Ureterocolic fistula in the presence of a solitary kidney
- Published 2 February 2009
Among the entero-urinary fistulae, those between the ureter and colon are rare. Most spontaneous ureterocolic fistulae are caused by urinary calculi. We report a case of a spontaneous ureterocolic fistula which occurred as a consequence of diverticular disease. This rare presentation was further complicated as it occurred in the presence of a solitary kidney. The patient underwent a laparoscopic defunctioning loop ileostomy and after 6 weeks underwent definitive surgical treatment of the ureterocolic fistula. We describe the presentation and management of this fistula and review the current literature.
This case describes a rare complication of diverticular disease, a ureterocolic fistula, the first to our knowledge to have occurred in a patient with a solitary kidney. This makes the diagnosis and management extremely important.
A 79-year-old man presented with dysuria, urinary frequency and left iliac fossa pain. Significant past medical history included diverticular disease and diabetes. Physical examination revealed a malnourished man and left iliac fossa tenderness. A computed tomography scan with contrast revealed severe diverticular disease in the sigmoid colon and a hydronephrotic solitary left kidney with streaking of the perinephric fat (fig 1). A pelvic collection containing air was demonstrated in the left iliac fossa; however, a fistula was not clearly demonstrated on this study.
Cystoscopy identified a single left ureteric orifice and a left retrograde pyelogram revealed leakage of contrast from the distal ureter into the sigmoid colon (fig 2). Ureteroscopy allowed direct visualisation of the ureterocolic fistula and a double J ureteric stent was inserted.
The colorectal team performed a laparoscopic defunctioning loop ileostomy and after 6 weeks of nutritional support the patient underwent definitive surgical treatment of his ureterocolic fistula. A laparotomy revealed a small abscess deep in the left pelvis. The mid and distal left ureter was grossly oedematous. A sigmoid colectomy was performed and omentum wrapped around the involved ureter.
OUTCOME AND FOLLOW-UP
The ureteric stent was removed after 8 weeks and the patient remains well 3 months postoperatively.
Fistulae between the upper urinary tract and the gastrointestinal systems are rare. Colovesical fistulae represent the vast majority of renoalimentary fistulae.1 Most spontaneous ureterocolic fistulae are caused by urinary calculi.2 Renoalimentary fistulae were first recognised in the mid 1800s and were predominantly the result of renal tuberculosis.3 Ureterocolic fistula resulting from colonic diverticular disease is rare and typically a result of iatrogenic injury.
A literature review by Cirocco et al detailed five reported cases of spontaneous ureterocolic fistula caused by diverticulitis between 1965 and 1994, their case being the fifth.2
A variety of pathological conditions of either organ system may lead to fistualisation. Predisposing factors include colonic carcinoma, surgery, irradiation, trauma and inflammatory processes.
Ureterocolic fistulae may be diagnosed using either urological or gastrointestinal imaging studies. An intravenous pyelogram may identify the fistula, although a poorly functioning kidney will make this less valuable. A retrograde pyelogram, as performed in our case, can be used to determine the exact location of the fistula.
Management of ureterocolic fistulae depends on the aetiology. Our case was complicated by the fact that the patient had a solitary functioning kidney, thus limiting the surgical options. In cases where the involved kidney is poorly or non-functioning with a contralateral normal kidney, a nephro-ureterectomy with excision and closure of the fistula appears to be the treatment of choice. Spontaneous closure of the fistula is rare.
In summary, spontaneous ureterocolic fistulae are extremely rare and management is directed at resection of the diseased colon as well as treatment of the underlying cause.
Ureterocolic fistulae are rare.
It is important to consider where risk factors exist (calculi, diverticular disease, tuberculosis).
Management of ureterocolic fistulae depends on the cause.