Renoalimentary Fistula Treatment & Management
- Author: Martha K Terris, MD, FACS; Chief Editor: Edward David Kim, MD, FACS more...
Antibiotic therapy is instituted to assist in the treatment of concomitant infection, but surgical intervention remains the definitive treatment for renoalimentary fistulae.
In rare cases, a fistula between the intestinal and urinary tracts due to inflammatory bowel disease resolves with aggressive medical therapy (anti-inflammatory agents and steroid therapy) of the inflammatory process.
In high–surgical-risk patients, a few case reports have described success with conservative management that consisted of prolonged percutaneous drainage along with a low-residue diet in cases of inflammatory etiology.
In the rare cases of renoalimentary fistula following radiofrequency ablation or cryoablation, conservative measures have been successful.
The choice of surgical therapies largely depends on the etiology of the fistula and the segment of bowel involved. Generally, surgical therapy involves resection of the involved bowel segment, reanastomosis, and resection of the fistula tract to the kidney. If renal function is severely compromised (ie, inadequate to maintain the patient without dialysis in the absence of the contralateral kidney), a nephrectomy may be more efficacious than attempts at repairing the urinary tract component of the fistula.
Successful percutaneous fulguration of the fistula tract has been reported in a case report and may be an option when the fistula caused by longstanding calculi and abscess after removal of the calculus and drainage of abscess in patients who are not candidates for more aggressive surgical intervention.[9, 10]
Obtain a history and perform a physical examination to evaluate for any increased surgical risks, including allergies. Patients should give consent for all possible surgical permutations required to repair the renoalimentary fistula, including nephrectomy (which may result in renal failure and possible dialysis), urinary diversion, intestinal diversion, and prolonged hospitalization with bowel rest and parenteral nutrition. The patient also may die, and this should be addressed during the consent process.
CBC count, electrolyte evaluation, renal function studies, urine culture, chest radiography, and ECG should be performed as described in Workup.
Mechanical bowel preparation consists of 2-3 days of a clear liquid diet and cathartics that do not result in excessive electrolyte imbalance (eg, polyethylene glycol & electrolytes [1 L of Go-Lytely]). Patients who have been on prolonged bowel rest may not need this aggressive cleansing approach. Antibiotic bowel preparation with oral neomycin (500 mg) and erythromycin base (1 g) should be used. Patients with diabetes or those who are immunocompromised may benefit from prophylactic oral rinses with antifungal agents and antifungal powder, such as nystatin in the intertriginous areas to prevent yeast overgrowth while undergoing bowel preparationand in the immediate postoperative period.
Patients on long-term steroid therapy to treat inflammatory bowel disease or other ailments should receive stress-dose steroid therapy perioperatively. Typically, this regimen consists of 100 mg hydrocortisone preoperatively and 100 mg/d for 3 days, followed by a tapered reduction in dose until the patient's standard steroid dosing schedule is reached.
Broad-spectrum antibiotics targeting both bowel flora and common urinary tract pathogens should be administered least 1 hour preoperatively and 1 day postoperatively. A longer duration of therapy may be necessary in patients with infectious complications of the fistula.
An anterior subcostal or midline transperitoneal incision is well suited because either allows easy exposure to the kidney and bowel. Pyeloduodenal fistulae may be accessed through retroperitoneal exposure alone. In addition to open surgical approaches, transperitoneal hand-assisted laparoscopic approach for exposure to bowel and kidney has been reported with success.
If the kidney is salvageable, repair may be possible, although bowel resection and reanastomosis are often required. This involves excision of the fistula complex, including the affected bowel and urinary tract segment, followed by repair of the kidney and/or ureter and reanastomosis and/or diversion of the bowel. If urinary stone disease is an etiology or secondary complication of the fistula, all stones should be cleared from the collecting system.
A stent or nephrostomy tube should be left in the kidney and a nasogastric tube in the stomach to prevent stressing the anastomotic suture lines in the immediate postoperative period. A urethral catheter should also be placed. To help prevent fistula recurrence, interposing the omentum or other viable tissue is important.
If the kidney is not functioning, a nephrectomy is indicated.
Intraperitoneal suction drains, such as a Jackson-Pratt drain, should be left in place to avoid life-threatening sepsis should the repairs fail.
Bowel sounds, passage of flatus, and an appetite should all be present before attempting oral nutrition. A clear liquid diet should be initiated slowly and advanced to a regular low-residue diet if well tolerated and if no intestinal contents are appreciated in the urinary or intraperitoneal drains. The urethral catheter can be removed as the diet is successfully advanced.
Although the absence of continued symptoms is an encouraging sign of successful repair, nephrostography or retrograde pyelography should be performed 4-6 weeks postoperatively. If no persistence or recurrence of communication is present, the stent and/or nephrostomy tube can be removed. If the urinary repair is at all tenuous, the intraperitoneal drains should be left in place until all urinary stents and drainage tubes are removed. If no urinary output is present once all tubes are removed, the drains can be removed.
Appropriate radiographic and laboratory follow-up studies should be performed as mandated by the histology and stage of malignancy for patients with renoalimentary fistulae occurring secondary to tumors. Fistulae due to calculi should prompt a metabolic evaluation and follow-up imaging with a plain abdominal film in approximately 6 months, or, if the patient develops any symptoms, IVU or a noncontrast CT scan should be performed.
Intravenous pyelography or another functional study for fistulae from other benign causes should be performed 3-6 months after repair to confirm stable renal function and adequate kidney drainage.
For excellent patient education resources, see eMedicineHealth's patient education article Intravenous Pyelogram.
Anastomotic breakdown of the bowel, bowel or urinary tract obstruction, abscess recurrence, or formation and recurrence of the fistula (when the kidney is salvageable), sepsis, and even death are all possible complications of this type of surgery.
Complete resection of the fistula and any associated abscess cavity, necrotic tissue, inflammatory mass, tumor, stones, or foreign bodies; perioperative antibiotics; tension-free closure of both the bowel and urinary components; interposition of healthy tissue, such as omentum; copious would irrigation; drain placement; and adequate nutritional support are all crucial to minimize the risk of complications. Exploration, percutaneous drain placement, nephrostomy tube placement, prolonged bowel rest, and/or aggressive antibiotic therapy may be necessary if postoperative complications develop.
Outcome and Prognosis
The prognosis depends on the etiology of the fistula. For benign processes, the prognosis is generally good provided sepsis is absent or limited and the entity is recognized quickly.
Malignancy that is sufficiently advanced to cause a renoalimentary fistula carries a poor prognosis. This is not due to the fistula itself, but because of the tumor.
Future and Controversies
Renoalimentary fistula will likely remain an occasional sequela of percutaneous nephrostomy tube placement, but management is relatively straightforward. With percutaneous radiofrequency ablation and cryoablation becoming a more popular and viable treatment option, patients should be aware that renoalimentary fistula is a potential complication of them. The use of hydrodissection during radiofrequency ablation with normal saline and vigilance of surrounding structures during these procedures should help keep the development of fistulae to a minimum.
In many cases, renoalimentary fistulae are secondary to neglected treatment of chronic disease. Continued efforts at early diagnosis and treatment of underlying problems should decrease the incidence of renoalimentary fistulae and improve the prognosis.
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