187 A Rare Case of Colovesical Fistula in A Patient with Situs Inversus

A 47 year old man with no past medical history presented to the urology clinic with recurrent urinary tract infections caused by E.Coli. He subsequently had a number of investigations including imaging and cystoscopy which showed a high possibility for a colovesical fistula and incidentally demonstrated subdiaphragmatic Situs inversus. The sigmoid colon was inflamed and adherent to the posterior wall of the bladder. Surgical management following a multi-disciplinary decision resulted in an elective Ureteric stent insertion followed by laparotomy with sigmoid colectomy and primary anastomosis. The bladder wall defect caused by fistula formation was repaired. We report an extremely rare case of colovesical fistula in the setting of subdiaphragmatic situs inversus in a relatively young patient. This would likely be seen in older patients with more severe diverticulitis and usually in an acute setting. Anatomical variation resulted in more severe diverticular disease and predisposed to fistula formation.

FÍSTULA VESICOSIGMOIDEA EN ENFERMEDAD DIVERTICULAR, REPORTE DE CASO Y REVISIÓN DE LITERATURA.

Introduction Colovesical fistulas (CVF) are pathologic communications between bowel and bladder. They represent 1 in 3000 surgical hospital admissions per year. Imaging studies play a crucial role establishing the site, course and complexity of the fistulas, and in identifying their etiology. The management of CVF depends on the underlying pathology, the site of the intestinal injury, and the preoperative state of the patient. A surgical and non-surgical approach can be performed. Case description A clinical case of an 82-year-old patient with multiple comorbidities is reported, who suddenly presented dysuria, stranguria and fecaluria. The abdominal and pelvic tomography revealed diverticulitis with the presence of a fistulous tract from the colon to the bladder. During his hospitalization, the patient presented septic shock of urinary focus due to colovesical fistula, which required management by intensive therapy. Broad-spectrum antibiotic therapy was started. Once stable, we opted for surgical resolution with partial cystectomy plus fistulectomy and Hartmann-type colostomy. After the procedure, the patient evolved favorably with resolution of the condition. Conclusion The nonsurgical approach may be a viable option in patients with poor preoperative condition, an inability to tolerate general anesthesia, or in cancer patients with a short life expectancy. Spontaneous closure of fistulas occurs in approximately 2% of patients and, since up to 75% may have septic complications, the presence of a FCV is an indication for surgery in all patients without contraindications for it. The most widely used surgical approach consists of resection of the compromised intestinal segment with primary anastomosis, without a protective stoma, and closure of the bladder defect. At present, there is no consensus on which is the best surgical strategy due to the lack of clinical trials. An updated review of the subject and its therapeutic management is carried out.