1亞東紀念醫院 外科部 泌尿科；2亞東紀念醫院 外科部 一般外科
A Bladder-Sparing Surgical Technique for Recurrent Enterovesical Fistula
Jen-Ting Hsu1, Kuo-Hsin Chen2, Shiu-Dong Chung1, Hsiao-Chun Chang1
Division of Urology1 Department of Surgery, Far Eastern Memorial Hospital, New Taipei City Division of General surgery2, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City
Introduction: Enterovesical fistula (EVF) is a rare pathological communication between bowel and bladder. The most common etiology of EVF is diverticulitis, followed by cancer and Crohn's disease. EVF is rare but markedly affects patient’s quality of life. Common clinical symptoms include pneumaturia, fecaluria, and/or suprapubic pain. The most sensitive radiographic examination is computed tomography (CT). Standard surgical techniques involve resection of defect ileum with anastomosis, fistulectomy and cystorrhaphy. Nevertheless, bladder repair for radiation-induced enterovesical fistula is challenging due to its easy re-adhesion and high recurrent rate. In the following case, we demonstrate a bladder-sparing surgical technique for recurrent enterovesical fistula.
Case report: A 84-year-old woman, with medical history of cervical cancer, received radiotherapy over 25 years ago. Relapsing-remitting hemorrhagic cystitis occurred for months. In April of 2014, the patient was admitted with weeks of fecaluria and iliac fossa pain. CT scan was suggestive of an enterovesical fistula. Laparoscopic fistulectomy and segmentectomy of terminal ileum with anastomosis were performed. Urinary bladder was repaired with 3-0 V-Loc™.
In April of 2020, she was presented to our emergency department with amounts of stools in her foley bag. Computed tomography urography (CTU) revealed insertion of foley catheter with tip thorough enterovesical fistula at distal ileum. In diagnosis of recurrent enterovesical fistula, we performed laparoscopic segmental ileal resection with Endo GIA™. The length of the resected ileum was about 10cm including the fistula, left as a patch covering over the bladder to prevent adhesion. Side to side ileoileal anastomosis was performed by using 3-0 and 4-0 Monocryl interrupted suture for two layers. In the following twenty months, regularly therapeutic use of antibiotics was no longer needed for her. A computed tomography with intravesical contrast irrigation revealed no contrast leakage to the peritoneal cavity, and nor contrast passing to adjacent bowel loops. The patient experienced a good recovery, without evidence of recurrence.