Tech Coloproctol DOI 10.1007/s10151-014-1157-5
REVIEW
Laparoscopic treatment of colovesical fistulas due to complicated colonic diverticular disease: a systematic review R. Cirocchi • G. Cochetti • J. Randolph C. Listorti • E. Castellani • C. Renzi • E. Mearini • A. Fingerhut
•
Received: 6 August 2013 / Accepted: 13 April 2014 Springer-Verlag Italia 2014
Abstract Colovesical fistulas originating from complicated sigmoid diverticular disease are rare. The primary aim of this review was to evaluate the role of laparoscopic surgery in the treatment of this complication. The secondary aim was to determine the best surgical treatment for this disease. A systematic search was conducted for studies published between 1992 and 2012 in PubMed, the Cochrane Register of Controlled Clinical Trials, Scopus, and Publish or Perish. Studies enrolling adults undergoing fully laparoscopic, laparoscopic-assisted, or hand-assisted laparoscopic surgery for colovesical fistula secondary to complicated sigmoid diverticular disease were considered. Data extracted concerned the surgical technique, intraoperative outcomes, and postoperative outcomes based on the R. Cirocchi C. Listorti E. Castellani C. Renzi (&) Department of General and Oncologic Surgery, St. Maria Hospital, University of Perugia, Localita` Sant’Andrea delle Fratte, Via Gambuli n.1, 06156 Perugia, Italy e-mail: [email protected] G. Cochetti E. Mearini Department of Surgical Specialties, Urological Andrological Surgery and Minimally Invasive Techniques, University of Perugia, Piazzale Tristano Di Joannuccio n. 1, 05100 Terni, Italy J. Randolph Tift College of Education, Mercer University, Atlanta, GA 30341, USA A. Fingerhut Athens First Department of Surgery (Prof Leandros), Hippokration University Hospital, University of Athens, Vas Sofias 114, 11527 Athens, Greece A. Fingerhut Section for Surgical Research (Prof Uranues), Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
Cochrane Consumers and Communication Review Group’s template. Descriptive statistics were reported according to the PRISMA statement. In all, 202 patients from 25 studies were included in this review. The standard treatment was laparoscopic colonic resection and primary anastomosis or temporary colostomy with or without resection of the bladder wall. Operative time ranged from 150 to 321 min. It was not possible to evaluate the conversion rate to open surgery because colovesical fistulas were not distinguished from other types of enteric fistulas in most of the studies. One anastomotic leak after bowel anastomosis was reported. There was zero mortality. Few studies conducted follow-up longer than 12 months. One patient required two reoperations. Laparoscopic treatment of colovesical fistulas secondary to sigmoid diverticular disease appears to be a feasible and safe approach. However, further studies are needed to establish whether laparoscopy is preferable to other surgical approaches. Keywords Colovesical fistula Diverticulitis Laparoscopic surgery Bladder Colon
Introduction Diverticular disease is located in the sigmoid colon in about 90 % of cases and, when complicated, accounts for about 60–70 % of all colovesical fistulas [1, 2]. Nevertheless, colovesical fistulas due to complicated sigmoid diverticular disease are rare despite the increased frequency of diverticular disease of the colon in Western countries [3]. The incidence of colovesical fistulas in men is estimated to be about three times greater than in women because of the interposition of the uterus between the communicating viscera [4]. Recurrent acute diverticulitis,
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which is one of the causes of complicated diverticular disease, has been considered to be an indication for elective surgical treatment. Recently, however, ‘‘case-by-case’’ management has been suggested; this has potentially increased the use of a non-operative approach to recurrent attacks [5] and has consequently led to an increased incidence of complicated diverticular disease [6]. To date, the most commonly used surgical procedure for this type of colovesical fistula is open surgery consisting of fistula removal, suture of the bladder wall, and segmental colectomy with primary anastomosis or colostomy [7]. Previous research has demonstrated that laparoscopy is a safe and appropriate option for diverticular disease and is associated with lower overall morbidity (p = 0.01) and lower complication rates (p = 0.008) than open surgery [8]. In the past, colovesical fistula was considered to be an absolute contraindication for laparoscopy, but several recent trials have evaluated the laparoscopic treatment of colovesical fistulas questioning whether laparoscopy is an efficacious and safe technique for this disease [3, 5, 6, 8, 9]. The primary aim of this systematic review was to evaluate the feasibility and safety of laparoscopic surgery in the treatment of colovesical fistulas due to complicated sigmoid diverticular disease and to assess the role of the laparoscopic approach in this disease. The secondary aim was to determine the best surgical treatment for this disease.
Materials and methods The methodology of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was used [10].
Inclusion criteria Published randomized and non-randomized studies in which adult patients (age C 18 years) underwent laparoscopic surgical treatment for colovesical fistula secondary to sigmoid diverticular disease were included in this review if they reported on intraoperative or postoperative outcomes. Exclusion criteria Studies were excluded from the analysis if the outcomes of interest were not reported or it was not possible to evaluate them based on the published results. Interventions Operations involving fully laparoscopic, laparoscopicassisted surgery, or hand-assisted laparoscopy surgery were included. Systematic literature search A systematic bibliography research for studies in English published from January 1992 until December 2012 was conducted in the following online databases: PubMed, Cochrane Register of Controlled Clinical Trials, Scopus, and Publish or Perish (Table 1). Two authors independently performed online bibliography searches in order to identify titles and abstracts of interest. Full texts of relevant articles were further assessed for inclusion in the study. In the case of multiple trials enrolling the same patients, either the most recent study or the one with the best methodological quality was included in the analysis.
Table 1 Literature search in PubMed Search number #
Search description
#1
(‘‘urinary bladder fistula’’[MeSH Terms] OR (‘‘urinary’’[All Fields] AND ‘‘bladder’’[All Fields] AND ‘‘fistula’’[All Fields]) OR ‘‘urinary bladder fistula’’[All Fields] OR (‘‘vesical’’[All Fields] AND ‘‘fistula’’[All Fields]) OR ‘‘vesical fistula’’[All Fields]) AND (‘‘diverticulitis’’[MeSH Terms] OR ‘‘diverticulitis’’[All Fields])
#2
Sigmoid-vesical[All Fields] AND (‘‘fistula’’[MeSH Terms] OR ‘‘fistula’’[All Fields]) AND (‘‘colon, sigmoid’’[MeSH Terms] OR (‘‘colon’’[All Fields] AND ‘‘sigmoid’’[All Fields]) OR ‘‘sigmoid colon’’[All Fields] OR ‘‘sigmoid’’[All Fields]) AND (‘‘diverticulitis’’[MeSH Terms] OR ‘‘diverticulitis’’[All Fields])
#3
Colovesical[All Fields] AND fistulae[All Fields] AND (‘‘colon, sigmoid’’[MeSH Terms] OR (‘‘colon’’[All Fields] AND ‘‘sigmoid’’[All Fields]) OR ‘‘sigmoid colon’’[All Fields] OR ‘‘sigmoid’’[All Fields]) AND (‘‘diverticulitis’’[MeSH Terms] OR ‘‘diverticulitis’’[All Fields])
#4
(‘‘fistula’’[MeSH Terms] OR ‘‘fistula’’[All Fields] OR ‘‘fistulas’’[All Fields]) AND complicating[All Fields] AND (‘‘diverticulum’’[MeSH Terms] OR ‘‘diverticulum’’[All Fields] OR (‘‘diverticular’’[All Fields] AND ‘‘disease’’[All Fields]) OR ‘‘diverticular disease’’[All Fields]) AND (‘‘colon, sigmoid’’[MeSH Terms] OR (‘‘colon’’[All Fields] AND ‘‘sigmoid’’[All Fields]) OR ‘‘sigmoid colon’’[All Fields] OR (‘‘sigmoid’’[All Fields] AND ‘‘colon’’[All Fields]))
#5
(‘‘intestinal fistula’’[MeSH Terms] OR (‘‘intestinal’’[All Fields] AND ‘‘fistula’’[All Fields]) OR ‘‘intestinal fistula’’[All Fields] OR (‘‘colovesical’’[All Fields] AND ‘‘fistula’’[All Fields]) OR ‘‘colovesical fistula’’[All Fields]) AND complicating[All Fields] AND (‘‘diverticulum’’[MeSH Terms] OR ‘‘diverticulum’’[All Fields] OR (‘‘diverticular’’[All Fields] AND ‘‘disease’’[All Fields]) OR ‘‘diverticular disease’’[All Fields])
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•
Primary outcomes The intraoperative outcomes were operative time, estimated intraoperative blood loss, and conversion rate. The early postoperative outcomes (within 30 days) were duration of postoperative hospital stay, anastomotic leakage after bowel anastomosis, bladder leakage, overall postoperative morbidity, overall mortality, and reoperation for colovesical fistula. Secondary outcomes The secondary outcomes were as follows: • • •
•
Type of laparoscopic treatment: fully laparoscopic, laparoscopic-assisted, or hand-assisted; Treatment of colovesical fistula; Treatment of colon: resection and primary anastomosis (single-stage procedure) versus resection and temporary colostomy and/or Hartmann’s procedure (two-stage procedure); Treatment of bladder: primary suture placement with or without resection of the bladder wall versus healing without primary closure;
Fig. 1 PRISMA flow chart of literature search
Records identified through database searching (n=256)
Late postoperative outcomes: recurrent colonic diverticulitis, recurrence of bladder fistula, reoperation for colovesical fistula.
