2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH,
Chennai
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3. Vesico-enteric Fistulae
• Abnormal communication between bladder and bowel
Etiology
• Diverticulitis 65%-75%
• Malignancy 10%-15%
Adeno ca of colon, rectum
Ca cervix
Ca Bladder
Ca Prostate
• Crohn disease 5%-6%
• Other (trauma, appendiceal
abscess, foreign body) <5%
Dept Of Urology, KMC and GRH,
Chennai
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4. Etiology
• Tuberculous ileitis
• Radiation enteritis
• Trauma
• Gunshot wounds
• Penetrating trauma
• Pelvic fractures with bony spicules
• Iatrogenic
• Foreign bodies in bowel
Dept Of Urology, KMC and GRH,
Chennai
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6. • Peak incidence - Between 55 and 65 years
• Ileovesical fistulae - More common in Crohn disease
• Colovesical fistulae - Common in diverticulitis.
• Colorectal ca- most common malignancy associated with fistula
• Colovesical fistula between sigmoid and dome of bladder – most
common site
Dept Of Urology, KMC and GRH,
Chennai
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7. Clinical features
• Pneumaturia 52%-77%
• Fecaluria 36%-51%
• Urinary tract infection symptoms
(frequency, urgency,dysuria) 44%-45%
• Fever and chills 41%
• Abdominal pain 25%
• Nonspecific gastrointestinal
symptoms 25%
• Hematuria 5%-22%
• Orchitis 10%
• Urine per rectum 5%
Dept Of Urology, KMC and GRH,
Chennai
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8. Gouverneur syndrome
• Classic presentation - suprapubic pain, urinary frequency
dysuria, and tenesmus
• Present with urologic symptoms rather than with symptoms
related to the bowel.
• Sepsis - rare
Dept Of Urology, KMC and GRH,
Chennai
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9. Diagnosis
• High index of suspicion
• Treated for recurrent UTI - >4 to 12 months
• Patients history
Urinalysis
• Reveal undigested intestinal food residue
Urine culture
• E-coli or mixed organism infection
Dept Of Urology, KMC and GRH,
Chennai
9
10. • Characteristic - reveals an
echogenic “beak sign”
connecting the peristaltic
bowel lumen and the urinary
bladder
• Transrectal and Transvaginal
ultrasonography - identify a
fistulous tract, as well as its
relation to the adjacent
anatomical structures
• Useful in the diagnosis of colovesical fistulae
Ultrasonography
Dept Of Urology, KMC and GRH,
Chennai
10
11. CT
• Most sensitive and specific modality with diagnostic
accuracy - 90% to 100%
• Cystogram – demonstrate contrast outside the bladder
• Localize fistula tract, as well as the involved segment of
bowel.
• Herald’s sign - Cresentric defect on upper margin of bladder
Represents perivesical abcess
Dept Of Urology, KMC and GRH,
Chennai
11
12. CT
• Triad of findings on CT
(suspicious for colovesical
fistulae)
(1) Bladder wall thickening
adjacent to a loop of thickened
colon
(2) Air in the bladder (in the
absence of previous lower
urinary manipulation)
(3) Presence of colonic diverticula
Dept Of Urology, KMC and GRH,
Chennai
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13. • Oral contrast medium in the bladder on non-intravenous
contrast enhanced scans
• Should be done after the administration of oral contrast but
prior to the administration of intravenous contrast
• To permit detection of barium within the bladder
Dept Of Urology, KMC and GRH,
Chennai
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14. Magnetic Resonance Imaging
• T1-weighted images
- Delineate extension of the fistula relative to sphincters and
adjacent hollow viscera
- Show inflammatory changes in fat planes.
• T2-weighted images
- Fistula typically produces a high-signal-intensity in fluid-
filled communication,
- Air-filled fistulous tract is seen as a low signal intensity,
Dept Of Urology, KMC and GRH,
Chennai
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15. • Use of intravenous gadolinium enhancement - improves
detection of bladder fistulae.
• Early postgadolinium T1-weighted images - show
enhancement of tract walls and signal void fluid centrally
MRI
Dept Of Urology, KMC and GRH,
Chennai
15
16. Barium enemas and/or colonoscopy
• Valuable adjunctive studies
in evaluating for colonic
disease, such as malignancy
• Limited utility in the
diagnosis
• Low sensitivity
Dept Of Urology, KMC and GRH,
Chennai
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17. Bourne test
• Performed following a barium enema.
• First voided urine following the barium enema is
immediately centrifuged and then examined radiographically.
