Laparoscopic management of colovesical fistula secondary to sigmoid diverticulitis: case report and the role of intraoperative indocyanine-green fluorescence

Abstract

Colovesical fistula is characterized by multifactorial etiology and the diagnosis is often challenging. Sigmoid diverticulitis accounts for more than two-third of the cases. Pneumaturia and air in the bladder at computed tomography are the most typical clinical-radiologic signs. There is still no evidencebased consensus on the optimal surgical approach for this rare condition. Sigmoid resection with or without bladder resection/enteral stoma are the conventional therapeutic options, but ureter identification may be difficult during the procedure and injury from a direct or indirect trauma can occur. Therefore, double-J stenting is commonplace during open surgical procedures. The laparoscopic approach has been shown to be feasible and effective in case-series, but ureteral protection may be difficult because of the limited tactile feedback. We report the case of a 55-year-old male patient with colovesical fistula complicating repeated episodes of acute left colon diverticulitis and eventually treated with one-stage bladder-sparing laparoscopic sigmoid resection. Indocyanine-green (ICG) fluorescence was used intraoperatively for visualization of the left ureter and for assessment of colonic blood perfusion. The post-operative course was uneventful.Laparoscopy is feasible, safe, and effective for the treatment of colovesical fistula. Magnified vision enhanced by fluorescence imaging allows a precise surgical dissection and has the potential to decrease complication rates and to improve postoperative outcomes.