Colovesical and Colovaginal Fistulas

1. 2012 MISS Meeting – Salt Lake City Colovesical and Colovaginal Fistulas Richard L. Whelan, MD St. Lukes Roosevelt Hospital Columbia University New York, NY

2. Whelan Disclosures • Ethicon Endosurgery • Olympus Corporation • Atrium Corporation • Convatec

3. Types of Colonic Fistulas • Colo-vesical • Colo-vaginal • Colo-enteric • Colo-colonic • Colo-cutaneous

4. Etiology of Colonic Fistulas • Diverticulitis • Cancer • Inflammatory Bowel Disease • Post-radiation (prostate, rectal cancer, GYN cancers) • Postoperative

5. Diagnosis • Most fistulas are easily diagnosed • Colovesical: pneumaturia, facaluria, UTI’s • Colovaginal: stool +/- gas per vagina • Colocutaneous: drainage through abdominal wall • Small bowel fistulas are harder to diagnose • History is important: • Prior pelvic surgery (TAH, prior rectal resection) • Prior fistula closure attempts • IBD hx • prior pelvic RT

6. Work Up is Critical • Colonoscopy (if possible): • Rarely, can clearly see the fistula • Reveals other colonic findings (tics, polyps, colitis, cancers, etc.) • CT scan with oral & IV contrast • Abscess in continuity? • Cystoscopy (colovesical fistulas): • inflamed edematous area in bladder • Rarely see the fistula • Barium enema for colonic fistula • SI follow through: will reveal SB fistulas

7. Pelvic & GYN Examination • Important for all patients who are to undergo pelvic bowel resection • Will alert surgeon to presence of uterine & ovarian masses • In vaginal fistula patients may reveal location of fistula • Outpatient methylene blue test to verify presence of vaginal fistula: dye in rectum, tampon in vagina, wait 30-60 minutes with patient ambulating

8. Colovesical fistula in Diverticulitis • Usually to the dome of the bladder • Many come down easily (lap assisted method) • Some are more densely adherent (may need hand-assisted method) • Some are broadly and very densely adherent (open methods may be needed) • Bladder resection is rarely necessary • An actual hole in bladder is rarely seen (& colon rarely leaks stool post takedown) • Bladder sutures are rarely needed

9. Diverticulitis-Related Colovesical Fistula • A few are so bad that proximal diversion alone (no resection done) • When there is no plane into the pelvis (anteriorly, lateral, or posteriorly) • When the bladder and colon have become one organ • Wait 6 months, then operate with stents and with Urologist.

10. Ureteral Stents • For simple cases they are not necessary • Not unreasonable to routinely place stents in fistula patients • Can place stents intraoperatively if need be • Stents can be associated with complications: • After stent removal bleeding, clot formation, and ureteral obstruction  often requires repeat urgent cystoscopy & j stent placement • Higher rate of UTI ?

11. Cancer-related Colo-vesical Fistula • Preop assessment of resectability (CT, MRI, PET) • Cystoscopy and ureteral stents mandatory • Usually colon cancer  bladder • Some bladder will need to be resected • Tumor location in bladder is critical • Can resect dome of bladder without difficulty • Base of bladder fistulas are difficult (ureteral orifice(s) & may require reimplantation

12. Role of Urologist in Colovesical Fistula Takedown • Not needed for simple cases • Definitely needed for difficult fistulas • Urologist should be lined up preop • OR should know that cystoscopy & ureteral placement is planned or might be needed

13. Intestinal-Vaginal Fistulas • Intestinal discharge or drainage via the vagina • Need to determine what part of the bowel is feeding the fistula (colon, rectum, small bowel) • Nature of the discharge ? • Colonoscopy, barium enema, upper GI series

14. Must distinguish between rectovaginal and colovaginal fistulas • Rectovaginal causes include birthing injury, IBD, post RT (or cryotherapy), cryptoglandular • Outpatient methylene blue test • EUA, bidigital exam may reveal distal fistulas • Colovesical fistulas are usually found in women who have had prior hysterectomy

15. Etiology of Colovaginal fistula • Diverticulitis • Cancer • Inflammatory Bowel Disease • Post-radiation (prostate, rectal cancer, GYN cancers) • Postoperative

16. Is the Colovaginal Fistula Approachable Surgically ? • Diverticulitis related fistulas should be feasible • IBD related fistulas should be feasible • If cancer, is the lesion resectable for cure ? • Biopsy the fistula, if possible • What is the origin (GYN vs colorectal) • Primary tumor or recurrence? • Post-RT fistulas are real challenge • Will the patient tolerate the operation • Diversion alone is an option in some patients • How symptomatic

17. Takedown of Colovaginal Fistula • Start laparoscopically and assess situation • How bad are the adhesions? • Can the small bowel be mobilized out of the pelvis • How adherent is the colon to the vagina & surrounding pelvis • If doable continue, • If very difficult  Hand-assist conversion • If prohibitive  Take splenic flexure down, devascularize proximally  convert

18. Sigmoid Resection for Colovaginal Fistula • Mobilize the sigmoid (easy parts first, then more difficult areas) • Ureteral stents if needed • Takedown the surrounding adhesions and then the fistula • Simultaneous vaginal exam can be helpful • If cancer, partial vaginal resection will be necessary

19. After Fistula Takedown • Resect the diseased colon • EEA anastomosis • If possible, place omentum in the pelvis between the large bowel and the vagina

20. Summary • Must determine the location of the fistula in the large bowel and in the second organ (anatomy is critical) • Determine the etiology • Cancer cases can be particular challenge • These are challenging cases • Use stents liberally • Lapaorscopic approach to start • Hand conversion if necessary • Convert to open if need be