptoms predominate, the urologist is usually consulted first. This was the case in 24 out of 28 of our cases. Cystoscopic examination of an incipient fistula simply shows a hyperemic area of bladder mucosa. Later it becomes surrounded with bulbous edema and papillomatous proliferation of the mucosa. The fistula was demonstrated by dye on barium enema studies in only 11 of our 28 cases. Biopsies should be taken where tumor is suspected. Urine cultures and sensitivity studies to antibiotics should be done. The most common organism is E. coli which was present in 26 of 28 patients. Bimanual pelvic and rectal examinations frequently reveal a tender extravesical mass. If general anesthesia is used for cystoscopy, palpation of a mass is simplified. Sigmoidoscopy was revealing in only the 3 cases of radiation necrosis. This is easily explained by the distortion and angulation of the intestinal tract associated with the development of a perimural abscess preceding the development of a full-blown fistula. It is hoped, by the author, that with the acquisition of the flexible fiberoptic scope a more accurate preoperative evaluation and demonstration of the underlying pathology can be made. Barium enema examination revealed colon pathology in all cases. However, in more than half, this was not striking and in only six of the 19 diverticulitis cases was a fistulous tract demonstrated by this method. In the 6 sigmoidal carcinomas, all tumors were demonstrated. In our two cases due to ileitis, the diagnosis was delayed 4 months in one and 18 months in the other because of a failure to obtain barium studies of the small bowel.
568
CLIFTON
F.
WEST, JR.
FACTORS DETERMINING CHOICE OF SURGICAL PROCEDURES The etiology, extent of pathology, degree of bowel obstruction as well as toxicity from massive bladder infection all enter into the decision as to a one-stage versus a multi-stage procedure. Here again, bimanual examination is our best method for determining the extent and secondary involvement of other structures by the fistulous process. Of our 17 cases due to diverticulitis, 12 underwent a three-staged procedure. The one death occurred in a 78 year old woman with advanced emphysema who suffered cardiac arrest in the operating room, was resuscitated, and died a cardiac death 6 days after operation. One case, an 84 year old man, with the only symptom of pneumaturia and diverticulosis on barium enema examination, was not operated on, and died 2 years later of a cerebral accident. Of the 5 patients with diverticulitis who underwent primary resection and closure of the fistula in one stage, there was one death from a disruption of the anastomosis and its subsequent peritonitis. Only 4 of the 6 primary colon carcinomas were resectable-2 by a one-stage procedure and 2 preceded by a diverting colostomy. There were no deaths in this group. Two patients with nonresectable lesions died within 2 months, one with a colostomy and one without. Our 2 patients with Crohn's disease underwent one-stage procedures and had uneventful recoveries. However, one has had a recurrence of his granulomatous enteritis 5 years after resection.
DISCUSSION One must keep his options open when dealing with this complicated problem. Any attempt to short-cut hospitalization or a patient's repugnance to a temporary colostomy, against better judgment, will frequently lead to disaster. Patients selected for a one-stage colon procedure should have little or no obstruction, and the ends of resection should be free of edema and inflammatory disease. Antibiotics will not prevent leakage of an ill-conceived anastomosis. The finding of an extra colonic-pelvic collection or extensive inflammatory involvement of other pelvic viscera are indications for a staged procedure. The time interval between the diverting colostomy and resection is variable. In our group it varied from 10 days to 3 months. In patients with carcinoma the average time interval was 14 days. These patients usually have less inflammatory reaction. One point which we have found useful in tumor cases, where a wide area of bladder must be resected, is to use not only catheter but also suprapubic drainage. This helps maintain adequate drainage of the urinary system in the presence of blood clots forming in the bladder after wide resection. Fortunately, the tumor usually invades the dome and leaves the trigone free. The suprapubic drain can be removed in 5 to 7 days and the catheter drainage in 14 days. In diverticulitis cases the fistulous opening into the bladder needs only to be closed with one or two sutures of catgut and catheter drainage maintained for approximately 14 days for complete healing. The sigmoid
569
VESICO-ENTERIC FISTULAS
resection is handled like any primary end-to-end anastomosis without pelvic drainage unless large raw areas are opened up or purulent collections are encountered during the second stage. If pelvic drainage after bowel resection is felt indicated following a one-stage procedure, then the surgeon probably has made a poor choice and a staged procedure would have been preferable. If omentum is available, it is deemed advisable to interpose it between the bladder repair and the bowel anastomotic line. In one of our cases involving diverticular disease, a secondary vesicocolic fistula developed 6 months later, requiring further colon resection. This might have been prevented by such a maneuver. The 2 patients with Crohn's disease and fistulas did very well following a one-stage procedure; however, recurrence of the ileocolitis is high, between 30 and 50 per cent of the cases resected. Therefore, it is our present policy to place these patients on maintenance doses of Azulfidine almost indefinitely and under the care of a gastroenterologist. Evidence of its value has been mounting with a lowered recurrence rate.