Data extraction We developed a data extraction sheet based on the Cochrane Consumers and Communication Review Group’s data extraction template [11]. Two authors (RC and CR) independently retrieved data of the included studies. Another author (CL) checked the extracted data. Disagreements were solved through discussion and, if necessary, by involving an independent fourth author (GC). Statistical analysis Two authors (GC and RC) performed the statistical analysis in line with recommendations from the PRISMA statement and the Cochrane Handbook for Systematic Reviews. Because the authors of the included articles often reported combined outcomes for different types of fistulas (for instance colovesical, colovaginal, enterocolic) and reported different metrics (e.g., means, medians), we did
Additional records identified through other sources (n=4)
Potentially relevant records (n=260)
Full-text articles assessed for eligibility (n = 31 )
Records excluded after duplicates’ removal (n = 229)
Full-text articles excluded (n = 5) [7, 14-17] reason: specific data about colovesical fistula not available
Studies included in qualitative synthesis (n = 26) [18-43]
Studies included in quantitative synthesis (n = 26) [18-43]
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Tech Coloproctol Table 2 Setting and design of the included studies Author
Duration (years)
City nation
Type of trial
Intention to treat analysis
Cochetti et al. [18]
1
Perugia, Italy
Case report
Yes
Colovesical fistula (unit) 1
Abraham et al. [19]
1
Kochi, India
Case report
–
1
Castillo et al. [20]
1
Santiago, Chile
Case report
–
1
Hirata et al. [21]
NA
Kumamoto, Japan
Prospective observational trial
Yes
5
Royds et al. [22]
4
Retrospective observational trial
Yes
21
Andrade-Platas et al. [23]
1
Dublin, Ireland Talpan, Me´xico
Case report
–
1
Lu and Ho [24] Takaba et al. [25]
3 NA
Queensland, Australia Toranomon, Japan
CCT Prospective observational trial
Yes Yes
8 5 22
Engledow et al. [26]
11
Colchester, UK
Retrospective observational trial
Yes
Nishimura et al. [27]
1
Nagaoka, Japan
Case report
–
1
Zapletal et al. [28]
4
Frankfurt, Germany
Prospective observational trial
Yes
8 7
Lee et al. [29]
3
New York, USA
Retrospective observational trial
Yes
Nguyen et al. [30]
10
New York, USA
Retrospective observational trial
Yes
8
Tsivian et al. [31]
1
Holon, Israel
Case report
–
1
Bartus et al. [32]
6
Yes
34
11
Dallas, USA Lie`ge, Belgium
Prospective observational trial
Laurent et al. [33]
Retrospective observational trial
Yes
11
Pokala et al. [34]
8
Cleveland, USA
Retrospective observational trial
Yes
9
Moorthy et al. [35]
10
Bedford, UK
Retrospective observational trial
Yes
4
Pugliese et al. [36]
7
Milano, Italy
Prospective observational trial
Yes
17
Regan et al. [37]
8
Los Angeles, USA
Retrospective observational trial
Yes
6
Menenakos et al. [38]
9
Athens, Greece
Prospective observational trial
Yes
15
Eijsbouts et al. [39] Joo et al. [40]
5 2
Amsterdam, Netherlands Fort Lauderdale, USA
Prospective observational trial Prospective observational trial
Yes Yes
4 1
Nassiopoulos et al. [41]
3
Fribourg Switzerland
Prospective observational trial
Yes
5
Hewett et al. [42]
NA
Broadview, Australia
Prospective observational trial
Yes
4
Puente et al. [43]
1
Miami, USA
Prospective observational trial
Yes
2
NA not available, CCT controlled clinical trial
not conduct a meta-analysis across studies. Instead, descriptive characteristics were reported for each article. Assessment of methodological quality of the included studies The included comparative studies were assessed by CR and RC for their methodological quality using the revised and modified grading system of the Scottish Intercollegiate Guidelines Network [12]. The included case series and case reports were assessed using the checklist for the quality of case series of the National Institute for Health and Clinical Excellence (NICE) [13].
Results The PRISMA flow diagram for systematic review is presented in Fig. 1. The initial search produced 260
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potentially relevant articles. After screening for relevance in the titles and abstracts and removal of duplicate publications, 31 remaining articles were further assessed for eligibility. Of these, 5 were excluded because they did not report data on outcomes of interest [7, 14–17]. Twenty-six studies were included in this systematic review [18–43] (Table 2). Quality assessment of included studies The methodological quality for each of the included clinical controlled trials (CCT) (4) was ‘‘fair’’ (with a mean score of 12.8 out of 21.0 points) (Table 3). The methodological quality of case series (22) was ‘‘fair’’ (with a mean score of 5.1 out of 8.0 points) (Table 4). In all of the comparative studies, the authors used an intention to treat analysis [24, 28, 29, 32]. Data were prospectively collected from all comparative studies [24, 28, 29, 32] and in 6 case series [22, 26, 33, 34, 39, 42].
Tech Coloproctol Table 3 Evaluation of methodological qualities of comparative studies included Items/authora
Lu [24]
Zapletal [28]
Lee [29]
Bartus [32]
Inclusion criteria
1
1
1
1
Exclusion criteria
1
0
0
1
Comparable demographics?
1
1
1
1
Could the number of participating centers be determined?
0
1
1
1
Could the number of surgeons who participated be determined?
1
1
1
1
Could the reader determine where the authors were on the learning curve for the reported procedure?
1
0
1
0
Were diagnostic criteria clearly stated for clinical outcomes if required? Was the surgical technique adequately described?
1 1
1 1
1 1
1 1
Did they try to standardize the surgical technique?
1
1
1
0
Did they try to standardize perioperative care?
0
0
0
0
Was the age and range given for patients in the study group?
0
0
1
0
Did the authors address whether there were any missing data?
1
1
1
1
Was the age and range given for patients in the control group?
0
0
1
0
Were patients in each group treated along similar timelines?
1
1
1
1
The patients asking to enter the study, did they actually take part to it?
0
0
0
0
Were drop-out rates stated?
0
0
0
0
Were outcomes clearly defined?
1
1
1
1
Were there blind assessors?
0
0
0
0
Were there standardized assessment tools?
1
1
1
0
Was the analysis by intention to treat?
1
1
1
1
13
12
15
11
Score Total score, 21; \8, poor quality; 8–14, fair quality; C15, good quality a
Named by reference number and listed in chronological order
Primary and secondary outcomes Outcomes of the interventions concerned a total of 202 patients. Primary outcomes Intraoperative outcomes: The length of surgical intervention ranged from 150 to 321 min. The estimated intraoperative blood loss was between 50 and 300 mL. It was not possible to estimate the real open conversion rate, because in most of the studies, colovesical fistulas were not distinctly reported from other types of enteric fistulas (Table 5). Immediate postoperative outcomes: The length of postoperative hospital stay depended on the type of bladder treatment and duration of perivesical drainage. No reoperation was necessary within 1 month of surgery. As for intraoperative outcomes, it was not possible to estimate overall morbidity since in some studies colovesical fistulas were not distinguished from other types of enteric fistulas. Only one patient had anastomotic leakage after fistula
separation and sigmoidectomy [21], and none had bladder leakage. There was no mortality (Table 6). Secondary outcomes Type of laparoscopic treatment: Most surgeons performed the laparoscopic-assisted procedure [20, 22, 27–30, 33, 35–37, 39–42], and 93 patients (52 %) underwent this procedure. 45 patients (25 %) were operated on with a fully laparoscopic approach [18, 19, 23, 24, 26, 31, 43], while 41 patients (23 %) underwent to the hand-assisted technique [29, 32] (Table 7). Treatment of fistula: Most of the studies reported fistulectomy as the treatment modality. [18–20, 23–31, 33–38, 40, 41, 43]. Other studies did not mention the technique employed to remove and to repair the fistula [21, 22, 32, 39, 42] (Table 7). Treatment of colon: Colon resection and primary anastomosis were carried out in the majority of studies [19–21, 23–38, 40, 41, 43] while a loop ileostomy was performed in a few cases [21, 34, 40]. Only one study reported a conservative laparoscopic approach including fistulectomy and
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123 7
Total score
a
Named by reference number and listed in chronological order
Total score, 8; B3, poor quality; 4–6, fair quality; C7, good quality
Yes = 1; No (not reported, not available) = 0
1 1
Are outcomes stratified? (e.g., by disease stage, abnormal test results, patient characteristics)
1
Is there an explicit statement that patients were recruited consecutively?
Are the main findings of the study clearly described?
1 1
Were data collected prospectively?
1
1
Is there a clear definition of the outcomes reported?
1
1
4
0
1
0
0
1
0
Is the hypothesis/aim/objective of the study clearly described? Are the inclusion and exclusion criteria (case definition) clearly reported?
4
0
1
0
0
1
1
1
0
Castillo et al. [20]
Moorthy et al. [35]
0
4
Case series collected in more than one center, i.e., multicenter study
4
Total score
0
Pokala et al. [34]
0
Are outcomes stratified? (e.g., by disease stage, abnormal test results, patient characteristics)
1
0
0
1
1
1
0
Abraham et al. [19]
Items/authora
1
Are the main findings of the study clearly described?
1
Is there a clear definition of the outcomes reported? 0
1
Are the inclusion and exclusion criteria (case definition) clearly reported?
0
1
Is the hypothesis/aim/objective of the study clearly described?
Is there an explicit statement that patients were recruited consecutively?
0
Case series collected in more than one center, i.e., multicenter study
Were data collected prospectively?
