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Three Part Question

In [colovesical fistula] is [conservative management better than surgical management]in [terms of future morbidity and mortality]?

Clinical Scenario

A 71 year old pleasant man presented to the Emergency Department complaining of dark urine, urgency, occasional dysuria, suprapubic pain and foul-smelling urine for 1 month. No frequency, haematuria or flank pain was reported. He has a past medical history of diverticulitis with lower gastro-intestinal bleeding in the past. You wonder whether all cases of colovesical fistula have to be managed surgically.

Search Strategy

Medline 1950 to November 2009 using the OVID interface
Multifield Search
[Colovesical fistula] and [Management] LIMIT [English]

Search Outcome

17 papers were found of which 12 irrelevant. The remaining papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Garcea, G.;Majid, I.;Sutton, C. D.;Pattenden, C. J.;Thomas, W. M 2006 USA	90 consecutive patients with colovesical fistulae over a six-year period.	Restropective review/ Observational	Mortaliy and complications	1 postoperative leak No mortality	Only involves surgical Management Biased as results from single surgeon No conservative management
Sebastian Melchior, Dragan Cudovic,Jon Jones, Christian Thomas, Rolf Gillitzer, Joachim Thüroff 2009 USA	49 patients who underwent surgery for colovesical fistula due to sigmoid diverticulitis	Observational	Morbidity Mortality & Recurrence	Postoperative morbidity was 8.2% (4 of 49) and mortality was 0%. During a median followup of 68 months there were no recurrent fistulas.	No conservative Management Short follow-up
Solkar, M. H.;Forshaw, M. J.;Sankararajah, D.;Stewart, M.;Parker, M. C. 2005 USA	50 patients with colovesical fistula over a 12-year period	Retrospective study	Morbidity and mortality	No significant difference between conservative and surgical Management in selected patients	Small sample
P. N. Rao, R. Knox, R. J. Barnard, P. F. Schofield 1987 UK	Review of 24 patients treated for colovesical fistula	Retrospective	Morbidity and mortality	No postoperative death Morbidity (5/23) – 1 PE, 1 Recurrence, 3 wound infection	No conservative Management
Amin M, Nallinger R, Polk HC Jr 1984 UK	Thirty patients with colovesical fistula due to diverticulitis in the past ten years	Retrospective	Mortality and morbidity	Six patients did not receive any of the standard operative therapies. Four of these patients were observed for three to 14 years with nonoperative management, with little inconvenience and without significant complications. Five of the 24 patients in the surgical group died in the postoperative period	Small conservative management group

Comment(s)

Only 2 studies directly answered the question. The evidence is variable with small sample data but points to the conclusion that in selected patients (benign cause), conservative Management should be offered as an option as there is no significant difference in disease-specific mortality in patients with benign colovesical fistula undergoing surgical intervention and patients treated conservatively.

Clinical Bottom Line

Colovesical fistula occur due to various causes (Diverticulitis, colon cancer, crohn's among others). If of benign etiology, option of conservative Management should be offered to the patient when possible.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Garcea, G.;Majid, I.;Sutton, C. D.;Pattenden, C. J.;Thomas, W. M. Diagnosis and management of colovesical fistula; six-year experience of 90 consecutive cases Colorectal Disease Vol 8 No. 4 2006, 347-352 (6)
2. Sebastian Melchior, Dragan Cudovic,Jon Jones, Christian Thomas, Rolf Gillitzer, Joachim Thüroff Diagnosis and Surgical Management of Colovesical Fistulas Due to Sigmoid Diverticulitis. The Journal of Urology Vol 182, Issue 3, September 2009, Pages 978-982
3. Solkar, M. H.;Forshaw, M. J.;Sankararajah, D.;Stewart, M.;Parker, M. C. Colovesical fistula – Is a surgical approach always justified? Colorectal Disease Volume 7, Number 5, September 2005 , pp. 467-471(5)
4. P. N. Rao, R. Knox, R. J. Barnard, P. F. Schofield Management of colovesical fistula BJS Volume 74,issue 5 , 362-363
5. Amin M, Nallinger R, Polk HC Jr Conservative treatment of selected patients with colovesical fistula due to diverticulitis Surgery, Gynecology & Obstetrics 159(5):442-4