• Radiodense (barium) particles in the urine
- Considered a positive test
- Evidence for a vesicoenteric fistula.
• Useful adjunctive study
Dept Of Urology, KMC and GRH,
Chennai
17
18. Other Diagnostic tests
• Oral administration of activated charcoal, chromium 151,
indocyanine green chromogen dye
• Will appear in the urine
• Useful in confirming the diagnosis in suspect case
Dept Of Urology, KMC and GRH,
Chennai
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19. Diagnosis
Cystoscopy
• Most reliable diagnostic test
• Highest yield in identifying
lesion - > 90%
• Findings
- Nonspecific localized
erythema,
- Congestion
- Papillary, or Bullous change
- Fecal material or mucus
Dept Of Urology, KMC and GRH,
Chennai
19
20. • Cystoscopy and Biopsy
- Abnormal-appearing
tissue,
- o r Established fistula
tract suspects malignancy
• Attempt be made to
catheterize suspected tract
with ureteral catheter
• Retrograde injection of
contrast material - confirm
fistula
Dept Of Urology, KMC and GRH,
Chennai
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21. Management
Conservative Management
• Nontoxic , minimally symptomatic patients with
non-malignant causes of enterovesical fistulae
• Trial of medical therapy - Intravenous total parenteral
nutrition, bowel rest, and antibiotics, steroids,
immunomodulatory drugs, and urethral catheter drainage
• Preferred initial approach in patients with Crohn disease
• Immediate exploratory laparotomy and bowel resection -
discouraged due to chronic relapsing nature of the disease
Dept Of Urology, KMC and GRH,
Chennai
21
22. Goals of operative management
• To separate and close the involved organs with minimal
anatomic disruption and
• Normal long-term function of both systems
Dept Of Urology, KMC and GRH,
Chennai
22
23. • Enterovesical fistulae may be complicated by
- Intense pelvic inflammation
- Pelvic abscess, and phlegmon formation
• Requires - complex staged reconstructions
• In absence of malignancy
Simple closure of bladder - adequate
Omentum – interposed
• Urethral catheter – left in situ for 2 weeks
• Cystogram - performed to verify bladder is intact before
catheter removal
Dept Of Urology, KMC and GRH,
Chennai
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25. • Bowel resection and/or partial cystectomy
- To obtain viable tissue margins to ensure adequate
- Watertight closure of the involved viscera.
- Interpositional flap of greater omentum is placed
between the repaired bowel and urinary bladder
• Indicated - colonic carcinoma
• Poor risk pts, cancer or complex fistula
- Diverting colostomy affords palliation
Dept Of Urology, KMC and GRH,
Chennai
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26. Choice of whether to proceed with a one-stage or two-stage
repair - Influenced by
• Location and cause of the fistula
• Patient’s general condition
• Presence of a pelvic abscess
• Presence of colonic obstruction
• Patients with an inflammatory cause of the fistula, but
without gross contamination
- can be treated with a one-stage procedure
• With unprepared bowel, gross contamination, or abscess
- Require a multistage procedure
Dept Of Urology, KMC and GRH,
Chennai
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27. Both single and multistage procedure
One stage
• Procedure involves removal of the fistula
• Closure of the involved organs
• Primary re-anastomosis of the bowel following resection of the
involved bowel segment
Two-stage approach
• Removal of the fistula, closure of the involved organs
• Creation of a temporary proximal diverting colostomy
• Colostomy take down once the fistula tract is closed.
Dept Of Urology, KMC and GRH,
Chennai
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28. • Laparoscopic management – been reported
• Relatively high rate of conversion to open repair
Dept Of Urology, KMC and GRH,
Chennai
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30. Vesicouterine Fistulae
• Communication between posterior wall of the bladder and
anterior wall of the uterus.
• Least common uro-gynecologic fistulae
• 1-4% of all urogenital fistulas
• Prevalence increases - frequent use of cesarean section.
Dept Of Urology, KMC and GRH,
Chennai
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31. Etiology
• Caesarean section - Most common
• Spontaneous ruptured uterus during obstructed labor.
• Bladder wall invasion by placenta percreta
• Intrauterine device (IUD)
• Uterine artery embolization
• Brachytherapy
• Traumatic bladder catheterization
Dept Of Urology, KMC and GRH,
Chennai
31
32. • Most common location of the
fistula
- Posterior bladder wall in the
midline
- From the genital side, just
cephalad to the internal cervical os.
• Simultaneous injury to the bladder and uterus - inciting event.
