The Feasibility of a Laparoscopic Approach to Complex Colovesical and Enterovesical fistulas

Daniel Bekele, MD, Sami Chadi, MD, Giovanna Dasilva, MD, Steven D Wexner, MD, PhD, Hon. Cleveland Clinic Florida, Weston, FL

Introduction: Despite the advantages of laparoscopy, few reports have discussed the practicality of a laparoscopic approach to complex fistulizing disease. The objective of this study was to demonstrate the feasibility of a laparoscopic approach to the management of enterovesical (EV)/colovesical (CV) fistulas.

Methods and Procedures: An IRB approved prospective surgical database was queried for all patients with a diagnosis of EV or CV fistula with a laparoscopic approach. Demographic data was tabulated and compared. A priori definitions were created for the type of laparoscopic approach as well as conversions. Cases were identified with a combination of CPT/ICD codes. Malignant cases were excluded given the need for an en bloc resection.

Results: 39 patients were identified (70% male, mean age 61 years, mean BMI 27kg/m2). 70% of patients presented with a chronic urinary tract infection with 61% describing pneumaturia. Complicated diverticulitis represented 82% of patients compared to Crohn’s disease (18%). Pre-operative CT was performed, most commonly revealing intravesical air (48%).  75% of operations began laparoscopically (LAP) while the others (25%) were started with hand-assist devices (HALS). 57% of LAP operations were converted to an open infraumbilical incision for the safety of the dissection. Three procedures (7.6%) were converted to a HALS technique for similar reasons. Thirty-two (83%) patients had a primary anastomosis with no diversion (67% sigmoid; 13% ileocolic) while 10% had a diverting loop ileostomy that was later reversed and 8% had an end stoma (2 end colostomy and 1 end ileostomy following total abdominal colectomy). The average operative time was 231 minutes with a mean blood loss of 187cc. 59% of patients had no intervention for the bladder opening, mostly because of the non-compliant inflammatory reaction. The median length of stay was 6 days with a post-operative cystogram performed at a median of 6 (3-20) days with the Foley removed at a median of 6.5 (3-30) days. The readmission rate for this cohort was 10% (2 surgical site infection, 1 pelvic abscess, 1 stoma-related dehydration). One ureteric injury occurred in this series, in a patient with an anastomotic leak.

Conclusion: Despite a high conversion rate in this series, we have demonstrated that a primarily laparoscopic approach to fistulizing bladder disease appears to be safe. Given the nature of conversions, surgeons are aware of when the limits of their laparoscopic skills have reached the limits of safety necessitating conversion.

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