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Colovesical and Enterovesical Fistula Repair

Enterovesical fistula (EVF) — pathological communication between bowel and bladder — arises most commonly from diverticular disease (41–75%), followed by colorectal cancer (16–20%), Crohn's disease (7–17%), and less commonly radiation.[1][2][3] Colovesical fistula (CVF) — the colon-specific subset — is the most common fistula complicating diverticulitis (~65% of diverticular fistulas).[4] Strong male predominance (M:F ~ 6:1) reflects the protective interposition of the uterus.[1][5]

For broader context see Colovesical / Small-Bowel Fistulas (clinical). For other transabdominal urology-side approaches see Transabdominal RUF / RVF Repair.

Clinical Presentation​

SymptomFrequency
Pneumaturia (most pathognomonic)71–95%[1][2][5]
Fecaluria36–82%
Recurrent UTI (often polymicrobial / enteric)57–88%
Dysuria, frequency, hematuria, orchitisVariable

Urine cultures grow enteric organisms (E. coli, mixed bowel flora).[7]

Diagnosis​

Primarily clinical — history + urine culture. Imaging confirms diagnosis, identifies etiology (especially malignancy), and plans surgery.

ModalitySensitivityRole
Poppy-seed test~95%Highest sensitivity to confirm fistula[1]
CT abdomen / pelvis55–90%Best for etiology, anatomy, surgical planning — intravesical air, bladder-wall thickening, fistulous tract[2][3]
Cystoscopy10–89%Identifies bladder-side pathology, rules out bladder cancer[1][4]
Colonoscopy8.5–65%Essential to exclude colorectal malignancy[1][4]
Barium enema20–65%Variable; may show tract[2][4]
Cystography11–27%Low sensitivity; presurgical planning[1][2]
MRI~60%Useful in Crohn's for tract characterization[1][9]

ACR Appropriateness Criteria — CVF can usually be diagnosed on contrast-enhanced CT alone (enhancing tracts ± gas extending from colon to bladder wall).[8] Colonoscopy and cystoscopy remain essential to rule out malignancy.[2][5][10]

Indications for Surgery​

ASCRS 2020 — elective colectomy for diverticulitis complicated by fistula (Strong, 1B).[11]

Indications:

  • Symptomatic fistula causing recurrent UTI, pneumaturia, fecaluria
  • Failure of medical management
  • Underlying malignancy
  • Associated abscess, obstruction, or stricture
  • Recurrent pyelonephritis (ACG relative indication)[12]

In Crohn's disease, fistula presence does not mandate surgery in the absence of malabsorption, intractable diarrhea, or recurrent infection.[13] Anti-TNF ± immunomodulators achieve complete durable response in 45–66% of EVF; surgery is avoided in > 50% of patients at 5 yr.[13][14] Sigmoid-originated fistulas and concurrent CD complications (obstruction, abscess, enterocutaneous fistula) predict eventual surgery.[15]

Preoperative Optimization​

Particularly important in Crohn's:

  • Nutritional support (malnutrition, albumin)
  • Treat active infection / UTI
  • Medical therapy (anti-TNF, immunomodulators) to reduce inflammation
  • Bowel rest when appropriate

Chen 2023 (n = 74 CD entero-urinary fistulas): preoperative optimization resolved urinary symptoms in 57%, reduced need for bladder repair, and improved surgical outcomes.[6]

Surgical Technique​

1. One-stage resection with primary anastomosis (procedure of choice)​

The default when no abscess, obstruction, or significant contamination:[3][11][16]

  1. Exploration and mobilization — identify fistula and inflammatory phlegmon; mobilize sigmoid; separate inflammatory mass from bladder

  2. Bowel resection — diseased segment (typically sigmoid colectomy for diverticular CVF; ileocecal / segmental for Crohn's); fistula tract taken down with the specimen

  3. Primary anastomosis — colorectal or ileocolic; typically without protective stoma

  4. Bladder management — key decision point:

    Bladder findingManagement
    No overt defect / negative leak testFoley catheter alone — sufficient in 68% of cases; defect heals within 1 wk with drainage alone (Ferguson 2008)[17]
    Overt large defect or positive leak testFormal 2-layer bladder repair with absorbable suture[16][17][18]

    Systematic review confirms bladder repair is not necessary after a negative intraoperative leak test.[16]

  5. Tissue interposition — omental flap between bowel anastomosis and bladder closure to reduce recurrence; particularly in irradiated fields or complex cases. Perivesical fat rotational flap is a described alternative when omentum is unavailable (Hwang 2023).[18][19][20]

  6. Foley catheter in place 7–14 days postoperatively.[17][21]

2. Multi-stage procedures​

For complicated presentations:[3][22]

  • Two-stage (Hartmann) — resection with end colostomy → later reversal — for significant contamination, abscess, poor nutritional status
  • Three-stage — diverting colostomy → definitive resection → colostomy reversal — for emergent peritonitis presentations

