Laparoscopic surgery for diverticular colovesical fistula: single-center experience of 11 cases

Abstract

Objective: Laparoscopic surgery for diverticular colovesical fistula (CVF) is technically challenging, and the incidence of conversion to open surgery (COS) is high. This study aimed to review our experience with laparoscopic surgery for diverticular CVF and identify preoperative risk factors for COS. Results: This was a single institution, retrospective, observational study of 11 patients (10 males and 1 female) who underwent laparoscopic sigmoid colon resection with fistula resection for diverticular CVF from 2014 to 2019. Preoperative magnetic resonance imaging (MRI) was performed to evaluate the fistula location in the bladder, patency of the rectovesical pouch (i.e., the destination of dissection procedure between sigmoid colon and bladder) and estimate the contact area between the sigmoid colon and bladder. The relationship between preoperative variables and COS incidence was analyzed between completed laparoscopy and COS groups. The overall incidence of postoperative morbidity (Clavien-Dindo classification Grade II or higher) was 36% (4/11). Severe morbidity, reoperation, and mortality were not observed. The incidence of COS was 27% (3/11). Posterior bladder fistulas were significantly associated with COS. CVFs located on the posterior bladder appears to be a risk factor for COS. Identifying risk factors for COS preoperatively could help guide the intraoperative course.

Burden of Colovesical Fistula and Changing Treatment Pathways: A Systematic Literature Review

“…No bladder repair was performed when the intraoperative bladder leak test was negative. The use of ureteral stents to visualize and preserve the ureter was reported in 7 studies; 16,[21][22][23]25,27,28 ureteral injury occurred in 4 patients, and in 3 of them was recognized and treated intraoperatively. The length of postoperative hospital stay and the length of urinary catheterization depended on the type of surgery and concomitant bladder treatment.…”

“…The role of prophylactic ureteral stenting in surgery for complicated sigmoid diverticulitis and CVF is still debated. Only 7 studies 16,[21][22][23]25,27,28 advocated double-J stenting to reduce the risk of ureteral injuries. To date, there is no evidence about the overall benefit of this procedure with respect to prolonged operative time and the risk of iatrogenic lesions; 45 on the other hand, prophylactic ureteral identification during laparoscopic surgery is increasingly adopted, justifying the need of less invasive techniques to improve visualization.…”

“…Routine methylene blue test also allows early urinary catheter removal (7 d or less) without the need of a cystogram. [26][27][28] The duration of postoperative Foley catheterization is extremely variable between studies, ranging from 2 to 15 days. A protocol, including early removal of the urinary catheter when intraoperative testing is negative, and use of a closed-suction drainage for serial creatinine sampling to rule out bladder leak in high-risk patients, has been proposed to limit the indications to postoperative cystography.…”

“…Fourteen papers [16][17][18][19][20][21][22][23][24][25][26][27][28][29] published between 2014 and 2020 and including a total of 1061 patients were considered for this review (Table 1). The main etiologies of CVF were sigmoid diverticulitis 87.2%, colon cancer 5.9%, Crohn's disease 4.9%, and iatrogenic (0.2%).…”

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

“…The laparoscopic approach has been reported to be feasible and effective, but conversion rate to an open procedure has been reported in up to 50% of patients depending on the degree of bladder infiltration (2). Traditionally, especially in open surgery, use of ureteral stents was common practice for intraoperative identification of the ureters.…”