• Unrecognized and unrepaired (occult) bladder injury
• Incorporation of a portion of the bladder during closure of the uterus
Dept Of Urology, KMC and GRH,
Chennai
32
33. Presentation
• May or may not present with constant urinary incontinence
due to the sphincter-like activity of the cervix
• Typically occurs following vaginal delivery,
- Urine flows from the bladder through the fistula
into the uterine cavity
- Then into the vagina through an incompetent
cervical os
• Present with menouria and cyclical hematuria
Youssef syndrome
• Describes symptom complex of menouria, cyclic hematuria
and urinary leakage with associated apparent amenorrhea,
infertility
Dept Of Urology, KMC and GRH,
Chennai
33
34. Diagnosis
Cystoscopy
• Demonstrate midline lesion
along the posterior bladder
wall
• Instillation of contrast
material into the bladder
(cystogram) will outline the
uterine cavity
Dept Of Urology, KMC and GRH,
Chennai
34
35. • Urine cytology - reveal endothelial cells
• Combination of cystoscopy and radiographic
studies - high degree of suspicion is
necessary
Dept Of Urology, KMC and GRH,
Chennai
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36. Hysterosalpingogram
• Demonstrate filling of the
bladder.
IVU or contrast-enhanced CT
• To exclude concomitant
ureteral injury.
Dept Of Urology, KMC and GRH,
Chennai
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37. CYSTOGRAM
Cystogram demonstrating vesicouterine fistula in a postpartum woman.
A, Filling of the bladder demonstrates a small amount of contrast material cephalad to
the tip of the Foley catheter. The uterine cavity is faintly seen.
B, Postvoid image demonstrates filling of the uterine cavity and cervical canal. The
bladder is not well seen. This patient is immediately postpartum. Contrast material in the
vagina outlines the incompetent cervical canal and os
Dept Of Urology, KMC and GRH,
Chennai
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38. USG
Dr.K.Malleswar Rao, MD, DGO ESI Hospital, Sanathnag ar, Hyderabad.
Used in the diagnosis and evaluation
Dept Of Urology, KMC and GRH,
Chennai
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40. Management
Small , Immature fistulae
• Prolonged bladder catheterization
• Hormonal induction of menopause - will induce involution of
the puerperal uterus
Principle - used with some success
• Spontaneous closure - 5% of patients
Dept Of Urology, KMC and GRH,
Chennai
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41. Surgical therapy
• Surgery - Mainstay and Definitive
• Different approaches - Vaginal, Transvesical,
Transperitoneal, Laparoscopic and Robotic procedures
• Surgical repair should be planned - at least 4-6 Weeks after
caesarean section
- For complete uterine involution
- Resolution of inflammation
• Depend upon on the specific reproductive wishes of the
patient as well as other surgical factors
Dept Of Urology, KMC and GRH,
Chennai
41
42. • Patient who desires preservation of fertility
-Uterine-sparing surgery -considered.
- Like O’Conor transabdominal VVF repair
• Bladder is opened and bivalved down to the
fistula tract.
Dept Of Urology, KMC and GRH,
Chennai
42
43. Careful dissection allows
separation of the bladder
from uterus beyond the
fistula tract.
Fistula tract - excised
Uterus and bladder -
closed individually
Interpositional flap with
omentum
Dept Of Urology, KMC and GRH,
Chennai
43
44. Surgical therapy
• If there - No further desire for childbearing
Transabdominal Hysterectomy and Bladder closure should
be considered.
• Ureteral stents -placed to facilitate identification of the
ureters intraoperatively
• Following hysterectomy,
- Fistula tract on the posterior bladder wall is excised
- Bladder is closed primarily.
- omental flap can be placed to buttress the bladder
closure
Dept Of Urology, KMC and GRH,
Chennai
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46. • Vesicoenteric fistulae , most common - diverticulitis.
• Presenting symptoms - usually urinary, most commonly - pneumaturia.
• Diagnosis - made with a combination of cystoscopy and cross-sectional
imaging CT scan.
• Repair of colovesical fistulae involves a single- or multistage procedure,
depending on a number of clinical factors, presence of gross fecal
contamination and infection
• Most common cause of vesicouterine fistulae - low segment
caesarean section.
• Vesicouterine fistulae do not always present with urinary incontinence.
• Management of vesicouterine fistulae depend upon reproductive
wishes of the patient.
• Hysterectomy followed by repair of the bladder is indicated for the
individual who no longer desires fertility.
• Uterine-sparing procedures can be used and successful pregnancy is
possible following vesicouterine fistula repair.
Take Home Message
Dept Of Urology, KMC and GRH,
Chennai
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