What is the pathophysiology of iatrogenic enterovesical fistula?

Updated: Dec 24, 2020
  • Author: Joseph Basler, MD, PhD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Iatrogenic fistulae are usually induced by surgical procedures, primary or adjunctive radiotherapy, and/or postprocedural infection. Surgical procedures, including prostatectomies, resections of benign or malignant rectal lesions, and laparoscopic inguinal hernia repair, are well-documented causes of rectovesical and rectourethral fistulae. [22, 23] Unrecognized rectal injury at the time of radical prostatectomy is an uncommon but well-documented etiology of rectourethral fistula.

External beam radiation or brachytherapy to bowel in the treatment field can eventually lead to fistula development. Radiation-associated fistulae usually develop years after radiation therapy for a gynecologic or urologic malignancy. The incidence of radiation-induced fistula associated with gynecological cancers (most commonly cervical cancer) is approximately 1%, many of which are rectovaginal or vesicovaginal. [24]

Fistulae develop spontaneously after perforation of the irradiated intestine, with the development of an abscess in the pelvis that subsequently drains into the adjacent bladder. Radiation-associated fistulae are usually complex and often involve more than one organ (eg, colon to bladder). Because of improvements in radiotherapy techniques, the incidence of this complication is decreasing.

Although rare, fistulae due to cytotoxic therapy have been reported. One case involved a patient undergoing a CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) regimen for non-Hodgkin lymphoma. [25] Another involved enterovesical fistula as a result of neutropenic enterocolitis (a complication of chemotherapy) in a pediatric patient with acute leukemia. [26]


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