Successful Endovascular Repair of a Ruptured Common Iliac Artery Aneurysm Associated with an Ileal Pouch Neobladder Fistula.

A spontaneous fistula between a ruptured common iliac artery aneurysm and the ileal pouch neobladder is quite rare. We present the case of a 74-year-old man presenting with intense abdominal pain and massive hematuria. Computed tomography angiography revealed a ruptured common iliac artery aneurysm-ileal pouch neobladder fistula. His hemodynamics was unstable; emergent endovascular aortic repair was performed successfully. Infection and dysfunction of the neobladder were avoided owing to appropriate management.

A case report of endorectal displacement of a right ureteral stent following radiochemotherapy and Bevacizumab.

BACKGROUND: The angiogenesis inhibitor monoclonal antibody Bevacizumab is presently the standard treatment for numerous neoplasms but particular toxicities are emerging, such as hypertension, haemorrhage, thromboembolism, gastrointestinal perforation, fistulae, and delayed wound healing. The addition of Bevacizumab to radio and chemotherapy has improved the overall survival rate in patients with metastatic, persistent or recurrent cervical carcinoma. However an increased risk of enteric or urinary fistula formation has been documented, related to hypoxia which is induced by the inhibition of angiogenesis. Moreover, previous pelvic surgery, repeated ureteral stenting and radiation are additional risk factors. CASE PRESENTATION: We describe the remarkable case of a right ureteral stent displacement inside the rectum lumen in a patient treated with Bevacizumab for pelvic recurrence of cervical cancer. The patient was referred to our Urology Department with urinary sepsis and bilateral hydronephrosis. Right ureteral stent substitution was planned; at cystoscopy the distal loop of the stent was not visualized inside the bladder. The presence of the distal loop of the right ureteral inside the rectum was clearly demonstrated with a CT scan. CONCLUSIONS: Since Bevacizumab is increasingly used in the treatment of gynaecological neoplasms and indwelling ureteral stents are often required to treat or prevent ureteral compressions, similar cases are likely to be diagnosed and this complication should be considered in the management of advanced pelvic cancers.

Colovesical fistula: review on conservative management, surgical techniques and minimally invasive approaches.

Colovesical fistula (CVF) is an abnormal communication between bowel and urinary bladder. Main causes are represented by complicated diverticular disease, colonic and bladder cancer and iatrogenic complications. Diagnosis is often based on patognomonic signs: faecaluria, pneumaturia and recurrent urinary tract infections. Treatment of CVF includes non-surgical and surgical strategy. The non-surgical treatment is reserved to selected patients who are unfit for surgery. Surgery of CVFs is determined by the site of the colonic lesion and patient's comorbidity. However the surgical one-stage approach should be preferred, reserving the multi-stage procedure in patients with a pelvic abscess, or with advanced malignancy, or previous radiation therapy. The sole defunctioning stoma may be an option to improve the quality of life in patients unfit for bowel resection. In open surgery the standard operative management consists in resection and anastomosis of the involved bowel segment and closure of the bladder. Laparoscopic treatment of CVFs is feasible and safe if performed by skilled surgeons. Robotic surgery for CVF treatment is safe and feasible similarly to laparoscopic one and it seems to reduce the conversion rate with respect to laparoscopy. However, further studies are needed to evaluate the advantages of robotic surgery over laparoscopy in the management of CVF. Currently, in Literature it is still debated which is the best surgical approach for CFV treatment due to the lack of RCTs and CCTs, the small sample size and the short follow-up. Further studies with higher quality and larger sample size are necessary to state the gold standard surgical treatment of CVFs.

Vesico-Adnexal Fistula Treated with Transurethral Embolization Under Fluoroscopic Guidance.

BACKGROUND Vesico-adnexal fistulae are rare. Potential causes of such fistulae include infection, endometriosis, and iatrogenic causes following pelvic surgeries. To the best of our knowledge, only 3 cases of vesico-adnexal fistulae have been reported, and all these patients were treated surgically by removing the involved adnexa, excising the fistulous duct, and suturing the bladder. We describe the first case of vesico-adnexal fistula that developed after pelvic surgery, and it was successfully treated by transurethral embolization under fluoroscopic guidance. CASE REPORT Our patient was a 27-year-old woman with a history of hysterectomy. She presented to our institution with urethral discharge and a recurrent urinary tract infection. The cystogram showed a fistula tract connecting the urinary bladder and left adnexal cystic cavity. She was treated conservatively with antibiotics and prolonged Foley catheterization to allow for spontaneous closure of the fistula; however, conservative management failed. The patient was successfully treated with transurethral embolization of the tract under fluoroscopic guidance. CONCLUSIONS In such a rare scenario with limited treatment options, interventional radiology offers an alternative minimally invasive treatment strategy.

