翁涵育、楊文宏

 國立成功大學醫學院附設醫院泌尿部

Han-Yu Wong, Wen-Horng Yang

Department of Urology, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan

 

Abstract: As we know, ileal neobladder reconstruction has gained wide acceptance and remains as one of the standard method for those with muscle-invasive bladder cancer. However, it is associated with some specific complications and neovesico-cutaneous fistula is a rare complication which develops mostly during early postoperative period. Here, we reported the case of a 84-year-old female who underwent ileal neobladder reconstruction 19 years ago, and complicated with neovesico-cutaneous fistula with initial presentation of abdominal wall cellulitis and peritonitis.

CASE PRESENTATION:_：A 84-year-old female with muscle-invasive bladder cancer underwent radical cystectomy with urinary diversion via an ileal neobladder 19 years ago. Post-operative wound infection was noted and debridement was later performed one month after the operation. She was generally well with totally cancer free during these years and without requiring clean intermittent catheterization. She presented to our emergency department with right lower quadrant pain for one week. The other associated symptoms included decreased urine output. A physical examination revealed lower abdominal skin redness and local peritoneal signs over lower abdomen. The laboratory findings were leukocytosis with left shifting and acute kidney injury. Contrast enhanced computed tomography revealed a distended neobladder with subcutaneous fluid accumulation inn the lower abdomen. Neovesico-cutaneous fistula was impressed and urethral Foley was then inserted with turbid urine and mucus drained out. Conservative treatment including parenteral antibiotics use and regular gentle manual irrigation were given but failed to have the fistula spontaneous closure nearly one month later. Fistulectomy was therefore performed after discussing with general surgeon. Video-urodynamic study was done one month after the operation which showed no more fistula tract with ileo-neobladder capacity around 200ml and a postvoid residual urine volume of ﹤50ml. Urethral Foley was removed after the study. The patient has been well until now.

Conclusion: A neovesicocutaneous fistula is a rare complication that occurs after orthotopic bladder reconstruction, especially during the early postoperative period. Conservative management including adequate, uninterrupted urinary drainage and broad-spectrum antibiotics therapy were considered adequate treatment for this condition according to previous case reports. We reported the first case of neovesicocutaneous fistula who underwent surgical intervention after the above conservative treatment failed. The result suggests that surgery is a feasible option to facilitate the closure of a fistulous tract in case of prolonged urine leakage from the ileal bladder.