Diagnosis and management of colovesical fistulae; six-year experience of 90 consecutive cases.

INTRODUCTION: Colovesical fistulae are well-recognized but relatively uncommon presentation to colorectal surgery. As a result, few centres have sufficient experience in the investigation and surgical treatment of colovesical fistulae to develop clear protocols in its management.

METHODS: This study examines the diagnostic and treatment pathways of 90 consecutive patients with colovesical fistulae presenting to a single surgeon, over a six-year period. Using the findings from this study and previously published data, the authors suggest tentative guidelines for the diagnosis and management of such patients.

RESULTS: Pneumaturia and faecaluria were present in 90.1% of all cases. The diagnosis of colovesical fistula is predominately a clinical one, however, cystoscopy was the most accurate test to detect fistulae (46.2%) followed by barium enema (20.1%). Barium enema was the most sensitive test to detect stricture formation (70.6%). Colonic endoscopy was the most reliable means of excluding a colonic malignancy. The most common pathology was diverticular disease (72.2%), colonic carcinoma (15.3%) and Crohn's disease (9.7%). Left sided colonic resections were undertaken in 73.6% of patients, right hemicolectomy in 4.2% and defunctioning loop colostomies in 18.5%. Of the left sided resections, primary anastomosis was achieved in 92% of cases (n = 48) with one postoperative leak and no mortality.

DISCUSSION: Resection and primary anastomosis should be the treatment of choice for colovesical fistulae, with an acceptable risk of anastomotic leak and mortality. Barium enema, colonic endoscopy and CT should be routine in the investigation of colovesical fistulae.