[Urological aspect of vesico-intestinal fistulas. Apropos of 14 cases]. / L'aspect urologique des fistules vésico-intestinales. A propos d'une série de 14 cas

This series of 14 cases of vesico-intestinal fistulae, together with a review of the literature, led to a certain number of remarks: From an aetiological standpoint, in addition to classical concepts with the predominance of diverticulosis of the colon accounting for 46% of cases, followed by carcinoma of the colon (14%) and Crohn's disease, we feel it to be of interest to stress the possible urinary origin of vesico intestinal fistulae (4 of our cases, and 4.5% of the total number collectedin the literature). From a diagnostic standpoint, we would emphasise that these fistulae present almost solely with urinary symptoms and signs and stress the clinical importance of what is now known, since J. Cibert, as "pre-fistulous cystitis" preceding the development of pathognomic signs--faecaluria and pneumatria. Radiological opacification of the colon and rectum is essential in patients with a syndrome of chronic urinary infection unexplained by a urological cause. From a therapeutic standpoint, the surgical treatment of vesico-intestinal fistulae is associated with a high operative mortality (2 deaths amongst our 14 patients) and which, independently of the aetiological factor (predominance of carcinomas) is explained above all by the septic nature of the lesions.

Reconstruction of previously diverted urinary tract in children.

We tried to reconstruct partly or completely the urinary tract in nine patients who underwent, some years before, attempts at urinary diversion, for severe urinary tract diseases, using the intestine as an ureteral or a bladder subtitute. Our aim was to do a two-stage procedure, trying to reconstruct one normal side without the use of bowel, then within 6 mo to reevaluate the reconstructed side and, if correct, to do a transureteroureterostomy from the diverted side into the reconstructed side. Two patients were operated on this way and cured. We then advanced to a more aggressive approach with a one-stage procedure. Two more patients were operated on and cured. We then attempted reconstruction in patients when the ureter was no longer available. Two patients were operated on using a tapered and reimplanted piece of small bowel in the bladder and cured. Next we came to the patients in whom neither ureter nor bladder was available. Two patients were undiverted from an ileal loop and transformed into an ureterosigmoidostomy with transureterostomy, with achievement of continence. Finally, when neither ureter, nor bladder, nor even rectum was available, one patient on hemodialysis for a nonfunctioning Duhamel rectal bladder was converted into a functioning ileal loop and freed from dialysis. Technical points are discussed, focused on a two-stage procedure with one reimplantation and a transureteroureterostomy. When a permanent diversion must be done, today, for rare indications, we prefer to perform a sigmoid conduit.