We reviewed our experience with laparoscopic surgery for diverticular CVF. In our cohort, no severe morbidities or mortalities were observed. The incidence of COS was as high as 27%, and a posterior bladder fistula location was a statistically significant risk factor.
Previous studies have shown that a laparoscopic colectomy can be safely utilized for complicated diverticulitis; however, most reports were limited by exceedingly small cohorts and highly selected patients [11,14–16]. In a recent large study of 111 consecutive diverticular fistula cases with minimal exclusion, reported by Martinolich et al. [22], the overall incidence of postoperative complications was 26.4%. In our study, although the overall incidence of postoperative morbidity was as high as 36%, all were no higher than Grade II of the Clavien–Dindo classification for severe complications. Based on these results, it could be concluded that laparoscopic surgery for diverticular CVF is safe and feasible.
Several small retrospective studies on diverticular fistulas have reported that the incidence of COS ranges from 0 to 50%, [9,11–20] and patients with a preoperative diagnosis of CVF were most likely to require COS. Recent studies on CVF by Badic et al. [14] and Martinolich et al. [22] reported COS incidence rates of 43% and 42%, respectively, comparable to our rate of 27%. During laparoscopic surgery in general, previously reported risk factors for COS included old age, male sex, high BMI, and previous abdominal operations [23–25]. Diverticular fistula cases, in particular, showed severe inflammation or dense fibrosis impeding safe dissection or ureteral visualization to be the most frequent reason for COS [22]. In our study, although age, BMI, and previous abdominal operations were not significantly correlated with COS, this may simply be a consequence of the small sample size. We proposed three novel MRI features as preoperative risk factors for COS, finding that fistula location on the bladder correlated with COS. Although patency of the rectovesical pouch and eCA did not correlate with COS in this study, this may also be due to the small sample size. It will be necessary to identify more cases and further investigate this topic.
As described by Engledowe et al. [12], small fistulas with accompanying inflammation of the bladder wall were not formally closed, and the Foley catheter was left in place for decompression for 5–7 postoperative days. There were no complications related to urinary leakage in these patients. In our study, bladder wall repair was not performed in patients with a negative leak test, and simple closure without partial resection was sufficient, regardless of the leak test outcome. As a result, no postoperative urinary leakages were observed in our cohort.
Although the decision on COS in the operating room can be subjective and dependent on individual surgeon skill, identifying objective preoperative risk factors associated with COS can provide a lower threshold for proceeding with the potentially inevitable open approach and can catalyze the decision on earlier COS. Furthermore, the ability to identify patients at a high risk of COS can aid surgeons in selecting those who may benefit from primary open surgery, thereby potentially reducing operative time, morbidity, and costs [25].