Cochetti et al. [18]
Items/author*
6
1
1
1
0
1
1
1
0
Pugliese et al. [36]
5
0
1
1
0
1
1
1
0
Hirata et al. [21]
Table 4 Evaluation of methodological qualities of the case report and case series included
4
0
1
0
0
1
1
1
0
5
0
1
1
0
1
1
1
0
5
0
1
1
0
1
1
1
0
5
0
1
1
0
1
1
1
0
6
0
1
1
1
1
1
1
0
6
1
1
0
1
1
1
1
0
4
0
1
0
0
1
1
1
0
5
0
1
1
0
1
1
1
0
5
0
1
1
0
1
1
1
0
Nguyen et al. [30]
6
1
1
1
0
1
1
1
0
Nassiopoulos et al. [41]
Nishimura et al. [27]
Joo et al. [40]
Engledow et al. [26]
Eijsbouts et al. [39]
Takaba et al. [25]
Menenakos et al. [38]
AndradePlatas et al. [23]
Regan and Salky [37]
7
1
1
1
1
1
1
1
0
Royds et al. [22]
6
0
1
1
1
1
1
1
0
Hewett et al. [42]
4
0
1
0
0
1
1
1
0
Tsivian et al. [31]
5
0
1
0
0
1
1
1
1
Puente et al. [43]
6
0
1
1
1
1
1
1
0
Laurent et al. [33]
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Tech Coloproctol Table 5 Intraoperative outcomes
NA not available a b
Mean Median (range)
Study
Operative time (min)
Intraoperative bleeding (mL)
N. laparotomic conversions
Cochetti et al. [18]
210
300
0
Abraham et al. [19]
165
100
0
Castillo et al. [20]
150
50
0
a
a
Hirata et al. [21]
280
43
0
Royds et al. [22]
NA
NA
NA
Andrade-Platas et al. [23]
NA
NA
0
Lu and Ho [24]
NA
NA
NA
Takaba et al. [25]
194a
NA
0
Engledow et al. [26]
NA
NA
NA
Nishimura et al. [27]
NA
NA
NA
Zapletal et al. [28] Lee et al. [29]
NA NA
NA NA
NA NA
Nguyen et al. [30]
NA
NA
NA 0
Tsivian et al. [31]
230
NA
Bartus et al. [32]
220a
NA
NA
Laurent et al. [33]
NA
NA
NA
Pokala et al. [34]
NA
NA
NA
Moorthy et al. [35]
NA
NA
NA
Pugliese et al. [36]
NA
NA
0
Regan and Salky [37]
NA
NA
NA
Menenakos et al. [38]
NA
NA
NA
Eijsbouts et al. [39]
NA
NA
NA
Joo et al. [40]
NA
NA
NA
Nassiopoulos et al. [41]
230a
NA
NA
b
Hewett et al. [42]
227 (205–240)
NA
0
Puente et al. [43]
321a
NA
0
suture of the colon (without resection) and the bladder wall [18]. In one case, a diverting ileostomy for the control of recurrent urinary tract infection was performed in an elderly patient with colovesical fistula [34] (Table 7). Treatment of bladder: In most cases, the treatment was primary suture closure with or without bladder resection. The choice of treatment depended solely on the characteristics of the fistula and the surrounding bladder tissue (Table 7). Late postoperative outcomes: Only a few studies reported a mean follow-up longer than 12 months [18, 20, 33, 35, 38]. Recurrent colonic diverticulitis was not observed; only one bladder fistula recurrence was reported after fistula division (‘‘stapled fistulectomy’’) and was managed by a sigmoid resection [35]. Reoperations were performed in two cases in which one patient had recurrent colovesical fistulas (Table 8).
Discussion This systematic review suggests that laparoscopic treatment of colovesical fistula secondary to complicated
sigmoid diverticular disease is feasible and safe; indeed, laparoscopic perioperative outcomes are comparable to open surgery ones, even if larger trials did not distinguish outcomes of colovesical fistulas from those of colovaginal and rarer ileocolic fistulas (Table 9). Therefore, this review cannot establish whether laparoscopy is the best strategy for colovesical fistula treatment. Our review showed that laparoscopic treatment of colovesical fistulas is not necessarily contraindicated because of adhesions and/or sigmoid diverticular disease as previously suggested [9]. However, due to the frequent findings of close or extensive adhesions between the bladder and the bowel and the steep learning curve [38], some authors suggested that the fully laparoscopic and laparoscopicassisted approaches should be performed by skilled surgeons only [19, 41]. Our review shows the laparoscopicassisted surgery was the most frequently performed surgical approach. Alternatively, the hand-assisted technique was carried out in order to preserve the tactile sense and proprioception of the surgeon [32], but our review found that only few surgeons performed this approach. According to Mutter et al. [44], mesocolon mobilization and division
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Tech Coloproctol Table 6 Early postoperative (30 day) outcomes Study
Overall morbidity
Anastomotic leak (bowel)
Bladder leak
Reoperation
Length postoperative hospital stay [days]
Overall mortality
Cochetti et al. [18]
0
0
0
–
8
0
Abraham et al. [19]
0
0
0
0
6
0
Castillo et al. [20]
0
0
0
0
5
0
Hirata et al. [21]
0
1
0
0
10a
0
Royds et al. [22]
NA
NA
NA
NA
NA
0
Andrade-Platas et al. [23]
0
0
0
0
NA
0
Lu and Ho [24] Takaba et al. [25]
NA 2b
0 0
0 0
NA 0
NA 14.6a
0 0
Engledow et al. [26]
NA
0
0
0
NA
0
Nishimura et al. [27]
NA
0
0
0
17
0
Zapletal et al. [28]
NA
0
0
NA
NA
0
Lee et al. [29]
NA
NA
NA
NA
NA
0
Nguyen et al. [30]
NA
0
0
0
NA
0
Tsivian et al. [31]
0
0
0
0
6
0
Bartus et al. [32]
NA
0
0
0
NA
0
Laurent et al. [33]
NA
0
0
0
NA
0
Pokala et al. [34]
1c
0
0
0
NA
0
Moorthy et al. [35]
NA
0
0
0
NA
0
Pugliese et al. [36]
0
0
0
0
NA
0
Regan and Salky [37]
NA
NA
0
NA
NA
0
Menenakos et al. [38]
NA
NA
0
NA
NA
0
Eijsbouts et al. [39] Joo et al. [40]
NA NA
NA 0
0 0
NA NA
NA 6.1a
0 0
Nassiopoulos et al. [41]
0
0
0
0
10a
0
Hewett et al. [42]
NA
0
0
0
4.7a
0
Puente et al. [43]
0
0
0
0
5a
0
NA not available a
Mean
b
Ureterostenosis
c
Ileus
of the vessels has to be executed through both a lateral and medial approach, identifying the fistula and resecting the diseased colic segment. Our review highlights that the majority of surgeons carried out sigmoidectomy with immediate colorectal anastomosis; recently, sigmoid colon sparing has been proposed in selected cases that are not due to complicated diverticular disease [18, 45]. Only one study reported laparoscopic conservative treatment of the fistula without colon resection including isolation of the fistula tract that was clipped with Hem-o-lok clips and removed, while the bladder wall was sutured after curettage of the fistula site [45]. Our review suggests that currently, there is no consensus on bladder treatment [46]. Resection is mandatory in the presence of extensive parietal inflammation or necrosis or when malignancy is suspected [38]. If a bladder wall defect is visible or palpable, the surgeon
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may perform a simple closure of the bladder defect [31, 47], as reported in most of the trials in this review [18–20, 23, 24, 26, 30, 33, 34, 36–38]. An omental patch or omental flap has been proposed when the bladder defect is wide in order to avoid postoperative complications and disease recurrence [48, 49]. Minor defects of the bladder wall may be treated with Foley catheter drainage only, usually for 7–10 days. This strategy allows bladder healing without surgical repair, and it is associated with low morbidity [47]. The length of postoperative hospital stays was extremely variable and was less the result of the surgical treatment of the bladder (i.e., primary repair or left to heal on its own) than of postoperative management, mainly the duration of catheterization [38, 50]. Our results are in agreement with a recent review by Scozzari and colleagues, which shows that the laparoscopic approach is a safe intervention [16].
