Monday, November 20, 2006


I suppose under the right circumstances, a person might think he was peeing champagne. Maybe if it happened early New Year's day, after intense celebration. Perhaps the hangover would dull the senses enough to make it seem like no big deal to piss air bubbles. Most people, though, find it disconcerting.

Colovesical fistula is the term for a connection between the colon and the urinary bladder, and pneumaturia is the name for air in the urine. It's most commonly due to diverticulits. In that circumstance, the sigmoid colon would have developed an abscess which plastered itself against the bladder and eventually eroded into it, creating a connection between the two organs, leading to leakage of air and stool from the one into the other. A similar connection can be made due to a cancer in the colon. In either case, rather than peeing champagne, the signs may be subtle for awhile: recurrent urinary infections are a frequent scenario. But for some people, the first sign of a problem is the passing of air in the urine. If it weren't scary, I'd think it would be sort of cool: "Hey, lookie here, honey! My dick's a damn bubble machine." "I don't care if it lights up like a Roman candle and plays the Star Spangled Banner, Charlie. Y'ain't getting any tonight."

I know I shouldn't make light of a serious situation, but the fact is fixing a colovesical fistula is fun. One of my favorite -- if uncommon -- operations, matter of fact. And it's a nice way to explain a couple of things along the way. Things like how different surgical specialties help one another; or foist themselves upon one another, depending how you look at it. And it's a literary vehicle for explaining the mysteries of complicated colon surgery.

General surgery is, we must agree, the queen of the surgical sciences, the fount from which all others have flowed. There may still be living (but likely no longer practicing) some icons from the day when a general surgeon was the only kind there was: drill heads, screw together bones, lift out uteri, remove a lung, repair an artery, while not otherwise occupied fixing hernias, taking out gallbladders, resecting colons. Our training still has us rotating through the various specialties, in part to give a taste on the basis of which to choose our future; but no less, I'd say, to give us the tools we need to handle things that have a way of arising in the course of an operation. After committing to general surgery, while still in training, we'd think nothing of removing a kidney, repairing a ureter, even yanking a uterus if it were attached, say, to an offending colon. And why not? They're all in or damn near in the belly; and the belly is the prime territory over which the general surgeon claims dominion. You simply can't be a general surgeon and not know the techniques involved in operating on any kind of tissue. The same cannot be said for other specialties; or at least for some who practice them. As I said in my book, with enough bananas you could teach a chimp to take out an ovary. If you only do a couple of operations, you could (can, in fact) learn to get through them without every really mastering certain subtleties. It's like this: I'm fairly sure a sculptor, if blessed with great patience, could teach me to chisel out something that might pass for a given body part. "Left index finger Schwab," they might call me. But there's no way in hell I'd be called Michaelangelo.

Brother Angelo, of course, made a hell of a left index finger. So I'm not saying if all you do is a couple of operations you don't know how to operate. I know some gynecologists who can handle pretty much any surgical surprises they encounter; others who call for help at the first sign of a fibroblast (the scar-tissue forming cells.) The same goes for urologists (a certain uroblogger, I have no doubt, is in the former category.) Nevertheless, it ought to surprise no one that it bugs the hell out of me to have a urologist assist me with the colovesical fistula, and to let him close up the bladder. Same guys who've, on occasion, called me in to find the ureter (the ureter!! the only tube in the whole damn body they need to know a thing about!!), or who needed bailing out after getting into the colon during a bladder removal, making their own colostomy without asking for help, and brought the wrong end out to the skin! (Yep.)( And yike.)

You'll pardon a second reference to my book. After it was too late, I thought that instead of calling it "Cutting Remarks" I should have used "Delicate Brutality," which is a phrase I conjured up in the writing. I meant it to describe the very technique needed when addressing a colovesical fistula. Most surgery is better when done delicately. Tissues like that, even though most of the time you can't tell if delicacy was used or not. Resecting a colon, for example, you can clamp a wad of fat and blood vessels and tie them off like a cowboy trussing a calf. I know a few who do. Or you can tease away the fat, see the important vessels and ligate them cleanly. The brutal method, in addition to being less artful and pleasing, leaves a lot of tissue beyond the suture to die. I'm not aware of any studies -- nor do I think they could be constructed -- that address it; but I think the more dead stuff for the body to deal with in the healing process, the less good it is. On the other hand, there are times when delicacy is simply impossible and if attempted has its own downside, in unnecessarily prolonging the anesthesia time. There's such a thing as brutality rendered with delicacy and gentle purpose. Delicate brutality.

For the most part, it seems the body was designed with surgeons in mind, like a Honda engine vis a vis a mechanic, as opposed to a crazy Italian car. There are ways to get to and around every organ in the body; planes exist -- even if subtly -- that separate one thing from another, so that it's nearly always possible to find your way around without poking holes in wrong places, or causing bleeding or other calamity. The ability to separate things gently is a very thrilling aspect of being a surgeon; knowing the little tricks that allow it. On the other hand, all bets are off when it comes to inflammation or big tumors; which is what causes today's subject. Approaching a colovesical fistula, you can expect a mess, complete with obliterated planes, unrecognizable and distorted tissues, often with the omentum having interloped its way into the mass-mess. A generation ago, it was considered so difficult and dangerous that the problem was solved in two or three stages: colostomy to keep stool from getting in the bladder, then remove the diseased section and close the bladder, then get rid of the colostomy. Now it's a one step procedure, if a little gross.