SUMMARY Vesico-enteric fistulas are a challenge to both urologist and general surgeon. The awareness of the possibility of enteric origin of recurrent urinary symptoms should help us prevent the long delays seen in diagnosis. Intestinal symptoms may be vague and minimal. Thorough and accurate preoperative evaluation, including use of the newer fiberoptic colonoscope, will help us make the proper selection as to a one-stage or multi-staged repair. There is room for both in the surgeon's armamentarium, and a wise decision can produce excellent results as seen in this series. When the fistula is of malignant origin, the long-term prognosis remains poor as in any colonic carcinoma that has extended beyond the serosa and involved a contiguous organ. Fistulas secondary to radiation necrosis or recurrent tumor have an extremely poor outlook with some palliation afforded by a diverting colostomy. Patients with fistulas due to diverticular disease and, to a lesser extent, Crohn's disease can look forward to complete correction with a low mortality and morbidity when sound, basic surgical judgment is followed.
REFERENCES 1. Asch, M. J., and Markowitz, A. M.: Diverticulitis coli: A surgical appraisal. Surgery, 62:239, 1967. 2. Colcock, B. P.: Indications for surgery in diverticulitis. SURG. CLIN. N. AMER., 44:785, 1964. 3. Giffin, J. M., Butcher, H. R., and Ackerman, L. V.: Surgical management of colonic diverticulitis. Arch. Surg., 94:619, 1967. 4. Henderson, M. A., and Small, W. P.: Vesico-colic fistula complicating diverticular disease. Brit. J. Urol., 41 :314, 1969. 5. Ingiulla, W., and CosIni, E. V.: Vesical, ureteral, and rectal fistulas following operation for cancer of the cervix. Amer. J. Obstet. Gynec., 99:1078,1967. 6. Kohler, F. P.: Urinary tract symptoms as manifestation of large bowel disease. J. Surg. Soc., Rep. of China, 1 :182,1968.
570
CLIFTON
F.
WEST, JR.
7. Mayo, C. W., and Blunt, C. P.: The surgical management of the complications of diverticulitis of the large intestine. SURG. CLIN. N. AMER., 30 :1005, 1950. 8. Ponka, J. L., and Shaalan, A. K.: Changing aspects in surgery of diverticulitis. Arch. Surg., 89:31, 1964. 9. Pugh, J. I.: On the pathology and behaviour of acquired non-traumatic vesico-intestinal fistula. Brit. J. Surg., 51 :644, 1964. 10. Ryan, P.: Solitary sigmoid diverticulitis. Brit. J. Surg., 52:85, 1965. 11. Scardino, P. L., and Lippitt, W. H.: Vesical intestinal fistula. J. Urol., 99:752,1968. 12. Sedgwick, C. E.: The surgical treatment of diverticulitis and its complications. SURG. CLIN. N. AMER., 31 :783, 1951. 13. Smithwick, R. H.: Surgical treatment of diverticulitis of the sigmoid. Amer. J. Surg., 99:192,1960. 14. Ward, J. N., et al.: Diagnosis and treatment of colovesical fistulas. Surg. Gynec. Obstet., 130:1082,1970. 15. Young, E. L., and Young, E. L., III: Diverticulitis of the colon: A review of the literature and an analysis of ninety-one cases. New Eng. J. Med., 230 :33, 1944. Lankenau Medical Building Suite 312 Philadelphia, Pennsylvania 19151
Vesico-Enteric Fistulas Clifton F. West, Jr, M.D.*
Vesico-enteric fistulas have been known to the medical profession for centuries. They were first described in detail as to etiology, pathology and treatment in the British literature in the late nineteenth century. However, it was not until more refined techniques in intestinal and urologic surgery evolved that progress was made in the complete correction of this relatively uncommon surgical problem. Collected reviews were common in the 1920's and 1930's from the Mayo Clinic and other leading medical centers in this country. Treatment consisted of an intestinal diverting procedure, usually a transverse colostomy. With our present surgical knowledge, the patient with this distressing problem, when due to benign disease, can look forward to complete correction with low morbidity and mortality. Certain basic principles must be observed. This report concerns 28 cases managed over a 10 year period.