16 simple dissection Fistulectomy/repair
Fully laparoscopic
Laparoscopic assisted
NA
Laparoscopic assisted
Fully laparoscopic
Fully laparoscopic NA
Fully laparoscopic
Laparoscopic assisted
Laparoscopic assisted
Laparoscopic assisted, hand-assisted laparoscopic
Laparoscopic assisted
Fully laparoscopic
Hand-assisted laparoscopic
Laparoscopic assisted
NA
Laparoscopic assisted
Laparoscopic assisted
Laparoscopic assisted
NA
Abraham et al. [19]
Castillo et al. [20]
Hirata et al. [21]
Royds et al. [22]
Andrade-Platas et al. [23]
Lu et al. [24] Takaba et al. [25]
Engledow et al. [26]
Nishimura et al. [27]
Zapletal et al. [28]
Lee et al. [29]
Nguyen et al. [30]
Tsivian et al. [31]
Bartus et al. [32]
Laurent et al. [33]
Pokala et al. [34]
Moorthy et al. [35]
Pugliese et al. [36]
Regan et al. [37]
Menenakos et al. [38]
8 simple dissection
Stapled fistulectomy
Fistulectomy
Fistulectomy
NA
Fistulotomy- suture of the bladder wall
Fistulectomy
Fistulectomy
Fistulectomy- intracorporeal closure
Fistulectomy
Fistulectomy
Fistulectomy Fistulectomy
Fistulectomy
NA
NA
Fistulectomy
Reconstruction
Fistulectomy
Fully laparoscopic
Cochetti et al. [18]
Treatment of fistula
Type of laparoscopic treatment
Author
Table 7 Surgical technique
1 resection of the vesical wall and two-layer closure of the defect
8 sigmoidectomy and primary anastomosis
15 sigmoidectomy and primary anastomosis
6 sigmoidectomy and primary anastomosis
17 sigmoidectomy and primary anastomosis
2 resection of the vesical wall and two-layer closure of the defect
2 primary suture placement
6 stapling device placement
6 primary suture placement
16 left to heal without primary closure
1 primary suture placement
2 stapling device placement
2 primary suture placement
1 diverting loop ileostomya
2 sigmoidectomy and primary anastomosis
11 primary suture placement
NA
1 left to heal without primary closure
5 left to heal without primary closure
3 primary suture placement
NA
Intracorporeal closure
NA
20 left to heal without primary closure
2 primary suture placement
8 primary suture placement 5 left to heal without primary closure
1 resection of the vesical wall and two-layer closure of the defect
NA
5 left to heal without primary closure
1 resection of the vesical wall and two-layer closure of the defect
1 resection of the vesical wall and two-layer closure of the defect
1 resection bladder wall and primary suture placement
Treatment of bladder (no. of patients)
11 sigmoidectomy and primary anastomosis
34 sigmoidectomy and primary anastomosis
1 sigmoidectomy and primary anastomosis
8 sigmoidectomy and primary anastomosis
7 sigmoidectomy and primary anastomosis
8 sigmoidectomy and primary anastomosis
1 sigmoidectomy and primary anastomosis
22 sigmoidectomy and primary anastomosis
8 sigmoidectomy and primary anastomosis 5 sigmoidectomy and primary anastomosis
1 sigmoidectomy and primary anastomosis
NA
5 sigmoidectomy and primary anastomosis with 1 covering ileostomy
1 sigmoidectomy and primary anastomosis
1 sigmoidectomy and primary anastomosis
1 suture of sigmoid
Treatment of sigmoid colon (no. of patients)
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2 resection of the vesical wall and left to heal without primary closure
For the control recurrent urinary tract infection in a elderly patient with a colovesical fistula a
NA not available
NA NA
2 sigmoidectomy and primary anastomosis Fully laparoscopic Puente et al. [43]
NA Laparoscopic assisted Hewett et al. [42]
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Table 8 Late postoperative outcomes
Fistulectomy
5 stapling device placement 5 sigmoidectomy and primary anastomosis Laparoscopic assisted Nassiopoulos et al. [41]
Fistulectomy
1 resection of the vesical wall and left to heal without primary closure 1 sigmoidectomy, primary anastomosis and loop ileostomy Laparoscopic assisted Joo et al. [40]
Pinch off technique
NA NA Laparoscopic assisted Eijsbouts et al. [39]
NA
Type of laparoscopic treatment Author
Table 7 continued
Treatment of fistula
Treatment of sigmoid colon (no. of patients)
Treatment of bladder (no. of patients)
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Author
Follow-up (months)
Recurrence of colonic diverticulitis
Recurrence of bladder fistula
Reoperation
Cochetti et al. [18]
42
0
0
0
Abraham et al. [19]
11
0
0
0
Castillo et al. [20]
24
0
Hirata et al. [21]
NA
NA
Royds et al. [22]
NA
NA
NA
NA
Andrade-Platas et al. [23]
NA
NA
NA
NA
Lu and Ho [24]
NA
0
Takaba et al. [25]
NA
NA
0
0
NA
NA
0
NA
NA
NA
Engledow et al. [26]
6
0
0
0
Nishimura et al. [27]
NA
0
0
0
Zapletal et al. [28]
NA
0
0
NA
Lee et al. [29]
NA
NA
NA
NA
Nguyen et al. [30]
NA
NA
0
1
Tsivian et al. [31]
6
0
0
0
Bartus et al. [32]
NA
NA
NA
0
Laurent et al. [33]
61 (7–141)a
0
0
0
Pokala et al. [34]
NA
NA
NA
NA
Moorthy et al. [35]
24
NA
1b
1c
Pugliese et al. [36]
NA
NA
NA
NA
Regan and Salky [37]
NA
NA
NA
NA
Menenakos et al. [38]
61.7 (8–99)a
0
0
NA
Eijsbouts et al. [39]
NA
NA
NA
NA
Joo et al. [40]
NA
NA
NA
NA
Nassiopoulos et al. [41]
NA
0
0
0
Hewett et al. [42]
11 (2–24)d
0
0
0
Puente et al. [43]
NA
NA
NA
0
NA not available a
Mean (range)
b
After ‘‘stapled fistulectomy’’
c
Sigmoidectomy and primary anastomosis for recurrence of fistula
d
Median (range)
The major limitations of this review are the limited generalizability and reproducibility of the included studies. This is due to absence of large, randomized, multicenter studies in the literature. Moreover, the sample size and follow-up duration, whenever reported, were not sufficient for evaluation of long-term complications. Another limitation is that several studies aggregated data concerning patients with colovesical fistulas with those of patients
102 patients with complicated diverticular disease
62 patients with recurrent and sigmoid diverticular disease
31 patients with sigmoid diverticular fistulae 26 patients with sigmoid diverticulitis complicated by abscess or fistulas
14 patients with diverticular disease complicated
14 patients with diverticular disease complicated by fistulae
36 patients with diverticular disease
16 patients with diverticular disease complicated by fistulae
24 patients with diverticular disease and 19 with Crohn’s disease
14 patients with enteric fistulas in diverticular (10 pts.) and Crohn’s disease (4 pts.)
72 patients with enteric fistulas in diverticular (10 %) and Crohn’s disease (90 %)
18 patients with sigmoid diverticulitis complicated
41 patients with diverticular disease
9 patients with enteric fistulas in diverticular (4 pts.), Crohn’s disease (3 pts.) and postoperative pouch complication (2 pts.)
7 patients with internal fistulae from sigmoid diverticulitis complicated
Royds et al. [22]
Lu and Ho [24]
Engledow et al. [26] Zapletal et al. [28]
Lee et al. [29]
Nguyen et al. [30]
Bartus et al. [32]
Laurent et al. [33]
Pokala et al. [34]
Moorthy et al. [35]
Regan and Salky [37]
Menenakos et al. [38]
Eijsbouts et al. [39]
Joo et al. [40]
Hewett et al. [42]
5 colovesical and 2 colovaginal
2 enterocolic, 2 pouch vaginal, 1 ileo-ileal, 1 colofallopian, 1 colovesical and 1 colocutaneous, 1 rectourethral
4 colovesical and 1 colovaginal
15 colovesical and 3 colovaginal
35 enterocolic, 30 ileo-ileal, 10 ileovesical, 6 colovesical, and 1 colovaginal
6 colovesical, 3 enterocolic, 3 ileo-ileal, 1 colocutaneous, 1 ileocutaneous, 1 ileovaginal
Diverticular disease (6 colovaginal, 9 colovesical, 8 coloenteric, 1 colocolic) and Crohn’s disease (9 ileosigmoid, 3 enterocolic, 4 enterovesical, 3 duodenoliecolic)
11 colovesical, 4 colovaginal, 1 colocutaneous
34 colovesical and 2 colovaginal
8 colovesical, 5 enterocolic, 1 colovaginal, 1 colosalpingal, 1 colocutaneous
7 colovesical
22 colovesical and 9 colovaginal 8 colovesical and 1 colovaginal
8 colovesical
21 colovesical, 2 colovaginal, 1 colouterine
Type of fistula (no. of patients)
f
e
s
c
b
a
Mean ± standard deviation
Mean (range)
Mean ± standard error of the mean
Median (range)
Complicated
Uncomplicated
NA not available, LAP laparoscopic sigmoidectomy, HAL hand-assisted laparoscopic sigmoidectomy
Pathology (no. of patients)
Author
Table 9 Characteristics of the included studies
d
20
195e
220c
0
33.3
5.5
237 (165–330)e
195 (75–360)
4.1
199 (62–400)e
e
23
119.2 ± 38.9f
18.75
25
32.6
e
163 ± 80f
172 (100–280)
220e
36
10 HAL
177 ± 34 HAL 209 (78–309)
75 LAP
255 ± 15fLAP e
29 11.5
3
4c
6.1 (3–12)e
6.5e
10e
5.2 (2–14)e
NA
5.2 ± 4.7f
5.7 (3–12)e
6.2
NA
7 HAL
6e LAP
7 (3–21)c 10 ± 6.4f
4.9e
9 (6–15)c
5.2a 10.8b
Postoperative hospital stay (days)
Laparotomic conversion (%)
150 (60–310)c 205 ± 41f
110.87 ± 4.8
NA
Operation time (min)
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with other types of enteric fistulas. Finally, a variety of different laparoscopic approaches were used, and often, they were not accurately described in each study.
Conclusions Although there are many published articles about the surgical treatments of colovesical fistulas secondary to complicated diverticular disease, these are observational studies or case reports, and several reports were poorly written. The lack of RCTs and CCTs, the small sample size, and the heterogeneity of published papers do not allow us to draw strong conclusions as to evidence-based surgical management of colovesical fistulas. Moreover, longer follow-up is necessary to evaluate the recurrence of bladder fistula and colon diverticular disease. Laparoscopic treatment of colovesical fistulas from sigmoid diverticular disease is feasible and safe when performed by surgeons with a high level of laparoscopic experience. Notwithstanding, the present systematic review could not definitely establish whether laparoscopy is the best approach for colovesical fistula treatment. Randomized trials are needed to compare the laparoscopic with the open approach. Conflict of interest
None.