[Post traumatic vesicocutaneous fistula]. / Fistule vesico cutanée post traumatique.

We here report the case of a 43-year old motorcyclist who was initially examined in the emergency department for injuries following a road accident with a car. The patient had pelvic trauma with extensive symphyseal disjunction (A). He underwent orthopedic treatment based on weight compensation. During the two weeks immediately following the trauma, patient's evolution was marked by the occurrence of fistulous orifice at the level of the inner right thigh (B) associated with urinary outflow and wounds due to local skin maceration around the fistula. Radiologically, abdominopelvic CT scan at extended injection-to-scan acquisition time showed contrast extravasation laterally, into the bladder and at the level of the right thigh root due to subperitoneal rupture of the bladder (C). Uretrocystography objectified symphyseal disjunction visible on the non-contrast abdominal X-ray film. Moreover, uretrocystography showed fistulous track after uterovesical opacification (D). Standard laboratory tests were normal. Given the subperitoneal rupture of the bladder and the absence of associated lesions, conservative treatment by prolonged bladder drainage with urethral catheter and local care of the fistulous orifice were performed. Patient's evolution was marked by complete drying up of the fistula.

["Barking" micturition noise as sign of acute hip-TEP-late infection]. / "Bellendes" Miktionsgeräusch als Ursachenzeichen des akuten Hüft-TEP-Spätinfektes.

This article presents the case of a patient with an acute late infection of the hip prosthesis. At first, complaints in the hip region were in the foreground. Shortly after the revision operation the patient noticed a barking noise during micturition, as sign of a pneumaturia. The following diagnostics showed a perforated sigmoid diverticulitis with a sigmoid-urinary bladder-fistula.

A Systematic Review Assessing Medical Treatment for Rectovaginal and Enterovesical Fistulae in Crohn's Disease.

BACKGROUND: Rectovaginal and enterovesical fistulae are difficult to treat in patients with Crohn's disease. Currently, there is no consensus regarding their appropriate management. AIM OF THE STUDY: The aim of the study was to review the literature on the medical management of rectovaginal and enterovesical fistulae in Crohn's disease and to assess their response to treatment. METHOD: A literature search of MEDLINE, EMBASE, Science Citation Index Expanded, and Cochrane was performed. RESULTS: Twenty-three studies were identified, reporting on 137 rectovaginal and 44 enterovesical fistulae. The overall response rates of rectovaginal fistulae to medical therapy were: 38.3% complete response (fistula closure), 22.3% partial response, and 39.4% no response. For enterovesical fistulae the response rates to medical therapy were: 65.9% complete response, 20.5% partial response, and 13.6% no response. Specifically, response to anti-tumor necrosis factor therapy of 78 rectovaginal fistulae was: 41.0% complete response, 21.8% partial response, and 37.2% no response. Response of 14 enterovesical fistulae to anti-tumor necrosis factor therapy was: 57.1% complete response, 35.7% partial response, and 7.1% no response. The response to a combination of medical and surgical therapy in 43 rectovaginal fistulae was: 44.2% complete response, 20.9% partial response, and 34.9% no response. CONCLUSIONS: Medical therapy, alone or in combination with surgery, appears to benefit some patients with rectovaginal or enterovesical fistula. However, given the small size and low quality of the published studies, it is still difficult to draw conclusions regarding treatment. Larger, better quality studies are required to assess response to medical treatment and evaluate indications for surgery.

Urinary catheterization as a successful treatment option for post-cesarean section vesicouterine fistula.

Surgery, the usual treatment option for vesicouterine fistula (VUF), is often delayed to allow involution of the uterus. The authors report a case of successful treatment with urinary catheterization. A 39-year-old, gravida 7, para 6, woman presented at term with obstructed labor. She had one previous cesarean section followed by a vaginal birth before. She underwent emergency cesarean section. She was readmitted after one week because of pelvic collection. Aspiration revealed pus and urine. Retrograde cystogram and pelvic MRI confirmed the presence of VHF. Urinary bladder catheterization for six weeks resulted in the successful treatment of the fistula. Urinary catheterization in the early postpartum period can result in resolution of post-cesarean section VUF, without delaying surgical intervention if it becomes necessary.

Vacuum-assisted Closure of a Vesicocutaneous Fistula in a Pediatric Patient After Bladder Cystoplasty.

A vesicocutaneous fistula is an abnormal communication from the bladder to the skin (Pritts et al, 2001). Recently, wound vacuum-assisted closure (VAC) has been used to facilitate fistula closure. There are no reports of using VAC to help fistula closure in the pediatric population. We present a case of an adolescent patient who develops a vesicocutaneous fistula after bladder augment cystoplasty and was treated with VAC only.