INCIDENCE The average hospital can expect two or three cases for every 10,000 admissions. Males predominate over females in a ratio ranging from 3:1 to 5:1. Our own recent series was 19 males to 9 females. However, this included 3 patients with radiation necrosis for female pelvic cancer. The uterus is thought to protect the bladder from the intestinal disease process by its usual anatomic interposition. This may be altered by the higher incidence of hysterectomy in our present population and, indeed, some recent series show a ratio approaching 50-50.
ETIOLOGY AND PATHOLOGY In the late nineteenth century tuberculosis, amebiasis, and syphilis were the common causes in the described cases. These are almost un*Associate Surgeon, Lankenau Hospital; Assistant Professor in Surgery, Jefferson Medical College, Philadelphia, Pennsylvania
Surgical Clinics of North America- Vol. 53, No.3, June 1973
565
566
CLIFTON
F.
WEST, JR.
Figure 1. Schematic drawing of vesico-enteric fistulas: A, vesicaappendiceal; B, ileovesical; C, colovesical; D, rectovesical.
known at the present time. Diverticulitis is by far the most common underlying pathology. Cases of vesico-appendiceal fistula which have been reported have always been due to a neglected or overlooked appendicitis with rupture. There were 19 cases of diverticulitis with two cases of Crohn's disease in our series. Carcinoma of the sigmoid was present in 6 cases. Radiation necrosis associated with treatment for female pelvic malignant disease comprised 3 cases. The fistula is initiated by ulceration and inflammation of the bowel wall with subsequent perforation and extramural suppuration from whatever the underlying cause happens to be. The route is determined by the anatomic pathway available and, fortunately, is usually located on the dome of the bladder. In malignant cases, where operable, this allows for adequate bladder resection with preservation of bladder function. However, none of our 6 patients with colon carcinoma survived more than 5 years, the longest survival being 4112 years, with an average of 2 yean. This is thought to reflect the advanced stage of colonic carcinoma.
CLINICAL FEATURES Urinary symptoms predominate the picture, with recurrent cystitis the most common feature. This was present in over 50 per cent of our cases. The delay in diagnosis of the fistula in our series ranged from several weeks to 18 months.
VESICO-ENTERIC FISTULAS
567
Pneumaturia is a pathognomonic sign and was present in 21 of 28 cases. Fecaluria was present in 15 cases. The intestinal signs were silent in over half of our cases and when manifested were relatively nonspecific. Pain and alteration in bowel habit were the most common. Three with carcinoma of the sigmoid complained of bloody stools in conjunction with their urinary symptoms. There was no bleeding with the 17 cases of diverticulitis and 2 of Crohn's disease. Interestingly enough, the 2 cases of Crohn's disease were diagnosed as "spastic colitis," thought to be related to the tension of their recurrent urinary symptoms. The ages of these patients were 32 and 34. The delay in one was 18 months in spite of having seen three separate urologists. The three cases due to radiation necrosis followed cobalt therapy and also had a finding of residual tumor. Both probably contributed to this disorder.