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42. Hewett PJ, Stitz R (1995) The treatment of internal fistulae that complicate diverticular disease of the sigmoid colon by laparoscopically assisted colectomy. Surg Endosc 9:411–413 43. Puente I, Sosa JL, Desai U, Sleeman D, Hartmann R (1994) Laparoscopic treatment of colovesical fistulas: technique and report of two cases. Surg Laparosc Endosc 4:157–160 44. Mutter D, Bouras G, Forgione A, Vix M, Leroy J, Marescaux J (2006) Two-stage totally minimally invasive approach for acute complicated diverticulitis. Colorectal Dis 8:501–505 45. Cochetti G, Lepri E, Cottini E et al (2013) Laparoscopic conservative treatment of colo-vesical fistulas following trauma and diverticulitis: report of two different cases. Cent Eur J Med 8:790–794 46. Yang HY, Sun WY, Lee TG, Lee SJ (2011) A case of colovesical fistula induced by sigmoid diverticulitis. J Korean Soc Coloproctol 27:94–98 47. Ferguson GG, Lee EW, Hunt SR, Ridley CH, Brandes SB (2008) Management of the bladder during surgical treatment of enterovesical fistulas from benign bowel disease. J Am Coll Surg 207:569–572 48. Rao PN, Knux R, Barnard RJ, Schofield PF (1987) Management of colovesical fistula. Br J Surg 74:362–363 49. Rames A, Bissada W, Adams DB (1991) Extent of bladder and ureteric involvement and urologic management in patients with enterovesical fistulas. Urology 38:523–552 50. de Moya MA, Zacharias N, Osbourne A et al (2009) Colovesical fistula repair: is early Foley catheter removal safe? J Surg Res 156:274–277
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REVIEW
Laparoscopic treatment of colovesical fistulas due to complicated colonic diverticular disease: a systematic review R. Cirocchi • G. Cochetti • J. Randolph C. Listorti • E. Castellani • C. Renzi • E. Mearini • A. Fingerhut
•
Received: 6 August 2013 / Accepted: 13 April 2014 Springer-Verlag Italia 2014
Abstract Colovesical fistulas originating from complicated sigmoid diverticular disease are rare. The primary aim of this review was to evaluate the role of laparoscopic surgery in the treatment of this complication. The secondary aim was to determine the best surgical treatment for this disease. A systematic search was conducted for studies published between 1992 and 2012 in PubMed, the Cochrane Register of Controlled Clinical Trials, Scopus, and Publish or Perish. Studies enrolling adults undergoing fully laparoscopic, laparoscopic-assisted, or hand-assisted laparoscopic surgery for colovesical fistula secondary to complicated sigmoid diverticular disease were considered. Data extracted concerned the surgical technique, intraoperative outcomes, and postoperative outcomes based on the R. Cirocchi C. Listorti E. Castellani C. Renzi (&) Department of General and Oncologic Surgery, St. Maria Hospital, University of Perugia, Localita` Sant’Andrea delle Fratte, Via Gambuli n.1, 06156 Perugia, Italy e-mail: [email protected] G. Cochetti E. Mearini Department of Surgical Specialties, Urological Andrological Surgery and Minimally Invasive Techniques, University of Perugia, Piazzale Tristano Di Joannuccio n. 1, 05100 Terni, Italy J. Randolph Tift College of Education, Mercer University, Atlanta, GA 30341, USA A. Fingerhut Athens First Department of Surgery (Prof Leandros), Hippokration University Hospital, University of Athens, Vas Sofias 114, 11527 Athens, Greece A. Fingerhut Section for Surgical Research (Prof Uranues), Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
Cochrane Consumers and Communication Review Group’s template. Descriptive statistics were reported according to the PRISMA statement. In all, 202 patients from 25 studies were included in this review. The standard treatment was laparoscopic colonic resection and primary anastomosis or temporary colostomy with or without resection of the bladder wall. Operative time ranged from 150 to 321 min. It was not possible to evaluate the conversion rate to open surgery because colovesical fistulas were not distinguished from other types of enteric fistulas in most of the studies. One anastomotic leak after bowel anastomosis was reported. There was zero mortality. Few studies conducted follow-up longer than 12 months. One patient required two reoperations. Laparoscopic treatment of colovesical fistulas secondary to sigmoid diverticular disease appears to be a feasible and safe approach. However, further studies are needed to establish whether laparoscopy is preferable to other surgical approaches. Keywords Colovesical fistula Diverticulitis Laparoscopic surgery Bladder Colon
Introduction Diverticular disease is located in the sigmoid colon in about 90 % of cases and, when complicated, accounts for about 60–70 % of all colovesical fistulas [1, 2]. Nevertheless, colovesical fistulas due to complicated sigmoid diverticular disease are rare despite the increased frequency of diverticular disease of the colon in Western countries [3]. The incidence of colovesical fistulas in men is estimated to be about three times greater than in women because of the interposition of the uterus between the communicating viscera [4]. Recurrent acute diverticulitis,
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which is one of the causes of complicated diverticular disease, has been considered to be an indication for elective surgical treatment. Recently, however, ‘‘case-by-case’’ management has been suggested; this has potentially increased the use of a non-operative approach to recurrent attacks [5] and has consequently led to an increased incidence of complicated diverticular disease [6]. To date, the most commonly used surgical procedure for this type of colovesical fistula is open surgery consisting of fistula removal, suture of the bladder wall, and segmental colectomy with primary anastomosis or colostomy [7]. Previous research has demonstrated that laparoscopy is a safe and appropriate option for diverticular disease and is associated with lower overall morbidity (p = 0.01) and lower complication rates (p = 0.008) than open surgery [8]. In the past, colovesical fistula was considered to be an absolute contraindication for laparoscopy, but several recent trials have evaluated the laparoscopic treatment of colovesical fistulas questioning whether laparoscopy is an efficacious and safe technique for this disease [3, 5, 6, 8, 9]. The primary aim of this systematic review was to evaluate the feasibility and safety of laparoscopic surgery in the treatment of colovesical fistulas due to complicated sigmoid diverticular disease and to assess the role of the laparoscopic approach in this disease. The secondary aim was to determine the best surgical treatment for this disease.
Materials and methods The methodology of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was used [10].
Inclusion criteria Published randomized and non-randomized studies in which adult patients (age C 18 years) underwent laparoscopic surgical treatment for colovesical fistula secondary to sigmoid diverticular disease were included in this review if they reported on intraoperative or postoperative outcomes. Exclusion criteria Studies were excluded from the analysis if the outcomes of interest were not reported or it was not possible to evaluate them based on the published results. Interventions Operations involving fully laparoscopic, laparoscopicassisted surgery, or hand-assisted laparoscopy surgery were included. Systematic literature search A systematic bibliography research for studies in English published from January 1992 until December 2012 was conducted in the following online databases: PubMed, Cochrane Register of Controlled Clinical Trials, Scopus, and Publish or Perish (Table 1). Two authors independently performed online bibliography searches in order to identify titles and abstracts of interest. Full texts of relevant articles were further assessed for inclusion in the study. In the case of multiple trials enrolling the same patients, either the most recent study or the one with the best methodological quality was included in the analysis.
Table 1 Literature search in PubMed Search number #
Search description
#1
(‘‘urinary bladder fistula’’[MeSH Terms] OR (‘‘urinary’’[All Fields] AND ‘‘bladder’’[All Fields] AND ‘‘fistula’’[All Fields]) OR ‘‘urinary bladder fistula’’[All Fields] OR (‘‘vesical’’[All Fields] AND ‘‘fistula’’[All Fields]) OR ‘‘vesical fistula’’[All Fields]) AND (‘‘diverticulitis’’[MeSH Terms] OR ‘‘diverticulitis’’[All Fields])
#2
Sigmoid-vesical[All Fields] AND (‘‘fistula’’[MeSH Terms] OR ‘‘fistula’’[All Fields]) AND (‘‘colon, sigmoid’’[MeSH Terms] OR (‘‘colon’’[All Fields] AND ‘‘sigmoid’’[All Fields]) OR ‘‘sigmoid colon’’[All Fields] OR ‘‘sigmoid’’[All Fields]) AND (‘‘diverticulitis’’[MeSH Terms] OR ‘‘diverticulitis’’[All Fields])
#3
Colovesical[All Fields] AND fistulae[All Fields] AND (‘‘colon, sigmoid’’[MeSH Terms] OR (‘‘colon’’[All Fields] AND ‘‘sigmoid’’[All Fields]) OR ‘‘sigmoid colon’’[All Fields] OR ‘‘sigmoid’’[All Fields]) AND (‘‘diverticulitis’’[MeSH Terms] OR ‘‘diverticulitis’’[All Fields])
#4
(‘‘fistula’’[MeSH Terms] OR ‘‘fistula’’[All Fields] OR ‘‘fistulas’’[All Fields]) AND complicating[All Fields] AND (‘‘diverticulum’’[MeSH Terms] OR ‘‘diverticulum’’[All Fields] OR (‘‘diverticular’’[All Fields] AND ‘‘disease’’[All Fields]) OR ‘‘diverticular disease’’[All Fields]) AND (‘‘colon, sigmoid’’[MeSH Terms] OR (‘‘colon’’[All Fields] AND ‘‘sigmoid’’[All Fields]) OR ‘‘sigmoid colon’’[All Fields] OR (‘‘sigmoid’’[All Fields] AND ‘‘colon’’[All Fields]))
#5
(‘‘intestinal fistula’’[MeSH Terms] OR (‘‘intestinal’’[All Fields] AND ‘‘fistula’’[All Fields]) OR ‘‘intestinal fistula’’[All Fields] OR (‘‘colovesical’’[All Fields] AND ‘‘fistula’’[All Fields]) OR ‘‘colovesical fistula’’[All Fields]) AND complicating[All Fields] AND (‘‘diverticulum’’[MeSH Terms] OR ‘‘diverticulum’’[All Fields] OR (‘‘diverticular’’[All Fields] AND ‘‘disease’’[All Fields]) OR ‘‘diverticular disease’’[All Fields])
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•
Primary outcomes The intraoperative outcomes were operative time, estimated intraoperative blood loss, and conversion rate. The early postoperative outcomes (within 30 days) were duration of postoperative hospital stay, anastomotic leakage after bowel anastomosis, bladder leakage, overall postoperative morbidity, overall mortality, and reoperation for colovesical fistula. Secondary outcomes The secondary outcomes were as follows: • • •
•
Type of laparoscopic treatment: fully laparoscopic, laparoscopic-assisted, or hand-assisted; Treatment of colovesical fistula; Treatment of colon: resection and primary anastomosis (single-stage procedure) versus resection and temporary colostomy and/or Hartmann’s procedure (two-stage procedure); Treatment of bladder: primary suture placement with or without resection of the bladder wall versus healing without primary closure;
Fig. 1 PRISMA flow chart of literature search
Records identified through database searching (n=256)
Late postoperative outcomes: recurrent colonic diverticulitis, recurrence of bladder fistula, reoperation for colovesical fistula.
