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We describe a 22-year-old man with Crohn's ileocolitis accompanied by intestinal stenosis and ileovesical fistula in whom laparoscopically-assisted surgery was successfully performed after thorough nutritional therapy. Laparoscopic procedures are characterized by minimal access and minimal invasion, features which can contribute to the early recovery of patients who undergo surgery. It is suggested that laparoscopic (or laparoscopically-assisted) surgery after strict nutritional therapy can be effective in the treatment of patients with Crohn's disease who have intestinal complications.

Enterovesical fistula is a known complication of several conditions involving the bowel or the genitourinary system. Its occurrence with primary small-bowel lymphoma is rare. The authors report a case of enterovesical fistula associated with secondary small-bowel non-Hodgkin's lymphoma. They review the criteria for classification of small-bowel lymphoma as primary or secondary and discuss the radiologic findings consistent with enterovesical fistula, with reference to the role of computed tomography as the initial radiologic study.

Internal fistula is a complication of Crohn's disease. Among 589 patients operated upon at Hôpital Saint-Antoine between 1970 and 1992, 17 (2.9%) had entero-vesical fistula. Ileovesical fistulas were twice as frequent as sigmoidovesical fistulas. Typical symptoms were pneumaturia, fecaluria, and recurrent urinary tract infection. Cystoscopy was performed in 8 patients and determined the site of the fistula in each case. The indication for operation was the fistula itself (35%) or another complication of Crohn's disease (65%). Associated lesions were as follows: 6 entero-enteral, 2 ileogenital, 5 enterocutaneous fistulas and 6 intraabdominal abscesses. Resection of the bowel segment responsible for the fistula was performed in every case, with primary anastomosis in 9 cases and enterostomy in 8 cases. The vesical opening was excised and sutured in 10 cases and left open in 7 cases. An urethral catheter was left in place for at least 7 days. There was no postoperative death; one postoperative external vesical fistula healed without reoperation. Seven enterostomies have been closed, one is definitive. There were no late recurrences of vesical fistula.

A case of squamous cell carcinoma of the urinary bladder with concomitant radionuclide uptake in the colon observed on bone scintigram in a 76-year-old female is presented. This finding reflected retrograde flow from the bladder to the intestine and suggested the presence of vesicoenteric fistula. The patient's pelvis had been irradiated with 23.4 Gy before the bone scintigram, she had been complaining only of diarrhea and not of any characteristic symptoms of vesicoenteric fistula, such as pneumaturia and fecaluria. Further examination including cysternography revealed a fistulous communication between the bladder and the ileum. The size of the tumor decreased markedly after radiation, tumor invasion to the ileum and the fistulous communication were verified at surgery.

Small bowel diverticulitis is an unusual condition but the development of a secondary enterovesical fistula is extremely rare. This report describes the second documented case of ileovesical fistula secondary to ileal diverticulitis. Definitive diagnosis was made by double-contrast enema and small bowel fluoroscopic examinations. Management should consist of dissection of the fistula with either resection or primary repair.

Ileovesical and ileosigmoid fistulae were found to coexist in 22 patients with Crohn's ileocolitis. Persistent or recurrent urinary tract infection was a complaint in all cases, and 11 patients reported pneumaturia and/or fecaluria. Thus, bladder involvement was either suspected or clinically apparent in each patient. The cystogram was the best confirmatory test for the ileovesical fistula (positive in 9 of 22 patients). The coexistence of the sigmoid fistula was best diagnosed on intestinal radiographs (positive in 9 of 22 patients); there were no clinical signs of its presence. The coexistence of ileosigmoid and ileovesical fistulae was the sole indication for operation in two patients. In all others, a combination of factors required surgical therapy. An ileocolonic resection with primary intestinal anastomosis was performed in 16 patients and exteriorization was performed in six patients. The sigmoid defect was closed primarily in 16 patients and required wedge resection in the other six patients. The bladder defect was sparingly excised and closed with absorbable sutures. All patients recuperated without anastomotic leaks, bladder leaks, or persistent cystitis. This experience indicates that coexisting ileosigmoid and ileovesical fistulae may add complexity to an ileocolonic resection for Crohn's disease, but is not a difficult management problem for the gastrointestinal surgeon.

During a period of 18 months, 24 patients were identified with enterovesical fistulas. The fistulas were colovesical in 18, ileovesical in four and rectovesical and appendicovesical in one each. Fifteen of the 23 patients in whom this information was available had pneumaturia and four had fecaluria. The standard battery of diagnostic tests for enterovesical fistulas was performed. Thirteen patients with colovesical fistulas had small intestinal series; the fistula was demonstrated in only five patients. Sixteen patients had an intravenous pyelogram and the fistula was demonstrated in none. Cystoscopy was performed upon 15 patients and the fistula was demonstrated in one. A cystogram was performed upon ten patients and the fistula was demonstrated in four. In contrast, all patients had positive computed tomographic findings. The pathognomonic finding of air within the bladder was demonstrated in 20 of 23 patients without recent transurethral instrumentation. All 24 computed tomographic scans demonstrated an abnormally thickened segment of intestine in intimate contact with a thickened bladder wall at the site of the fistula. This was associated with a paravesical mass in 23 of the patients. Two of the four patients in whom bladder air was not seen had a vesical fistula of the small intestine. All 24 fistulas were confirmed by operation (22 patients) or subsequent clinical course (two patients). These findings suggest that computed tomography is the most accurate diagnostic tool available for demonstrating enterovesical fistulas. Computed tomography should supplant the use of other less sensitive diagnostic test currently included in the evaluation of patients with a suspected enterovesical fistula.

The complication of spontaneous vesicoileal fistula formation in an eleven-year-old male two years after ureteroileoneocystostomy undiversion is presented.