CLINICAL INVESTIGATTON The patient with a suspected vesico-enteric fistula demands the efforts of both the urologist and surgeon. Since urological symptoms predominate, the urologist is usually consulted first. This was the case in 24 out of 28 of our cases. Cystoscopic examination of an incipient fistula simply shows a hyperemic area of bladder mucosa. Later it becomes surrounded with bulbous edema and papillomatous proliferation of the mucosa. The fistula was demonstrated by dye on barium enema studies in only 11 of our 28 cases. Biopsies should be taken where tumor is suspected. Urine cultures and sensitivity studies to antibiotics should be done. The most common organism is E. coli which was present in 26 of 28 patients. Bimanual pelvic and rectal examinations frequently reveal a tender extravesical mass. If general anesthesia is used for cystoscopy, palpation of a mass is simplified. Sigmoidoscopy was revealing in only the 3 cases of radiation necrosis. This is easily explained by the distortion and angulation of the intestinal tract associated with the development of a perimural abscess preceding the development of a full-blown fistula. It is hoped, by the author, that with the acquisition of the flexible fiberoptic scope a more accurate preoperative evaluation and demonstration of the underlying pathology can be made. Barium enema examination revealed colon pathology in all cases. However, in more than half, this was not striking and in only six of the 19 diverticulitis cases was a fistulous tract demonstrated by this method. In the 6 sigmoidal carcinomas, all tumors were demonstrated. In our two cases due to ileitis, the diagnosis was delayed 4 months in one and 18 months in the other because of a failure to obtain barium studies of the small bowel.
568
CLIFTON
F.
WEST, JR.
FACTORS DETERMINING CHOICE OF SURGICAL PROCEDURES The etiology, extent of pathology, degree of bowel obstruction as well as toxicity from massive bladder infection all enter into the decision as to a one-stage versus a multi-stage procedure. Here again, bimanual examination is our best method for determining the extent and secondary involvement of other structures by the fistulous process. Of our 17 cases due to diverticulitis, 12 underwent a three-staged procedure. The one death occurred in a 78 year old woman with advanced emphysema who suffered cardiac arrest in the operating room, was resuscitated, and died a cardiac death 6 days after operation. One case, an 84 year old man, with the only symptom of pneumaturia and diverticulosis on barium enema examination, was not operated on, and died 2 years later of a cerebral accident. Of the 5 patients with diverticulitis who underwent primary resection and closure of the fistula in one stage, there was one death from a disruption of the anastomosis and its subsequent peritonitis. Only 4 of the 6 primary colon carcinomas were resectable-2 by a one-stage procedure and 2 preceded by a diverting colostomy. There were no deaths in this group. Two patients with nonresectable lesions died within 2 months, one with a colostomy and one without. Our 2 patients with Crohn's disease underwent one-stage procedures and had uneventful recoveries. However, one has had a recurrence of his granulomatous enteritis 5 years after resection.
DISCUSSION One must keep his options open when dealing with this complicated problem. Any attempt to short-cut hospitalization or a patient's repugnance to a temporary colostomy, against better judgment, will frequently lead to disaster. Patients selected for a one-stage colon procedure should have little or no obstruction, and the ends of resection should be free of edema and inflammatory disease. Antibiotics will not prevent leakage of an ill-conceived anastomosis. The finding of an extra colonic-pelvic collection or extensive inflammatory involvement of other pelvic viscera are indications for a staged procedure. The time interval between the diverting colostomy and resection is variable. In our group it varied from 10 days to 3 months. In patients with carcinoma the average time interval was 14 days. These patients usually have less inflammatory reaction. One point which we have found useful in tumor cases, where a wide area of bladder must be resected, is to use not only catheter but also suprapubic drainage. This helps maintain adequate drainage of the urinary system in the presence of blood clots forming in the bladder after wide resection. Fortunately, the tumor usually invades the dome and leaves the trigone free. The suprapubic drain can be removed in 5 to 7 days and the catheter drainage in 14 days. In diverticulitis cases the fistulous opening into the bladder needs only to be closed with one or two sutures of catgut and catheter drainage maintained for approximately 14 days for complete healing. The sigmoid
569
VESICO-ENTERIC FISTULAS
resection is handled like any primary end-to-end anastomosis without pelvic drainage unless large raw areas are opened up or purulent collections are encountered during the second stage. If pelvic drainage after bowel resection is felt indicated following a one-stage procedure, then the surgeon probably has made a poor choice and a staged procedure would have been preferable. If omentum is available, it is deemed advisable to interpose it between the bladder repair and the bowel anastomotic line. In one of our cases involving diverticular disease, a secondary vesicocolic fistula developed 6 months later, requiring further colon resection. This might have been prevented by such a maneuver. The 2 patients with Crohn's disease and fistulas did very well following a one-stage procedure; however, recurrence of the ileocolitis is high, between 30 and 50 per cent of the cases resected. Therefore, it is our present policy to place these patients on maintenance doses of Azulfidine almost indefinitely and under the care of a gastroenterologist. Evidence of its value has been mounting with a lowered recurrence rate.