Data extraction We developed a data extraction sheet based on the Cochrane Consumers and Communication Review Group’s data extraction template [11]. Two authors (RC and CR) independently retrieved data of the included studies. Another author (CL) checked the extracted data. Disagreements were solved through discussion and, if necessary, by involving an independent fourth author (GC). Statistical analysis Two authors (GC and RC) performed the statistical analysis in line with recommendations from the PRISMA statement and the Cochrane Handbook for Systematic Reviews. Because the authors of the included articles often reported combined outcomes for different types of fistulas (for instance colovesical, colovaginal, enterocolic) and reported different metrics (e.g., means, medians), we did
Additional records identified through other sources (n=4)
Potentially relevant records (n=260)
Full-text articles assessed for eligibility (n = 31 )
Records excluded after duplicates’ removal (n = 229)
Full-text articles excluded (n = 5) [7, 14-17] reason: specific data about colovesical fistula not available
Studies included in qualitative synthesis (n = 26) [18-43]
Studies included in quantitative synthesis (n = 26) [18-43]
123
Tech Coloproctol Table 2 Setting and design of the included studies Author
Duration (years)
City nation
Type of trial
Intention to treat analysis
Cochetti et al. [18]
1
Perugia, Italy
Case report
Yes
Colovesical fistula (unit) 1
Abraham et al. [19]
1
Kochi, India
Case report
–
1
Castillo et al. [20]
1
Santiago, Chile
Case report
–
1
Hirata et al. [21]
NA
Kumamoto, Japan
Prospective observational trial
Yes
5
Royds et al. [22]
4
Retrospective observational trial
Yes
21
Andrade-Platas et al. [23]
1
Dublin, Ireland Talpan, Me´xico
Case report
–
1
Lu and Ho [24] Takaba et al. [25]
3 NA
Queensland, Australia Toranomon, Japan
CCT Prospective observational trial
Yes Yes
8 5 22
Engledow et al. [26]
11
Colchester, UK
Retrospective observational trial
Yes
Nishimura et al. [27]
1
Nagaoka, Japan
Case report
–
1
Zapletal et al. [28]
4
Frankfurt, Germany
Prospective observational trial
Yes
8 7
Lee et al. [29]
3
New York, USA
Retrospective observational trial
Yes
Nguyen et al. [30]
10
New York, USA
Retrospective observational trial
Yes
8
Tsivian et al. [31]
1
Holon, Israel
Case report
–
1
Bartus et al. [32]
6
Yes
34
11
Dallas, USA Lie`ge, Belgium
Prospective observational trial
Laurent et al. [33]
Retrospective observational trial
Yes
11
Pokala et al. [34]
8
Cleveland, USA
Retrospective observational trial
Yes
9
Moorthy et al. [35]
10
Bedford, UK
Retrospective observational trial
Yes
4
Pugliese et al. [36]
7
Milano, Italy
Prospective observational trial
Yes
17
Regan et al. [37]
8
Los Angeles, USA
Retrospective observational trial
Yes
6
Menenakos et al. [38]
9
Athens, Greece
Prospective observational trial
Yes
15
Eijsbouts et al. [39] Joo et al. [40]
5 2
Amsterdam, Netherlands Fort Lauderdale, USA
Prospective observational trial Prospective observational trial
Yes Yes
4 1
Nassiopoulos et al. [41]
3
Fribourg Switzerland
Prospective observational trial
Yes
5
Hewett et al. [42]
NA
Broadview, Australia
Prospective observational trial
Yes
4
Puente et al. [43]
1
Miami, USA
Prospective observational trial
Yes
2
NA not available, CCT controlled clinical trial
not conduct a meta-analysis across studies. Instead, descriptive characteristics were reported for each article. Assessment of methodological quality of the included studies The included comparative studies were assessed by CR and RC for their methodological quality using the revised and modified grading system of the Scottish Intercollegiate Guidelines Network [12]. The included case series and case reports were assessed using the checklist for the quality of case series of the National Institute for Health and Clinical Excellence (NICE) [13].
Results The PRISMA flow diagram for systematic review is presented in Fig. 1. The initial search produced 260
123
potentially relevant articles. After screening for relevance in the titles and abstracts and removal of duplicate publications, 31 remaining articles were further assessed for eligibility. Of these, 5 were excluded because they did not report data on outcomes of interest [7, 14–17]. Twenty-six studies were included in this systematic review [18–43] (Table 2). Quality assessment of included studies The methodological quality for each of the included clinical controlled trials (CCT) (4) was ‘‘fair’’ (with a mean score of 12.8 out of 21.0 points) (Table 3). The methodological quality of case series (22) was ‘‘fair’’ (with a mean score of 5.1 out of 8.0 points) (Table 4). In all of the comparative studies, the authors used an intention to treat analysis [24, 28, 29, 32]. Data were prospectively collected from all comparative studies [24, 28, 29, 32] and in 6 case series [22, 26, 33, 34, 39, 42].
Tech Coloproctol Table 3 Evaluation of methodological qualities of comparative studies included Items/authora
Lu [24]
Zapletal [28]
Lee [29]
Bartus [32]
Inclusion criteria
1
1
1
1
Exclusion criteria
1
0
0
1
Comparable demographics?
1
1
1
1
Could the number of participating centers be determined?
0
1
1
1
Could the number of surgeons who participated be determined?
1
1
1
1
Could the reader determine where the authors were on the learning curve for the reported procedure?
1
0
1
0
Were diagnostic criteria clearly stated for clinical outcomes if required? Was the surgical technique adequately described?
1 1
1 1
1 1
1 1
Did they try to standardize the surgical technique?
1
1
1
0
Did they try to standardize perioperative care?
0
0
0
0
Was the age and range given for patients in the study group?
0
0
1
0
Did the authors address whether there were any missing data?
1
1
1
1
Was the age and range given for patients in the control group?
0
0
1
0
Were patients in each group treated along similar timelines?
1
1
1
1
The patients asking to enter the study, did they actually take part to it?
0
0
0
0
Were drop-out rates stated?
0
0
0
0
Were outcomes clearly defined?
1
1
1
1
Were there blind assessors?
0
0
0
0
Were there standardized assessment tools?
1
1
1
0
Was the analysis by intention to treat?
1
1
1
1
13
12
15
11
Score Total score, 21; \8, poor quality; 8–14, fair quality; C15, good quality a
Named by reference number and listed in chronological order
Primary and secondary outcomes Outcomes of the interventions concerned a total of 202 patients. Primary outcomes Intraoperative outcomes: The length of surgical intervention ranged from 150 to 321 min. The estimated intraoperative blood loss was between 50 and 300 mL. It was not possible to estimate the real open conversion rate, because in most of the studies, colovesical fistulas were not distinctly reported from other types of enteric fistulas (Table 5). Immediate postoperative outcomes: The length of postoperative hospital stay depended on the type of bladder treatment and duration of perivesical drainage. No reoperation was necessary within 1 month of surgery. As for intraoperative outcomes, it was not possible to estimate overall morbidity since in some studies colovesical fistulas were not distinguished from other types of enteric fistulas. Only one patient had anastomotic leakage after fistula
separation and sigmoidectomy [21], and none had bladder leakage. There was no mortality (Table 6). Secondary outcomes Type of laparoscopic treatment: Most surgeons performed the laparoscopic-assisted procedure [20, 22, 27–30, 33, 35–37, 39–42], and 93 patients (52 %) underwent this procedure. 45 patients (25 %) were operated on with a fully laparoscopic approach [18, 19, 23, 24, 26, 31, 43], while 41 patients (23 %) underwent to the hand-assisted technique [29, 32] (Table 7). Treatment of fistula: Most of the studies reported fistulectomy as the treatment modality. [18–20, 23–31, 33–38, 40, 41, 43]. Other studies did not mention the technique employed to remove and to repair the fistula [21, 22, 32, 39, 42] (Table 7). Treatment of colon: Colon resection and primary anastomosis were carried out in the majority of studies [19–21, 23–38, 40, 41, 43] while a loop ileostomy was performed in a few cases [21, 34, 40]. Only one study reported a conservative laparoscopic approach including fistulectomy and
123
123 7
Total score
a
Named by reference number and listed in chronological order
Total score, 8; B3, poor quality; 4–6, fair quality; C7, good quality
Yes = 1; No (not reported, not available) = 0
1 1
Are outcomes stratified? (e.g., by disease stage, abnormal test results, patient characteristics)
1
Is there an explicit statement that patients were recruited consecutively?
Are the main findings of the study clearly described?
1 1
Were data collected prospectively?
1
1
Is there a clear definition of the outcomes reported?
1
1
4
0
1
0
0
1
0
Is the hypothesis/aim/objective of the study clearly described? Are the inclusion and exclusion criteria (case definition) clearly reported?
4
0
1
0
0
1
1
1
0
Castillo et al. [20]
Moorthy et al. [35]
0
4
Case series collected in more than one center, i.e., multicenter study
4
Total score
0
Pokala et al. [34]
0
Are outcomes stratified? (e.g., by disease stage, abnormal test results, patient characteristics)
1
0
0
1
1
1
0
Abraham et al. [19]
Items/authora
1
Are the main findings of the study clearly described?
1
Is there a clear definition of the outcomes reported? 0
1
Are the inclusion and exclusion criteria (case definition) clearly reported?
0
1
Is the hypothesis/aim/objective of the study clearly described?
Is there an explicit statement that patients were recruited consecutively?