Severe hematuria after transurethral electrocoagulation in a patient with an arteriovesical fistula.

BACKGROUND: Arteriovesical fistulas are extremely rare. Only eleven cases were previously reported in the literature. They can occur iatrogenically, traumatically or spontaneously. CASE PRESENTATION: We report an unusual case of a 62-year-old woman with arteriovesical fistula that developed fatal hematuria after transurethral electrocoagulation. Computed tomography (CT) and selective angiography revealed a pseudoaneurysm of the right superior vesical artery with arteriovesical fistula formation, which was managed by transarterial embolization. CONCLUSIONS: Contrast enhanced CT or CT angiography should be performed when a pulsatile hemorrhage is revealed during cystoscopy. Therapeutic vesical arterial embolization should be considered as a safe and effective procedure for arteriovesical fistulas. Transurethral electrocoagulation may cause severe hematuria for pulsatile bladder bleeding in patients with pelvic vascular malformation.

Crohn's disease presenting as enterovesical fistula.

Enterovesical fistulae in Crohn's disease are relatively rare. We present the first report of a child presenting with an enterovesical fistula as the initial presentation of Crohn's disease. Management comprises of timely diagnosis, and treatment involving surgical resection with adjunctive medical management including immunomodulators. This case highlights the need to be aware of the rare but important occurrence of Crohn's enterovesical fistula as a cause for urinary symptoms in a child with inadequate weight gain.

Pseudoaneurysm associated with an arteriovesical fistula after bladder substitution surgery definitively treated with a covered stent: a report of 3 cases.

A fistula between the iliac artery and a bladder pouch is a rare but potentially life-threatening condition. In 3 patients presenting with massive hematuria after urinary diversion, an iliac artery pseudoaneurysm was found on imaging studies. These pseudoaneurysms were considered to be associated with a fistula between artery and pouch, causing the hematuria. All patients were successfully treated with a covered stent to exclude the pseudoaneurysm and the arteriovesical fistula. Clinical follow-up of 10 weeks, 16 months, and 27 months, respectively, showed no residual hematuria. In addition, no clinical signs of stent graft infection or thrombosis were identified during follow-up. In conclusion, the placement of a covered stent is a valuable therapeutic treatment option in the management of hematuria due to an arteriovesical fistula after urinary diversion surgery.

Unique complication of a Shirodkar cerclage: remote formation of a vesicocervical fistula in a patient with the history of cervical cerclage placement: a case report and literature review.

BACKGROUND: Cervical cerclage placement is an accepted treatment for cervical insufficiency and recurrent second-trimester pregnancy loss. The most commonly described complications of cerclage include rupture of fetal membranes, intra-amniotic infection, endometritis, and peripartum bleeding. We present a unique case of a vesicocervical fistula formation remote from cerclage placement. CASE: A vesicocervical fistula was diagnosed in a 51-year-old patient who presented with a chief complaint of vaginal bleeding. The fistula was found on cystoscopic examination after the extrusion, from the cervix, of Mersilene tape from a Shirodkar cerclage placed 13 years earlier for management of cervical insufficiency. CONCLUSION: Although the presented condition was managed conservatively, one should discuss remote formation of urogenital fistulae as a rare complication of cervical cerclage at the time of informed consent.

How safe is it to manage diverticular colovesical fistulation non-operatively?

AIM: Colovesical fistula (CVF) is an uncommon condition. Diagnosis and management varies according to presentation and aetiology. The identification of patients suitable for conservative management and their outcome following this approach has not been well documented. METHODS: The clinical outcomes of all patients diagnosed with a CVF over a 7-year period from an uro-radiological database were reviewed. Cases secondary to diverticular disease were analysed with respect to the approach by which they were managed: those treated surgically and those managed conservatively. RESULTS: Sixty-two patients (32 men) were diagnosed with CVF of whom 53 (85%) had diverticular disease. Twenty-seven (mean age 69 years, range 42-90) underwent surgery (with a stoma in 59%) with a 30-day mortality of 15%. Those managed conservatively (n = 26) were older (mean age 76 years, range 39-87) and frailer (62% American Society of Anesthesiologists Grades III and IV). At 1 and 3 years following diagnosis there was no difference in mortality between these two groups and only one death was as a consequence of urosepsis. CONCLUSION: Many patients with CVF secondary to diverticular disease can be safely managed non-operatively.

Urogenital fistula in a Saudi Arabian referral center.

