ON-LINE CASE REPORT

Ann R Coll Surg Engl 2010; 92:

doi 10.1308/147870810X12699662981555

Covered metallic stents for the palliation of

colovesical fistula
Mukhtar Ahmad1, Colin Nice2, Mark Katory1

Departments of 1Colorectal Surgery and 2Radiology, Queen Elizabeth Hospital, Gateshead, UK

ABSTRACT
Colovesical fistula is a distressing condition that is usually managed surgically. For some patients in whom surgery is not feasi-
ble, covered colonic stents offer palliation. We present two challenging cases with contrasting outcomes. The first case is a
colovesical fistula secondary to malignancy with a successful outcome after stenting and the second a complex diverticular fis-
tula with a poor outcome. From our limited experience, it is a useful technique but careful patient selection is essential to its
safe application. There is little published experience of the use of these stents for colovesical fistula.

KEYWORDS
Colovesical fistula – Metallic stents
Accepted 17 June 2010; published online 2 July 2010

CORRESPONDENCE TO
Mark Katory, Department of Colorectal Surgery, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
E: mark.katory@ghnt.nhs.uk

Colovesical fistula is a distressing condition leading to
recurrent urinary tract infections and passage of faeces in
the urine. This abnormal communication between the uri-
nary bladder and the bowel is most commonly caused by
diverticular disease. Of patients with sigmoid diverticulosis,
6–12% present with symptoms related to fistulation.1,2 Other
causes include malignancy, Crohn’s disease, radiotherapy
and iatrogenic injury.3 Colovesical fistulae are more com-
mon in males, with a male-to-female ratio of 3:1.
Surgery in the form of resection of the diseased colon or
a diversion stoma remains the mainstay of management for
colovesical fistula in patients fit for anaesthesia. However,
patients with malignant fistulae usually present in the
advanced stages of their cancer when radical surgery or
even a defunctioning stoma may not be appropriate.
Stenting offers an alternative for these patients either as
palliation or as a stop-gap measure while optimising the
patient for surgery. Covered, self-expanding, metallic stents
have been used to treat such patients in only a limited num-
ber of cases with varied outcomes.4–6
The use of self-expanding, metallic colonic stents to
relieve acute colonic obstruction has increased in recent
times and is more widely accepted as standard practice.7,8
Current national randomised trials are in progress to estab-
lish whether stents in this role reduce morbidity and mor-
tality of emergency colonic surgery.9 Though the technique
for deploying covered colonic stents is similar to that for
their uncovered counterparts, experience of using stents to
treat colonic fistula remains limited and published litera-
ture regarding their outcomes is rather sparse. We describe
two cases with contrasting outcomes following stenting for
colovesical fistula.
Case histories
Patient 1 – malignant colovesical fistula
A 62-year-old man with metastatic locally advanced adeno-
carcinoma of the sigmoid colon presented with recurrent
urinary tract infections and faecaluria. At initial presenta-
tion, the patient declined surgery in view of his metastatic
disease and his frailty. He had palliative radiotherapy.
Computed tomography (CT) scan showed progression of his
cancer (Fig. 1) but no definite evidence of fistulation. He
was septic with pyrexia, tachycardia and raised inflamma-
tory markers. Intravenous antibiotics were commenced
with a good response. A water-soluble contrast enema
clearly demonstrated the fistula (Fig. 2).
Under image guidance (Fig. 3), a ComVi® covered
colonic stent (10 cm long, 30 mm diameter; Niti S Comvi®;
TaeWong Medical, Korea) was deployed to cover the site of
the previously identified fistula (Fig. 4). There were no
immediate complications and the gross faecaluria immedi-
ately resolved. The patient was discharged home 3 days
later. At 4-week follow-up, urine culture was negative for
coliforms. Six months after stenting, he continued to enjoy
a reasonable quality of life in spite of advanced malignancy.