0
Case series collected in more than one center, i.e., multicenter study
Were data collected prospectively?
Cochetti et al. [18]
Items/author*
6
1
1
1
0
1
1
1
0
Pugliese et al. [36]
5
0
1
1
0
1
1
1
0
Hirata et al. [21]
Table 4 Evaluation of methodological qualities of the case report and case series included
4
0
1
0
0
1
1
1
0
5
0
1
1
0
1
1
1
0
5
0
1
1
0
1
1
1
0
5
0
1
1
0
1
1
1
0
6
0
1
1
1
1
1
1
0
6
1
1
0
1
1
1
1
0
4
0
1
0
0
1
1
1
0
5
0
1
1
0
1
1
1
0
5
0
1
1
0
1
1
1
0
Nguyen et al. [30]
6
1
1
1
0
1
1
1
0
Nassiopoulos et al. [41]
Nishimura et al. [27]
Joo et al. [40]
Engledow et al. [26]
Eijsbouts et al. [39]
Takaba et al. [25]
Menenakos et al. [38]
AndradePlatas et al. [23]
Regan and Salky [37]
7
1
1
1
1
1
1
1
0
Royds et al. [22]
6
0
1
1
1
1
1
1
0
Hewett et al. [42]
4
0
1
0
0
1
1
1
0
Tsivian et al. [31]
5
0
1
0
0
1
1
1
1
Puente et al. [43]
6
0
1
1
1
1
1
1
0
Laurent et al. [33]
Tech Coloproctol
Tech Coloproctol Table 5 Intraoperative outcomes
NA not available a b
Mean Median (range)
Study
Operative time (min)
Intraoperative bleeding (mL)
N. laparotomic conversions
Cochetti et al. [18]
210
300
0
Abraham et al. [19]
165
100
0
Castillo et al. [20]
150
50
0
a
a
Hirata et al. [21]
280
43
0
Royds et al. [22]
NA
NA
NA
Andrade-Platas et al. [23]
NA
NA
0
Lu and Ho [24]
NA
NA
NA
Takaba et al. [25]
194a
NA
0
Engledow et al. [26]
NA
NA
NA
Nishimura et al. [27]
NA
NA
NA
Zapletal et al. [28] Lee et al. [29]
NA NA
NA NA
NA NA
Nguyen et al. [30]
NA
NA
NA 0
Tsivian et al. [31]
230
NA
Bartus et al. [32]
220a
NA
NA
Laurent et al. [33]
NA
NA
NA
Pokala et al. [34]
NA
NA
NA
Moorthy et al. [35]
NA
NA
NA
Pugliese et al. [36]
NA
NA
0
Regan and Salky [37]
NA
NA
NA
Menenakos et al. [38]
NA
NA
NA
Eijsbouts et al. [39]
NA
NA
NA
Joo et al. [40]
NA
NA
NA
Nassiopoulos et al. [41]
230a
NA
NA
b
Hewett et al. [42]
227 (205–240)
NA
0
Puente et al. [43]
321a
NA
0
suture of the colon (without resection) and the bladder wall [18]. In one case, a diverting ileostomy for the control of recurrent urinary tract infection was performed in an elderly patient with colovesical fistula [34] (Table 7). Treatment of bladder: In most cases, the treatment was primary suture closure with or without bladder resection. The choice of treatment depended solely on the characteristics of the fistula and the surrounding bladder tissue (Table 7). Late postoperative outcomes: Only a few studies reported a mean follow-up longer than 12 months [18, 20, 33, 35, 38]. Recurrent colonic diverticulitis was not observed; only one bladder fistula recurrence was reported after fistula division (‘‘stapled fistulectomy’’) and was managed by a sigmoid resection [35]. Reoperations were performed in two cases in which one patient had recurrent colovesical fistulas (Table 8).
Discussion This systematic review suggests that laparoscopic treatment of colovesical fistula secondary to complicated
sigmoid diverticular disease is feasible and safe; indeed, laparoscopic perioperative outcomes are comparable to open surgery ones, even if larger trials did not distinguish outcomes of colovesical fistulas from those of colovaginal and rarer ileocolic fistulas (Table 9). Therefore, this review cannot establish whether laparoscopy is the best strategy for colovesical fistula treatment. Our review showed that laparoscopic treatment of colovesical fistulas is not necessarily contraindicated because of adhesions and/or sigmoid diverticular disease as previously suggested [9]. However, due to the frequent findings of close or extensive adhesions between the bladder and the bowel and the steep learning curve [38], some authors suggested that the fully laparoscopic and laparoscopicassisted approaches should be performed by skilled surgeons only [19, 41]. Our review shows the laparoscopicassisted surgery was the most frequently performed surgical approach. Alternatively, the hand-assisted technique was carried out in order to preserve the tactile sense and proprioception of the surgeon [32], but our review found that only few surgeons performed this approach. According to Mutter et al. [44], mesocolon mobilization and division
123
Tech Coloproctol Table 6 Early postoperative (30 day) outcomes Study
Overall morbidity
Anastomotic leak (bowel)
Bladder leak
Reoperation
Length postoperative hospital stay [days]
Overall mortality
Cochetti et al. [18]
0
0
0
–
8
0
Abraham et al. [19]
0
0
0
0
6
0
Castillo et al. [20]
0
0
0
0
5
0
Hirata et al. [21]
0
1
0
0
10a
0
Royds et al. [22]
NA
NA
NA
NA
NA
0
Andrade-Platas et al. [23]
0
0
0
0
NA
0
Lu and Ho [24] Takaba et al. [25]
NA 2b
0 0
0 0
NA 0
NA 14.6a
0 0
Engledow et al. [26]
NA
0
0
0
NA
0
Nishimura et al. [27]
NA
0
0
0
17
0
Zapletal et al. [28]
NA
0
0
NA
NA
0
Lee et al. [29]
NA
NA
NA
NA
NA
0
Nguyen et al. [30]
NA
0
0
0
NA
0
Tsivian et al. [31]
0
0
0
0
6
0
Bartus et al. [32]
NA
0
0
0
NA
0
Laurent et al. [33]
NA
0
0
0
NA
0
Pokala et al. [34]
1c
0
0
0
NA
0
Moorthy et al. [35]
NA
0
0
0
NA
0
Pugliese et al. [36]
0
0
0
0
NA
0
Regan and Salky [37]
NA
NA
0
NA
NA
0
Menenakos et al. [38]
NA
NA
0
NA
NA
0
Eijsbouts et al. [39] Joo et al. [40]
NA NA
NA 0
0 0
NA NA
NA 6.1a
0 0
Nassiopoulos et al. [41]
0
0
0
0
10a
0
Hewett et al. [42]
NA
0
0
0
4.7a
0
Puente et al. [43]
0
0
0
0
5a
0
NA not available a
Mean
b
Ureterostenosis
c
Ileus
of the vessels has to be executed through both a lateral and medial approach, identifying the fistula and resecting the diseased colic segment. Our review highlights that the majority of surgeons carried out sigmoidectomy with immediate colorectal anastomosis; recently, sigmoid colon sparing has been proposed in selected cases that are not due to complicated diverticular disease [18, 45]. Only one study reported laparoscopic conservative treatment of the fistula without colon resection including isolation of the fistula tract that was clipped with Hem-o-lok clips and removed, while the bladder wall was sutured after curettage of the fistula site [45]. Our review suggests that currently, there is no consensus on bladder treatment [46]. Resection is mandatory in the presence of extensive parietal inflammation or necrosis or when malignancy is suspected [38]. If a bladder wall defect is visible or palpable, the surgeon
123
may perform a simple closure of the bladder defect [31, 47], as reported in most of the trials in this review [18–20, 23, 24, 26, 30, 33, 34, 36–38]. An omental patch or omental flap has been proposed when the bladder defect is wide in order to avoid postoperative complications and disease recurrence [48, 49]. Minor defects of the bladder wall may be treated with Foley catheter drainage only, usually for 7–10 days. This strategy allows bladder healing without surgical repair, and it is associated with low morbidity [47]. The length of postoperative hospital stays was extremely variable and was less the result of the surgical treatment of the bladder (i.e., primary repair or left to heal on its own) than of postoperative management, mainly the duration of catheterization [38, 50]. Our results are in agreement with a recent review by Scozzari and colleagues, which shows that the laparoscopic approach is a safe intervention [16].
