Urinary fistula

The uterine fistula is a pathological communication between the urinary tract and the intestine.

Epidemiology

The number of new cases in patients with sigmoid diverticulosis in the US reaches 2%. Specialized medical centers produce higher figures. Malignant neoplasms of the large intestine are accompanied by the formation of urolithiasis in 0.6% of cases.

At the same time, in recent decades, the number of patients with renal and intestinal and ureteric-fistula fistulas has significantly decreased, which is associated with early diagnosis and effective treatment of purulent-inflammatory diseases of the kidneys and urinary tract. According to the data of VS Ryabinskii and V.N. Stepanova, only six (6.7%) of ninety observed patients with uro-intestinal fistulas suffered from renal and ureteric-intestinal fistulas. The remaining patients were diagnosed with vesicoureteral and urethrerectal fistulas. Urinary fistula is 3 times less common in women than in men, which can be explained by more frequent diseases and damage to the large intestine and bladder in the latter.

[1],

Causes of the urolithic fistula

The urinary fistula can be congenital and acquired. Congenital vesicouteral fistulas are extremely rare. Usually they arise between the rectum and the region of the urinary bladder, sometimes combined with atresia of the anus. The most commonly found are the acquired uroliths. They are divided into posttraumatic and spontaneously arising (as a result of various pathological conditions). The causes of the first are simultaneous injuries of the urinary tract and intestines due to iatrogenic injuries, radiation therapy, as well as surgical interventions (trocar epicystostomy, TUR of the prostate and bladder neck, RPE).

Spontaneous intestinal fistulas are usually formed as a result of various inflammatory processes, neoplasms, perforation of foreign bodies of the intestinal wall and bladder. Renal-fistulae often arise as a result of purulent-inflammatory, including specific, diseases of the kidney and pericardial cellulose. Urolithic-intestinal fistulas are mostly iatrogenic in nature and are formed during combined damage to the ureter and intestine during operations on the organs of the abdominal cavity and urinary tract. Thus, renal and ureteric-intestinal fistulas, as a rule, arise as a result of inflammatory diseases of the kidneys and urinary tracts with secondary involvement of various parts of the intestine in the process, and vesicouteral fistulas due to primary diseases and intestinal damages that spread to the bladder.

Diverticulosis  and chronic colitis are the most common cause of the development of entero-cystic fistula. These diseases lead to the formation of internal communication between the intestine and urinary bladder in 50-70% of patients. In 10% of cases, fistulas result from Crohn's disease, and they usually form between the bladder and ileum. More rarely, intestinal-vesicular anastomoses are formed as a result of Meckelian diverticulum, appendicitis, urogenital coccidiomycosis and pelvic actinomycosis.

The second most important (20% of cases) is the cause of the formation of enteric-fistula fistula - malignant neoplasms (most often - colorectal cancer). With tumors of the bladder, the formation of vesicouteral fistulas is observed extremely rarely, which can be explained by early diagnosis of the disease.

Remote radiation therapy or brachytherapy can lead to the formation of pathological messages between the intestines and urinary tracts even after several years. The appearance of a fistula due to radiation damage and perforation of the intestine with the formation of a pelvic abscess, which broke into the bladder, is described. There are many publications devoted to the formation of intestinal cystic fistula due to the presence of foreign bodies in the body. The latter may be in the intestines (bones, toothpicks, etc.), the abdominal cavity (stones that got into it from the gallbladder during laparoscopic cholecystectomy). Urinary bladder (prolonged organ catheterization). The cause of urethrectectal fistulas may be iatrogenic damage to the urethra and intestines during transurethral manipulation.

Symptoms of the urolithic fistula

Complaints of patients with uro-intestinal fistulas are usually due to changes in the urinary system. With renal and ureteric-intestinal fistula on the background of urostasis there are pains in the lumbar region, an increase in body temperature, chills. Patients with vesicouteral fistulas note discomfort or moderate  pain in the lower abdomen, frequent painful urination, tenesmus. The urine of the patients acquires a fetid odor. The rise in temperature is caused by acute pyelonephritis or the formation of an intercute abscess preceding the formation of an enterococcus fistula.

Specific symptoms of the enteric-fistula fistula are absent in some cases, and the disease of the duodenal fistula occurs under the mask of a recurrent urinary tract infection. Fecaluria and pneumaturia can occur sporadically, and therefore special attention should be paid to collecting an anamnesis. Pneumaturia is found in 60% of patients, but it is not considered a specific sign of the disease. It is also observed in the presence of gas-forming microorganisms (clostridia), fungi in the bladder in patients with diabetes mellitus, after an instrumental examination. Pneumaturia is more often found in diverticulosis of the sigmoid colon or Crohn's disease than in neoplasms of the intestine.