Diverting colostomy alone (without resection) is not recommended — persistent fistula and ongoing urinary sepsis in all patients.[3]

3. Open vs minimally invasive​

MIS (laparoscopic or robotic) is increasingly preferred:

ParameterOpenMISSource
LOS7.3–8 d5–6.9 d (significantly shorter)Volkert 2025, Froiio 2022, Trejo-Avila 2021[23][24]
Overall complicationsHigherLower (OR 0.55)Volkert[23]
Anastomotic leakNo differenceNo difference
Mortality1%1% (no difference)
Conversion (lap)N/A27–36%Trejo-Avila[24]
Conversion (robotic)N/A~1%Sassun 2025[26]

Robotic appears particularly advantageous — Sassun 2025 Mayo (n = 89): conversion 1%, AL 3%, fistula recurrence 1% at median 16.5 mo; ureteral ICG fluorescence in 44%.[26] Posterior bladder fistula location is a significant lap-conversion risk factor.[25]

4. Endoscopic OTS clip​

Over-the-scope clip is an emerging option for poor surgical candidates — initial technical success 80%, long-term success ~50%.[27]

Outcomes​

Excellent overall:

  • Clavien-Dindo ≥ 3 complications: 7.4%[16]
  • 30-day mortality: 0–1.5%[5][16]
  • Fistula recurrence: 0–1%[5][16][26]
  • Anastomotic leak: 3%[26]
  • Bladder leak: ~1%[6]

Long-term (median 68 mo): no recurrent fistulas after definitive resection.[5] In Crohn's, recurrence is uncommon but associated with postoperative sepsis and multiple fistulas at the time of surgery.[21]

Medical Management (Crohn's Disease)​

When surgery is not immediately indicated:

  • Anti-TNF agents (infliximab, adalimumab) — complete response in 57% of EVF[13][14]
  • Immunomodulators (azathioprine, 6-MP) — often combined
  • Antibiotics (metronidazole, ciprofloxacin) — adjunctive
  • Mesalamine and corticosteroids ineffective for fistulizing CD[12]

ACG: recurrent symptomatic UTI, especially with pyelonephritis, is a relative indication for surgery even in patients on medical therapy.[12]

Special Considerations​

  • Malignancy — exclude preoperatively in all cases; malignancy was not diagnosed preoperatively in 50% of cancer-related fistulas in one series.[3]
  • Radiation-induced fistulas — more complex, higher complications; often require tissue interposition (omental or myocutaneous flap) and may require multi-stage procedures.
  • Ureteral protection — preoperative ureteral stent in complex cases; ICG fluorescence increasingly used in robotic approaches.[26]

Key Takeaways​

  • One-stage resection + primary anastomosis is the procedure of choice for benign EVF / CVF without abscess.
  • Foley alone manages the bladder in 68% — formal repair is reserved for overt defects or positive leak test.
  • Robotic approach offers very low conversion (~ 1%) vs lap (27–36%); ICG fluorescence aids ureteral identification.
  • Anti-TNF first for Crohn's EVF — > 50% avoid surgery at 5 yr; pyelonephritis is a relative surgical indication.
  • Diverting colostomy alone does not resolve the fistula — always combine with definitive resection.

References​

1. Daniels IR, Bekdash B, Scott HJ, Marks CG, Donaldson DR. "Diagnostic lessons learnt from a series of enterovesical fistulae." Colorectal Dis. 2002;4(6):459–462. doi:10.1046/j.1463-1318.2002.00370.x

2. Najjar SF, Jamal MK, Savas JF, Miller TA. "The spectrum of colovesical fistula and diagnostic paradigm." Am J Surg. 2004;188(5):617–621. doi:10.1016/j.amjsurg.2004.08.016

3. Moss RL, Ryan JA. "Management of enterovesical fistulas." Am J Surg. 1990;159(5):514–517. doi:10.1016/s0002-9610(05)81259-0

4. Brown RF, Lopez K, Smith CB, Charles A. "Diverticulitis." JAMA. 2025. doi:10.1001/jama.2025.10234

5. Melchior S, Cudovic D, Jones J, et al. "Diagnosis and surgical management of colovesical fistulas due to sigmoid diverticulitis." J Urol. 2009;182(3):978–982. doi:10.1016/j.juro.2009.05.022

6. Chen Y, Cao L, Qiu J, et al. "Surgical management and outcome of entero-urinary fistula complicating Crohn's disease: a single center study." World J Surg. 2023;47(12):3365–3372. doi:10.1007/s00268-023-07196-x

7. An Y, Cao Q, Liu Y, et al. "Sigmoido-vesical fistula secondary to sigmoid colon cancer presenting as urinary tract infection: a case report." Front Oncol. 2023;13:1054978. doi:10.3389/fonc.2023.1054978