16 simple dissection Fistulectomy/repair
Fully laparoscopic
Laparoscopic assisted
NA
Laparoscopic assisted
Fully laparoscopic
Fully laparoscopic NA
Fully laparoscopic
Laparoscopic assisted
Laparoscopic assisted
Laparoscopic assisted, hand-assisted laparoscopic
Laparoscopic assisted
Fully laparoscopic
Hand-assisted laparoscopic
Laparoscopic assisted
NA
Laparoscopic assisted
Laparoscopic assisted
Laparoscopic assisted
NA
Abraham et al. [19]
Castillo et al. [20]
Hirata et al. [21]
Royds et al. [22]
Andrade-Platas et al. [23]
Lu et al. [24] Takaba et al. [25]
Engledow et al. [26]
Nishimura et al. [27]
Zapletal et al. [28]
Lee et al. [29]
Nguyen et al. [30]
Tsivian et al. [31]
Bartus et al. [32]
Laurent et al. [33]
Pokala et al. [34]
Moorthy et al. [35]
Pugliese et al. [36]
Regan et al. [37]
Menenakos et al. [38]
8 simple dissection
Stapled fistulectomy
Fistulectomy
Fistulectomy
NA
Fistulotomy- suture of the bladder wall
Fistulectomy
Fistulectomy
Fistulectomy- intracorporeal closure
Fistulectomy
Fistulectomy
Fistulectomy Fistulectomy
Fistulectomy
NA
NA
Fistulectomy
Reconstruction
Fistulectomy
Fully laparoscopic
Cochetti et al. [18]
Treatment of fistula
Type of laparoscopic treatment
Author
Table 7 Surgical technique
1 resection of the vesical wall and two-layer closure of the defect
8 sigmoidectomy and primary anastomosis
15 sigmoidectomy and primary anastomosis
6 sigmoidectomy and primary anastomosis
17 sigmoidectomy and primary anastomosis
2 resection of the vesical wall and two-layer closure of the defect
2 primary suture placement
6 stapling device placement
6 primary suture placement
16 left to heal without primary closure
1 primary suture placement
2 stapling device placement
2 primary suture placement
1 diverting loop ileostomya
2 sigmoidectomy and primary anastomosis
11 primary suture placement
NA
1 left to heal without primary closure
5 left to heal without primary closure
3 primary suture placement
NA
Intracorporeal closure
NA
20 left to heal without primary closure
2 primary suture placement
8 primary suture placement 5 left to heal without primary closure
1 resection of the vesical wall and two-layer closure of the defect
NA
5 left to heal without primary closure
1 resection of the vesical wall and two-layer closure of the defect
1 resection of the vesical wall and two-layer closure of the defect
1 resection bladder wall and primary suture placement
Treatment of bladder (no. of patients)
11 sigmoidectomy and primary anastomosis
34 sigmoidectomy and primary anastomosis
1 sigmoidectomy and primary anastomosis
8 sigmoidectomy and primary anastomosis
7 sigmoidectomy and primary anastomosis
8 sigmoidectomy and primary anastomosis
1 sigmoidectomy and primary anastomosis
22 sigmoidectomy and primary anastomosis
8 sigmoidectomy and primary anastomosis 5 sigmoidectomy and primary anastomosis
1 sigmoidectomy and primary anastomosis
NA
5 sigmoidectomy and primary anastomosis with 1 covering ileostomy
1 sigmoidectomy and primary anastomosis
1 sigmoidectomy and primary anastomosis
1 suture of sigmoid
Treatment of sigmoid colon (no. of patients)
Tech Coloproctol
123
2 resection of the vesical wall and left to heal without primary closure
For the control recurrent urinary tract infection in a elderly patient with a colovesical fistula a
NA not available
NA NA
2 sigmoidectomy and primary anastomosis Fully laparoscopic Puente et al. [43]
NA Laparoscopic assisted Hewett et al. [42]
123
Table 8 Late postoperative outcomes
Fistulectomy
5 stapling device placement 5 sigmoidectomy and primary anastomosis Laparoscopic assisted Nassiopoulos et al. [41]
Fistulectomy
1 resection of the vesical wall and left to heal without primary closure 1 sigmoidectomy, primary anastomosis and loop ileostomy Laparoscopic assisted Joo et al. [40]
Pinch off technique
NA NA Laparoscopic assisted Eijsbouts et al. [39]
NA
Type of laparoscopic treatment Author
Table 7 continued
Treatment of fistula
Treatment of sigmoid colon (no. of patients)
Treatment of bladder (no. of patients)
Tech Coloproctol
Author
Follow-up (months)
Recurrence of colonic diverticulitis
Recurrence of bladder fistula
Reoperation
Cochetti et al. [18]
42
0
0
0
Abraham et al. [19]
11
0
0
0
Castillo et al. [20]
24
0
Hirata et al. [21]
NA
NA
Royds et al. [22]
NA
NA
NA
NA
Andrade-Platas et al. [23]
NA
NA
NA
NA
Lu and Ho [24]
NA
0
Takaba et al. [25]
NA
NA
0
0
NA
NA
0
NA
NA
NA
Engledow et al. [26]
6
0
0
0
Nishimura et al. [27]
NA
0
0
0
Zapletal et al. [28]
NA
0
0
NA
Lee et al. [29]
NA
NA
NA
NA
Nguyen et al. [30]
NA
NA
0
1
Tsivian et al. [31]
6
0
0
0
Bartus et al. [32]
NA
NA
NA
0
Laurent et al. [33]
61 (7–141)a
0
0
0
Pokala et al. [34]
NA
NA
NA
NA
Moorthy et al. [35]
24
NA
1b
1c
Pugliese et al. [36]
NA
NA
NA
NA
Regan and Salky [37]
NA
NA
NA
NA
Menenakos et al. [38]
61.7 (8–99)a
0
0
NA
Eijsbouts et al. [39]
NA
NA
NA
NA
Joo et al. [40]
NA
NA
NA
NA
Nassiopoulos et al. [41]
NA
0
0
0
Hewett et al. [42]
11 (2–24)d
0
0
0
Puente et al. [43]
NA
NA
NA
0
NA not available a
Mean (range)
b
After ‘‘stapled fistulectomy’’
c
Sigmoidectomy and primary anastomosis for recurrence of fistula
d
Median (range)
The major limitations of this review are the limited generalizability and reproducibility of the included studies. This is due to absence of large, randomized, multicenter studies in the literature. Moreover, the sample size and follow-up duration, whenever reported, were not sufficient for evaluation of long-term complications. Another limitation is that several studies aggregated data concerning patients with colovesical fistulas with those of patients
102 patients with complicated diverticular disease
62 patients with recurrent and sigmoid diverticular disease
31 patients with sigmoid diverticular fistulae 26 patients with sigmoid diverticulitis complicated by abscess or fistulas
14 patients with diverticular disease complicated
14 patients with diverticular disease complicated by fistulae
36 patients with diverticular disease
16 patients with diverticular disease complicated by fistulae
24 patients with diverticular disease and 19 with Crohn’s disease
14 patients with enteric fistulas in diverticular (10 pts.) and Crohn’s disease (4 pts.)
72 patients with enteric fistulas in diverticular (10 %) and Crohn’s disease (90 %)
18 patients with sigmoid diverticulitis complicated
41 patients with diverticular disease
9 patients with enteric fistulas in diverticular (4 pts.), Crohn’s disease (3 pts.) and postoperative pouch complication (2 pts.)
7 patients with internal fistulae from sigmoid diverticulitis complicated
Royds et al. [22]
Lu and Ho [24]
Engledow et al. [26] Zapletal et al. [28]
Lee et al. [29]
Nguyen et al. [30]
Bartus et al. [32]
Laurent et al. [33]
Pokala et al. [34]
Moorthy et al. [35]
Regan and Salky [37]
Menenakos et al. [38]
Eijsbouts et al. [39]
Joo et al. [40]
Hewett et al. [42]
5 colovesical and 2 colovaginal
2 enterocolic, 2 pouch vaginal, 1 ileo-ileal, 1 colofallopian, 1 colovesical and 1 colocutaneous, 1 rectourethral
4 colovesical and 1 colovaginal
15 colovesical and 3 colovaginal
35 enterocolic, 30 ileo-ileal, 10 ileovesical, 6 colovesical, and 1 colovaginal
6 colovesical, 3 enterocolic, 3 ileo-ileal, 1 colocutaneous, 1 ileocutaneous, 1 ileovaginal
Diverticular disease (6 colovaginal, 9 colovesical, 8 coloenteric, 1 colocolic) and Crohn’s disease (9 ileosigmoid, 3 enterocolic, 4 enterovesical, 3 duodenoliecolic)
11 colovesical, 4 colovaginal, 1 colocutaneous
34 colovesical and 2 colovaginal
8 colovesical, 5 enterocolic, 1 colovaginal, 1 colosalpingal, 1 colocutaneous
7 colovesical
22 colovesical and 9 colovaginal 8 colovesical and 1 colovaginal
8 colovesical
21 colovesical, 2 colovaginal, 1 colouterine
Type of fistula (no. of patients)
f
e
s
c
b
a
Mean ± standard deviation
Mean (range)
Mean ± standard error of the mean
Median (range)
Complicated
Uncomplicated
NA not available, LAP laparoscopic sigmoidectomy, HAL hand-assisted laparoscopic sigmoidectomy
Pathology (no. of patients)
Author
Table 9 Characteristics of the included studies
d
20
195e
220c
0
33.3
5.5
237 (165–330)e
195 (75–360)
4.1
199 (62–400)e
e
23
119.2 ± 38.9f
18.75
25
32.6
e
163 ± 80f
172 (100–280)
220e
36
10 HAL
177 ± 34 HAL 209 (78–309)
75 LAP
255 ± 15fLAP e
29 11.5
3
4c
6.1 (3–12)e
6.5e
10e
5.2 (2–14)e
NA
5.2 ± 4.7f
5.7 (3–12)e
6.2
NA
7 HAL
6e LAP
7 (3–21)c 10 ± 6.4f
4.9e
9 (6–15)c
5.2a 10.8b
Postoperative hospital stay (days)
Laparotomic conversion (%)
150 (60–310)c 205 ± 41f
110.87 ± 4.8
NA
Operation time (min)
Tech Coloproctol
123
Tech Coloproctol
with other types of enteric fistulas. Finally, a variety of different laparoscopic approaches were used, and often, they were not accurately described in each study.
Conclusions Although there are many published articles about the surgical treatments of colovesical fistulas secondary to complicated diverticular disease, these are observational studies or case reports, and several reports were poorly written. The lack of RCTs and CCTs, the small sample size, and the heterogeneity of published papers do not allow us to draw strong conclusions as to evidence-based surgical management of colovesical fistulas. Moreover, longer follow-up is necessary to evaluate the recurrence of bladder fistula and colon diverticular disease. Laparoscopic treatment of colovesical fistulas from sigmoid diverticular disease is feasible and safe when performed by surgeons with a high level of laparoscopic experience. Notwithstanding, the present systematic review could not definitely establish whether laparoscopy is the best approach for colovesical fistula treatment. Randomized trials are needed to compare the laparoscopic with the open approach. Conflict of interest
None.
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