With urethro-rectal fistulas, patients complain of pneumaturia, secretion of intestinal gases from the external opening of the urethra outside the act of urination. Fecaluria is a pathognomonic symptom of the duodenal fistula observed in 40% of patients. Very characteristic of the symptoms of the duodenal fistula is the departure of small, formless fecal particles with urine. The transfer of content occurs in most cases from the intestine to the bladder, and not vice versa. Patients rarely notice an admixture of urine in intestinal contents.

When combined strictures of the posterior urethra (its poor passableness) with urethrerectal fistula, all urine or most of it can enter the rectum, as a result of which patients urinate through it, as happens after a ureteral transplantation into the sigmoid colon. In the renal and ureteric-intestinal fistula in urine, an admixture of bile and food pieces is detected.

Often there  flatulence, diarrhea or constipation. In some cases, an admixture of blood in the feces is observed. The clinical picture largely depends on the disease that caused the formation of the fistula. That is why the renal and intestinal fistula manifests itself with symptoms of purulent pyelo- and paranephritis. The flow of purulent urine into the intestines can be accompanied by diarrhea, nausea and vomiting. With the penetration of fecal matter into the kidney it is possible to excrete urine with an admixture of bile, food particles, gases and feces.

With external urokishechnom fistula detect the cutaneous opening of the latter. Through which urine is excreted with an admixture of intestinal contents and gas, when palpation of the abdomen in patients with diverticulosis and chronic colitis determine the soreness in the course of the sigmoid colon. Formation of the intercusive infiltrate and its abscessing accompany the symptoms of irritation of the peritoneum. You can determine the volume formation in the abdominal cavity, which is also characteristic of Crohn's disease and malignant neoplasms.

Forms

For localization, the urolithiasis fistulas are divided into:

• renal and intestinal;
• ureter-intestinal;
• gastrointestinal;
• uretro-rectal.

Depending on the message through the cutaneous fistula with the external environment, open and closed ileal fistulas are distinguished.

[2], [3], [4], [5], [6]

Diagnostics of the urolithic fistula

In the study of urine, leucocytes, erythrocytes, bacteria and fecal admixture are found. It is recommended to conduct a test for the detection of coal (after ingestion) in the urine sediment. In the bacteriological analysis of urine, the growth of several species of microorganisms with a predominance of E. Coli is usually observed. In patients with oncological diseases, anemia is noted, an increase in ESR. Leukocytosis can be a consequence of a urinary tract infection a sign of an emerging abscess. Be sure to conduct a  biochemical blood test  (determination of creatinine, electrolytes, etc.).

Instrumental diagnosis of the duodenal fistula

Ultrasound is not sufficiently informative, so it has not been widely used in the diagnosis of urolithiasis.

With an external uro-fistula fistula, fistulography can be performed, in which contrasting fistula of the intestine and urinary tract is noted.

With a survey and excretory urography, you can find concrements and foreign bodies in the lumen of the urinary tract or intestine, assess the kidney function and tone of the upper urinary tract. In renal and ureteric-intestinal fistula on the side of the lesion, ectasia and deformation of the calyx and pelvis are noted, and the kidney function decreases. With descending cystography, as a result of the contrast medium entering the sigmoid and rectum, it is possible to determine the contours of the latter (with vesicouteral fistulae). In renal and ureteral-intestinal fistulas, retrograde ureteropyelography is informative.

With retrograde cystography, which should be performed in two projections and with a tight filling of the bladder, it is possible to detect the flow of contrast material into the intestine.

CT with contrasting is the most sensitive method for diagnosing intestinal fistula, which should be included in the survey standard for this disease.

MPT is  effective for the diagnosis of deep perineal fistulas (used according to indications).

Radiopaque examination of the intestine does not always allow detection of the urokinus fistula, but it helps in the differential diagnosis of diverticulosis and neoplasm of the intestine.

The introduction of a colored solution into the bladder improves the visualization of the fistula opening with sigmoidoscopy and colonoscopy. With their help, you can determine the disease of the intestine, which caused the formation of the fistula, the localization and size of the latter, the degree of perifocal inflammation, and perform a targeted biopsy.

Cystoscopy is one of the most informative methods of research, allowing not only to visually determine the presence of a fistula, but also to make a biopsy to exclude the oncological process. Limited hyperemia, papillary or bullous changes in the mucosa, mucus or fecal matter in the bladder are found in 80-90% of patients. In connection with the development of bulbar edema of the mucous membrane, it is not always possible to determine the fistulous course. In this case, it is advisable to try to catheterize and contrast the latter. It should be remembered that fistulae are most often located in the area of the tip of the bladder.

Given that the intestinal cystitis fistulas (found most often) arise as a result of a primary bowel disease, the surgeon should take part in the diagnostic process and determine the therapeutic tactics.

[7], [8]

Treatment of the urolithic fistula

Conservative treatment in renal and ureteral-intestinal fistula is ineffective. Continuous intake of intestinal contents, accompanied by exacerbation of pyelonephritis, contributes to the development of its purulent forms and sepsis, which is considered an indication for early surgical treatment.

