Diagnosis and management of vesicoenteric fistulas.

Vesicoenteric fistulas represent challenging clinical problems and may be characterized by difficulty in diagnosis as well as controversy in management. We present our experience with 56 patients with vesicoenteric fistulas. The results of our series were compared with a report of 1,100 in the literature during the past 20 years. Fecaluria (48 per cent), abdominal pain (43 per cent) and pneumaturia (41 per cent) were the most common presenting symptoms among the patients we studied. Fistulas were most frequently attributable to diverticulitis (52 per cent), Crohn's disease (18 per cent), carcinoma of the colon (11 per cent) or other pelvic malignant conditions (9 per cent). The most accurate diagnostic modalities in our series were cystoscopy (88 per cent), cystography (56 per cent) and barium enema (32 per cent). The combined findings of these studies led to the diagnosis of a fistula in all patients. Intravenous urography, intestinal endoscopy and computed tomography were less useful, providing a diagnosis in only 5, 6 and 11 per cent, respectively. Surgical treatment was single staged in 57 per cent and multistaged in 35 per cent, while 8 per cent of the patients underwent intestinal diversion only. Comparison of the single versus multistaged approaches revealed that the total complication rate, frequency of additional procedures, rate of infectious complications and length of hospitalization were no higher for the single stage group. Based on these findings, we advocate single stage repair, except in those patients who have unusual complications.