8. Weinstein S, Kim DH, Fowler KJ, et al. "ACR Appropriateness Criteria® left lower quadrant pain: 2023 update." J Am Coll Radiol. 2023;20(11S):S471–S480. doi:10.1016/j.jacr.2023.08.013

9. Tjandra D, Garg M, Behrenbruch C, et al. "Review article: investigation and management of internal fistulae in Crohn's disease." Aliment Pharmacol Ther. 2021;53(10):1064–1079. doi:10.1111/apt.16326

10. Zimniak L, Ritz JP, Wullstein C, et al. "The diagnostic journey in fistulizing sigmoid diverticulitis: a multicenter retrospective study and proposal for a structured workup." Dig Dis. 2026;44(2):147–155. doi:10.1159/000549576

11. Hall J, Hardiman K, Lee S, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis." Dis Colon Rectum. 2020;63(6):728–747. doi:10.1097/DCR.0000000000001679

12. Lichtenstein GR, Loftus EV, Isaacs KL, et al. "ACG clinical guideline: management of Crohn's disease in adults." Am J Gastroenterol. 2018;113(4):481–517. doi:10.1038/ajg.2018.27

13. Lightner AL, Vogel JD, Carmichael JC, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the surgical management of Crohn's disease." Dis Colon Rectum. 2020;63(8):1028–1052. doi:10.1097/DCR.0000000000001716

14. Kaimakliotis P, Simillis C, Harbord M, et al. "A systematic review assessing medical treatment for rectovaginal and enterovesical fistulae in Crohn's disease." J Clin Gastroenterol. 2016;50(9):714–721. doi:10.1097/MCG.0000000000000607

15. Zhang W, Zhu W, Li Y, et al. "The respective role of medical and surgical therapy for enterovesical fistula in Crohn's disease." J Clin Gastroenterol. 2014;48(8):708–711. doi:10.1097/MCG.0000000000000040

16. Froiio C, Bernardi D, Asti E, et al. "Burden of colovesical fistula and changing treatment pathways: a systematic literature review." Surg Laparosc Endosc Percutan Tech. 2022;32(5):577–585. doi:10.1097/SLE.0000000000001099

17. Ferguson GG, Lee EW, Hunt SR, Ridley CH, Brandes SB. "Management of the bladder during surgical treatment of enterovesical fistulas from benign bowel disease." J Am Coll Surg. 2008;207(4):569–572. doi:10.1016/j.jamcollsurg.2008.05.006

18. Gruner JS, Sehon JK, Johnson LW. "Diagnosis and management of enterovesical fistulas in patients with Crohn's disease." Am Surg. 2002;68(8):714–719.

19. Hwang A, Watson M, Talluri S, Okafor H, Singh A. "A novel perivesical fat rotational flap as an alternative to omental interposition in challenging urological reconstruction." Urology. 2023;182:e262–e263. doi:10.1016/j.urology.2023.08.023

20. O'Leary DP. "Use of the greater omentum in colorectal surgery." Dis Colon Rectum. 1999;42(4):533–539. doi:10.1007/BF02234183

21. Yamamoto T, Keighley MR. "Enterovesical fistulas complicating Crohn's disease: clinicopathological features and management." Int J Colorectal Dis. 2000;15(4):211–215. doi:10.1007/s003840000233

22. El-Haddad HM, Kassem MI, Sabry AA, Abouelfotouh A. "Surgical protocol and outcome for sigmoidovesical fistula secondary to diverticular disease of the left colon: a retrospective cohort study." Int J Surg. 2018;56:115–123. doi:10.1016/j.ijsu.2018.05.742

23. Volkert A, Nigam A, Stover D, et al. "Comparison of open versus minimally invasive repair of colovesical fistula: a case report and propensity-matched national database analysis." J Clin Med. 2025;14(17):6065. doi:10.3390/jcm14176065

24. Trejo-Avila M, Vergara-Fernández O. "Open versus laparoscopic surgery for the treatment of diverticular colovesical fistulas: a systematic review and meta-analysis." ANZ J Surg. 2021;91(9):E570–E577. doi:10.1111/ans.16985

25. Kitaguchi D, Enomoto T, Ohara Y, et al. "Laparoscopic surgery for diverticular colovesical fistula: single-center experience of 11 cases." BMC Res Notes. 2020;13(1):177. doi:10.1186/s13104-020-05022-4

26. Sassun R, Sileo A, Ng JC, et al. "Diverticular disease complicated by colovesical and colovaginal fistulas: not so complex robotically." Surg Endosc. 2025;39(6):3941–3946. doi:10.1007/s00464-025-11754-w

27. DeLong CG, Scow JS, Morrell DJ, et al. "Endoscopic management of colovesical and colovaginal fistulas with over-the-scope clips." Colorectal Dis. 2022;24(3):314–321. doi:10.1111/codi.15987