In some cases, it is advisable to conduct conservative treatment with small vesicouteral fistulas caused by sigmoid colon diverticulosis or Crohn's disease, in weakened, severe somatic patients as a preparation for surgical intervention. Assign sulfonamides, metronidazole, broad-spectrum antibiotics, glucocorticoids, mercaptopurine, etc.

Operative intervention, the purpose of which is closure of the duodenal fistula and elimination of the disease that caused his basic and radical method of treatment.

Operative treatment of urolithic fistula

Radical operative treatment of urolithiasis fistulas. Indications - a urolithic fistula. The standard method of surgical treatment is the implementation of a one-stage or multi-stage fistuloplasty with the removal of the pathological focus that caused the formation of the fistula.

Multistage fistuloplasty involves the preliminary derivation of urine and feces. With renal and duodenal fistulas, there may be a need to sanitize the purulent focus and drain the retroperitoneal tissue. Violation of urodynamics requires the implementation of nephrostomy. Multistage intervention, which is more easily tolerated by patients, causes fewer postoperative complications.

A one-stage operation is performed outside the exacerbation of the inflammatory process (pyelonephritis, cystitis, colitis) and with the preserved function of the kidneys, urinary tract and intestine. It significantly shortens the terms of treatment and rehabilitation of patients.

Single-time operation with renal-intestinal fistula is performed, as a rule, through lumbar access. First, the kidney is performed (in most cases, a nephrectomy is shown), then a thorough excision of the fistulous course is performed. The next stage is an operation on the intestine, the volume of which depends on the nature of the primary disease, the patient's condition, and the localization of the fistulous opening. Complete the operation by draining the retroperitoneal tissue.

The most common surgical intervention with intestinal ureteral fistulae with purulent lesion and loss of kidney function is nephroureterectomy. Fistulous opening of the intestine is sutured, less often it is resected. With a good function of the kidneys perform organ-saving operations: resection of the ureter with superimposition of ureterocystoanastomosis, Boari operation or intestinal ureteral plasty.

A one-stage operation with vesicouteral fistulas is performed through the lower-median peri-abdominal access. When revising the abdominal cavity determine the state of its organs, especially those. Which are involved in the formation of the fistula. Stupidly and acutely mobilize the loops of the intestine, the wall of the bladder and the area of the fistulous course. With further isolation, it is advisable to go around the area of the latter, and then open the wall of the bladder at a distance of 1.5-2 cm from the fistula and a fissure incision separate the bladder from the fistulous conglomerate and intestine.

If it is necessary to determine the etiology of bowel and bladder disease, perform an emergency biopsy and then check the bladder. In the absence of other pathological changes that require prompt correction. Suture it tightly with a two-row incessantly nodular vikrilovym seam with drainage through the urethra by the Foley catheter. In a number of cases (pronounced cystitis, IVO, hypotonia m. Detrusor urinae, etc.) perform epicystostomy. Further, an operation is performed on the intestine, the volume of which depends on the features of the detected disease, the degree of prevalence of the pathological process and the state of the gastrointestinal tract.

When the bladder is communicating with the appendix, appendectomy is performed. The method of choice in the small intestine fistula is the resection of the intestine with the restoration of the patency of the intestine as "end-to-end" or "side-to-side". The bladderworm fistula, caused by diverticulosis of the intestine, requires a thorough revision of the mobilized gut to detect areas with diverticula. With single diverticula in a limited area of the intestine, excision of the fistulous course within healthy tissues is possible, with sigmoid colon defect suturing in the transverse direction by a two-row vikril suture.

With multiple diverticulists leading to destructive changes in the sigmoid colon wall, the formation of dolichosigma or tumor lesions of the organ requires the removal of the sigmoid colon within the healthy tissues with the application of an end-to-end anastomosis and a two-row continuous nodular vicryl suture.

The abdominal cavity is drained with silicone tubing and layered.

The implementation of multi-stage surgery is recommended for acute onset of the disease, inflammatory infiltrate, major pelvic abscesses, radiation injuries, intoxication, as well as severe oncological patients. At the first stage it is necessary to perform colostomy and withdraw urine. After improving the general condition of the patient (an average of 3-4 months), fistuloplasty can be performed.

Surgical treatment of patients at high risk consists of a full drainage of the bladder with the help of a Foley catheter or epicystostomy. Dilution of feces is carried out by applying colostomy.

Prevention

The urinary fistula can be prevented. This prevention consists in the timely diagnosis and treatment of inflammatory diseases and neoplasms of the kidneys, urinary tract and intestines. When performing such common surgical interventions as TUR of the prostate and bladder neck, RPE, laparoscopic operations, as well as with brachiotherapy of prostate cancer should be remembered and avoid the possibility of a combined wound of the urethra, bladder and intestinal wall.

[9], [10],

Forecast

Prognosis of the duodenal fistula depends on the severity of the primary disease that caused the urolithiasis fistula. It should be noted that spontaneous healing of the duodenal fistula is rarely observed, so a good prognosis is associated with timely and quality surgical treatment.

[11], [12], [13]