PURPOSE: To review all cases of genitourinary fistula, their causes, management and outcome. MATERIALS AND METHODS: A retrospective chart review of all fistula cases referred to the Urogynecology Department, King Fahad Medical City, Riyadh, Saudi Arabia, from January 2005 to December 2011. RESULTS: Sixteen genitourinary fistula cases were identified; nine (56 %) cases of vesicovaginal fistula, four (25 %) cases of vesicouterine fistula, and three (19 %) cases of vesicocervical fistula. Mean age was 41 (29-61) and mean parity was 7.4 (2-15). Out of the 16 cases, 12 (75 %) had obstetrical surgical complications, of which 8 (50 %) had complications of cesarean sections. Twelve of 15 cases (80 %) were cured after primary surgical repair, 2 (13 %) after secondary repair and 1 after tertiary repair. One case was cured after conservative management. CONCLUSION: Most of the genitourinary fistulae were of iatrogenic obstetric causes, mainly cesarean section with none of the cases due to obstructed labor unlike fistulae in developing countries or developed countries fistulae (iatrogenic gynecologic origin).

Ureteric embolization for lower urinary tract fistulae: use of two amplatzer vascular plugs and N-butyl cyanoacrylate employing the "sandwich" technique.

PURPOSE: This study describes and evaluated the effectiveness of occluding distal ureters in the clinical setting of urinary vaginal (vesicovaginal or enterovesicovaginal) fistulae utilizing a new technique which combines Amplatzer vascular plugs and N-butyl cyanoacrylate. MATERIALS: This is a retrospective study (January 2007-December 2010) of patients with urinary-vaginal fistulae undergoing distal ureter embolization utilizing an Amplatzer-N-butyl cyanoacrylate-Amplatzer sandwich technique. An 8-12-mm type-I or type-II Amplatzer vascular plug was delivered using the sheath and deployed in the ureter distal to the pelvic brim. Instillation of 0.8-1.5 cc of N-butyl cyanoacrylate into ureter proximal to the Amplatzer plug was performed. This was followed by another set of 8-12-mm type-I or type-II Amplatzer vascular plugs in a technique referred to as the "sandwich technique." RESULTS: Five ureters in three patients were occluded utilizing the above-described technique during the 4-year study period. Mean maximum size Amplatzer used per ureter was 10.8 mm (range, 8-12). One ureter required three Amplatzer plugs and the rest required two. Two patients (3 ureters) were clinically successful with complete resolution of symptoms in 36-48 h. The third patient (2 ureters) was partly successful and required a second Amplatzer-N-butyl cyanoacrylate sandwich technique embolization. The mean clinical follow-up was 11.3 months (range, 1.7-29.2). CONCLUSIONS: The Amplatzer-N-butyl cyanoacrylate-Amplatzer sandwich technique for occluding the distal ureter is safe and effective with a quick (probably due to the N-butyl cyanoacrylate) and durable (probably due to the Amplatzer plugs) clinical response.

Repair of a vesicocutaneous fistula using negative-pressure wound therapy and urinary diversion via a nephrostomy tube.

BACKGROUND: This article describes an unusual case of a vesicocutaneous fistula in a patient with a history of radiation therapy and recent abdominal surgery. CASE: A 61-year-old woman was transferred to our acute care facility from a rehabilitation facility, with poor nutritional intake and a concern for urine draining from her wound. A nephrostomy tube was placed (she had only 1 functioning kidney) and negative-pressure wound therapy was used to close the fistula. CONCLUSION: Urinary diversion via a nephrostomy tube and negative-pressure wound therapy were used to successfully and safely close this vesicocutaneous fistula.

Urinary tract fistulas in radical surgery for cervical cancer: the importance of early diagnosis.

BACKGROUND: Urinary fistulas are a well-recognised complication of radical gynaecological oncology surgery for cervical cancer. Reported incidence varies between 0.6 and 5.1%. METHODS: A retrospective case-note review of vesical and ureteric fistulas diagnosed in cases that underwent radical surgery for the new diagnosis of early stage cervical cancer between January 2000 and June 2010. RESULTS: A total of 323 radical procedures for cervical cancer were performed during the study period. There were nine urinary tract fistulas found in eight women undergoing radical surgery for stage 1b1 cervical cancer, giving an incidence of 2.7%. Haemorrhage was the commonest associated factor and the commonest presenting symptom for fistula was leaking of urine per vagina. The fistulas were managed conservatively or surgically depending on their nature and severity. The longer the delay in confirming the diagnosis and initiating treatment the more severe were the long-term symptoms and morbidity. CONCLUSION: Identification of predisposing factors, high index of suspicion, early investigations and multidisciplinary team management of urinary tract fistula are necessary to reduce post-operative morbidity and minimise renal loss.