SUMMARY Vesico-enteric fistulas are a challenge to both urologist and general surgeon. The awareness of the possibility of enteric origin of recurrent urinary symptoms should help us prevent the long delays seen in diagnosis. Intestinal symptoms may be vague and minimal. Thorough and accurate preoperative evaluation, including use of the newer fiberoptic colonoscope, will help us make the proper selection as to a one-stage or multi-staged repair. There is room for both in the surgeon's armamentarium, and a wise decision can produce excellent results as seen in this series. When the fistula is of malignant origin, the long-term prognosis remains poor as in any colonic carcinoma that has extended beyond the serosa and involved a contiguous organ. Fistulas secondary to radiation necrosis or recurrent tumor have an extremely poor outlook with some palliation afforded by a diverting colostomy. Patients with fistulas due to diverticular disease and, to a lesser extent, Crohn's disease can look forward to complete correction with a low mortality and morbidity when sound, basic surgical judgment is followed.
REFERENCES 1. Asch, M. J., and Markowitz, A. M.: Diverticulitis coli: A surgical appraisal. Surgery, 62:239, 1967. 2. Colcock, B. P.: Indications for surgery in diverticulitis. SURG. CLIN. N. AMER., 44:785, 1964. 3. Giffin, J. M., Butcher, H. R., and Ackerman, L. V.: Surgical management of colonic diverticulitis. Arch. Surg., 94:619, 1967. 4. Henderson, M. A., and Small, W. P.: Vesico-colic fistula complicating diverticular disease. Brit. J. Urol., 41 :314, 1969. 5. Ingiulla, W., and CosIni, E. V.: Vesical, ureteral, and rectal fistulas following operation for cancer of the cervix. Amer. J. Obstet. Gynec., 99:1078,1967. 6. Kohler, F. P.: Urinary tract symptoms as manifestation of large bowel disease. J. Surg. Soc., Rep. of China, 1 :182,1968.
570
CLIFTON
F.
WEST, JR.
7. Mayo, C. W., and Blunt, C. P.: The surgical management of the complications of diverticulitis of the large intestine. SURG. CLIN. N. AMER., 30 :1005, 1950. 8. Ponka, J. L., and Shaalan, A. K.: Changing aspects in surgery of diverticulitis. Arch. Surg., 89:31, 1964. 9. Pugh, J. I.: On the pathology and behaviour of acquired non-traumatic vesico-intestinal fistula. Brit. J. Surg., 51 :644, 1964. 10. Ryan, P.: Solitary sigmoid diverticulitis. Brit. J. Surg., 52:85, 1965. 11. Scardino, P. L., and Lippitt, W. H.: Vesical intestinal fistula. J. Urol., 99:752,1968. 12. Sedgwick, C. E.: The surgical treatment of diverticulitis and its complications. SURG. CLIN. N. AMER., 31 :783, 1951. 13. Smithwick, R. H.: Surgical treatment of diverticulitis of the sigmoid. Amer. J. Surg., 99:192,1960. 14. Ward, J. N., et al.: Diagnosis and treatment of colovesical fistulas. Surg. Gynec. Obstet., 130:1082,1970. 15. Young, E. L., and Young, E. L., III: Diverticulitis of the colon: A review of the literature and an analysis of ninety-one cases. New Eng. J. Med., 230 :33, 1944. Lankenau Medical Building Suite 312 Philadelphia, Pennsylvania 19151