As messy as it occasionally can be, for some reason I really like slogging through a mess of colon; probably because I've managed to do it without disaster. Maybe "like" is the wrong word: I'm ok with it, because I always feel I'll be able to unravel the mystery. Instead of tidy dissection with scissors, as you get where the action is, usually you're insinuating a finger into the area, wiggling your way into non-planes, pinching between your fingers to thin things out: it's not likely you'd be able to pinch through something important. Or you're using the end of a suction catheter, or the unopened jaws of those scissors. As wooden as it can often be, an amazing fact is that practically without exception, when you get beyond the inflammatory mass attached to the bladder, at some point you will work your way to soft and normal upper rectum, to which it's going to be possible safely to sew or staple the other end of the colon.

I got an email the other day about blogging, asking on what basis I decide how long a post should be. When do I break it into more than one day? I just got back from New York a couple of hours ago. Feeling behind in my writing, I started writing this on the plane. Now, I'm going to bed. No editorial reason. Tired. I hope when I read this tomorrow, I'll know where to pick it up, and won't wonder what the hell I had in mind when I began this convoluted mess....


#1 Dinosaur said...

When I was in med school, there was a weekly "puzzler" film put up on a light board in the Radiology lobby, along with a brief history. The history that went with the x-ray that demonstrated this problem was a non-English speaking patient whose CC was: "I Pierre."

keagirl said...

I try my best to avoid being in the OR when a colovesical fistula repair is in progress since the problem is almost always related to a bowel issue. But sometimes the general surgeon will feel obligated to suck me in...

The PCP will frequently send me the fistula patient first (since the symptoms seem all urological in nature at first glance), and then when I refer to the general surgeons, they feel it's common courtesy to let sew up the bladder. I usually tell them that I trust them to do an excellent job and the bladder is a very forgiving organ. :)

And shame on those urologists who couldn't find the ureter!!!

Bongi said...

when i was a registrar we did one of these. my consultant got me to cathererise the patient before the time and place the catheter underwater to watch the bubbles come out. champaign didn't come to mind. "you're not getting any tonight" did.

Ali said...

I was curious to learn more about fistula, and came across what is probably the most horrifying article I have ever read. [Warning: graphic descriptions.]

Not to derail the topic - I just have a lot of respect for the doctors who are there trying to repair this kind of damage, in what are sometimes futile cases. Those skills you have to put people back together aren't just making parts work again, they sometimes can restore sanity, honor and families.

aitchellsee said...

I'm having my colovesical fistula repaired at the end of this month, and it's fascinating and reassuring to come across this post of yours, as I've been trying to educate myself about the procedure and (even more) the recovery process afterwards. Thanks!

osto island said...

Twenty one years post-radiation treatment for a pelvic tumor, I developed a colovesical fistula. Five surgeries later, including a permanent colostomy and and a gracilis transpostion, I have developed a 4th recurrance of the fistula, this time to the stump rectum. Any idea if there are many people I might contact who are living with this condition.

Sid Schwab said...

osto island: yours is a really difficult situation and, I'd expect, fairly unique. I'm sorry to hear of your ongoing problems. I wish I had suggestions for finding others. Perhaps searching "support groups" along with "radiation enteritis," "colovesicle fistula," etc.

Anonymous said...

I recently (6 days ago) underwent colovesical fistulae repair, along with sigmoidectomy. The procedure had to be 'open', due to complications (adhesions/scar tissue) from (2) previous intrabdominal procedures-- 1. 'exploratory' surgery (my appendix perforated while 'in-hospital' under "obserevation??" for severe abdom pain in 12/06 followed by peritonitis--yup, those SoCal staff bozo's really blew it!) then in 6/07 I had laporoscopic ventral hernia repair (massive) because the 1st incision did'nt close properly. Anyway, luckily I found a great colorectal surgeon and bilateral stents werre placed by an equally talented urologic surgeon. Procedure was successful and stents were removed before closure.
They/he decided however to leave a urinary catheter in for 7 full days post-op and ordered a cytoplasty on Day 7 post-op.
Is this SOP, or is there concern that the bladder was not succcesfully repaired? Should I be concerned?
My PCA though this was 'quite unusual'.
NOTE: I did have mild diverticulosis, but the cause of the fistulae were ahedsions/scar tissue/mesh degradation per my cutter.
Any thoughts on this? Feedback/advice would be greatly apprectiated! Thanks.

Sid Schwab said...

I'd say it's quite routine to leave a urinary catheter for a week or so after bladder repair. I assume by "cystoplasty" you actually mean cystoscopy. I'd agree that part is less usual, but I have no basis for speculating why they want to do it. There's certainly no reason you should hesitate to ask your surgeons.

Same with the fistula: I'd say that's an uncommon cause, but the ones who did the surgery are in a far better position to explain. You should ask them what exactly they think the process was. I see no reason why they'd have a problem with you asking.

Anonymous said...

I was recently diagnosed with a colovesical fistula due to diverticulosis. No passing of gas or fecal matter, but I did get a urinary infection. I have a consult with a nurse practitioner at a sureon's office next month. What kid of questions should I be asking? I've also heard that there is a laparoscopic tre4atment that entails the use of a clamp or clip. Have you any info to share on that? Thanks.

Sid Schwab said...

Well, I guess I'd ask how come you're not seeing the surgeon... (snarky, I admit; but for a potential major operation, I'd think it's appropriate to go to the mouth of the horse.)

I'm not aware of a clip that would solve the problem: when a colovesical fistula occurs, in general it's felt necessary to remove that portion of the colon from which it occurred, both for permanent cure and for definitive diagnosis. The operation to remove the colon can be done laparoscopically, depending on how dense adhesions are.