Ann R Coll Surg Engl 2010; 92: 1

AHMAD NICE KATORY COVERED METALLIC STENTS FOR THE PALLIATION OF COLOVESICAL
FISTULA

Figure 1 CT scan showing locally advanced rectosigmoid tumour

invading the bladder.

Figure 2 Water soluble contrast enema demonstrating colovesical

fistula (arrow).

Figure 3 Guide-wire passed through tumour prior to stenting. Image

guidance confirms the stent will straddle the fistula once deployed
(arrow).

Patient 2 – benign colovesical fistula

A 74-year-old woman presented with recurrent urinary
tract infections, and progressive left groin pain and
swelling. She also had pneumaturia for 3 years prior to her Figure 4 Covered stent deployed successfully.
presentation. Her medical history was quite complicated

2 Ann R Coll Surg Engl 2010; 92:

AHMAD NICE KATORY
including type II diabetes, hypertension, myocardial infarction
and atrial fibrillation for which she was on warfarin. Her sur-
gical history included a hysterectomy for endometrial cancer,
open cholecystectomy and incisional hernia repair.
Physical findings were a body mass index of 39 kg/m2,
left lower quadrant abdominal and groin tenderness.
During the course of a protracted hospital stay, the groin
swelling evolved into a faecal fistula. Urine culture yielded
a heavy growth of coliforms. CT scan showed complicated
diverticular disease with evidence of colovesical and colo-
cutaneous fistula to the left groin. Flexible sigmoidoscopy
showed extensive diverticulosis but no evident fistulous
opening.
Surgery was considered initially but was considered too
high risk because of her significant co-morbidities. She had
a ComVi® stent (12 cm long, 30 mm diameter Niti-S Comvi®
covered colonic stent; TaeWong Medical, Korea) inserted
with reasonable expansion though the procedure was tech-
nically very difficult. She had a protracted after stent period
in which she had recurrent episodes of diverticulitis. She
subsequently perforated her colon 3 months following stent
insertion and succumbed to peritonitis. Post-mortem exam-
ination confirmed the perforation was stent-related.
Discussion
® 3. Pollard SG, Macfarlane R, Greatorex R, Everett WG, Hartfall WG. Colovesical
The Niti-S ComVi stent is flexible and retains shape-mem-
ory when deployed. It was originally designed for palliation
of advanced obstructing colon cancers.10 It is described as a
covered stent because polytetrafluoroethylene is inserted
between the stent wires to prevent tumour in-growth. When
used in the treatment of colovesical fistula, covered stents
are thought to function in a similar manner creating a new
barrier between the bowel lumen and the fistula tract there-
by alleviating the symptoms associated with fistulation.
Technically, the first case was straightforward due to the
presence of a clearly defined stricture and fistula on the
procedural imaging, which aided stent positioning. Case
two was technically very difficult due to patient immobility
and difficulties in demonstrating the exact site of the fistula
and correlating procedural appearances with the prior
imaging. The contrasting outcomes between these cases
could be attributed to the nature of the strictures, the
underlying pathology and patient co-morbidities.
Diverticular strictures tend to be longer than malignant
COVERED METALLIC STENTS FOR THE PALLIATION OF COLOVESICAL
FISTULA
ones making stenting technically more difficult and
decreasing the long-term survival of the stent. Covered
stents are thought to help close fistulae by compressing the
tissues around them.11 They may, therefore, increase the
risk of perforation considering the significant pericolic
inflammation that already exists. In contrast, malignant fis-
tulae occur due to tumour invasion and there is not usually
festering sepsis around these fistulae.
Conclusions
The use of a covered stent is a valuable option in the palli-
ation of colovesical fistulae secondary to malignancy in
cases where surgery is not feasible or appropriate. This
includes locally advanced rectal cancer and inoperable
metastases. The outcome in patients with inflammatory
conditions such as diverticular disease is at present equivo-
cal and complication rates anecdotally appear to be higher
than the malignant group. Covered stents could improve
quality of life in this select group of patients while avoiding
invasive surgical treatment.
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