THE JOURNAL OF UROLOGY Copyright © 1977 by The Williams & Wilkins Co.
Vol. 118, November Printed in U.SA.
AN UNUSUAL RENOCOLIC FISTULA J. WESTON UNDERWOOD From the St. James Hospital, Ealham, England
ABSTRACT
A case of a left renocolic fistula that was caused by a combination of diverticular disease and renal calculi is presented. It is suggested that bowel disease will only produce such a fistula ifthere is pre-existing chronic renal disease. A renocolic fistula is rare and was thought to be predominantly tuberculous in nature. 1 However, in recent years chronic renal infection, trauma and calculous disease have been the 3 major causes of this type of fistula. 2 Bowel disease has been incriminated rarely in the etiology of any renoalimentary fistula but such a case is reported herein.
had closed, resection of the splenic flexure and descending colon was done with end-to-end anastomosis. Histological examination of the resected specimen showed diverticulitis. The greater omentum was sutured over the renal pelvis.
CASE REPORT
E. S., a 69-year-old woman, was hospitalized for abdominal pain and vomiting 9 days in duration. There were no other
Fm. l. Plain x-ray of renal areas shows bilateral calculi symptoms or significant history. On physical examination she was ill and dehydrated but afebrile, with a dull tender firm mass with an ill-defined edge occupying the left side of the abdomen. Sigmoidoscopy revealed urine in the rectum. Laboratory investigations included hemoglobin 12 gm. per dl., total white cell count 15,300 per cu. mm. and blood urea 88 mg. per 100 ml. A mid stream urine specimen was sterile but with marked pyuria. Blood cultures yielded a Proteus organism. The bladder mucosa was erythematous on cystoscopy. An abdominal x-ray showed an absent left psoas margin, calculi in the left kidney and a staghorn calculus in the right kidney (fig. 1). Extravasation of contrast medium from the left renal pelvis was seen on excretory urography (IVP) and barium tracked from at least 4 diverticula of the descending colon into the same cavity (fig. 2). Attempts to defunctionalize the fistula by draining the left renal pelvis via a ureteral catheter left in situ for 48 hours were unsuccessful because of blockage. At operation a large inflammatory mass of transverse and descending colon was encountered and a right transverse double barreled colostomy was performed. The abdominal mass disappeared in 2 weeks. Three months later, after x-rays had shown that the fistula Accepted for publication July 1, 1977.
Fm. 2. Barium enema. Note that barium has left colon via diverticula and is passing towards renal calculi.
4
Convalescence was uneventful and the colostomy was closed 2 months later. The patient has been in excellent health in the subsequent 2 years. COMMENT
This case is unusual because the fistula was demonstrated on IVP, thus indicating that the affected kidney had moderate function. Since the patient had bilateral renal calculous dis847
848
UNDERWOOD
ease the standard treatment of nephrectomy and closure of the colonic defect was inappropriate. 3 Brust and Morgan4 described a renocolic fistula from a pericolic abscess with a colonic adenocarcinoma and Husted 5 reported such a fistula from diverticular disease. Both of their patients, as in this case, had pre-existing renal calculous disease. Meyers has shown that perinephritis produces radiographic abnormalities in the colon and it appears that atrophy of perinephric fat is necessary before a renocolic fistula can develop. 6 Thus, chronic renal disease is an essential prerequisite for a renocolic fistula, whether the final impetus is provided by renal or bowel disease. Mr. J. Burke allowed me to report on his patient. Dr. Jean Dow provided the x-rays.
REFERENCES
1. Abeshouse, B. S.: Renal and ureteral fistula of visceral and
2. 3. 4. 5. 6.
cutaneous types: report of four cases. Urol. & Cutan. Rev., 53: 641, 1949. Bissada, N. K., Cole, A. T. and Fried, F. A.: Reno-alimentary fistula: an unusual urological problem. J. Urol., 110: 273, 1973. Arthur, G. W. and Morris, D. G.: Reno-alimentary fistulae. Brit. J. Surg., 53: 396, 1966. Brust, R. W., Jr. and Morgan, A. L.: Renocolic fistula secondary to carcinoma of the colon. J. Urol., 111: 439, 1974. Husted, J. W.: An unusual case of pyelonephritis: nephrocolic fistula o:wing to a ruptured colonic diverticulum. J. Urol., 111: 724, 1974. Meyers, M. A.: Colonic changes secondary to left perinephritis: new observations. Radiology, 111: 525, 1974.
Vol. 118, November Printed in U.SA.
AN UNUSUAL RENOCOLIC FISTULA J. WESTON UNDERWOOD From the St. James Hospital, Ealham, England
ABSTRACT
A case of a left renocolic fistula that was caused by a combination of diverticular disease and renal calculi is presented. It is suggested that bowel disease will only produce such a fistula ifthere is pre-existing chronic renal disease. A renocolic fistula is rare and was thought to be predominantly tuberculous in nature. 1 However, in recent years chronic renal infection, trauma and calculous disease have been the 3 major causes of this type of fistula. 2 Bowel disease has been incriminated rarely in the etiology of any renoalimentary fistula but such a case is reported herein.
had closed, resection of the splenic flexure and descending colon was done with end-to-end anastomosis. Histological examination of the resected specimen showed diverticulitis. The greater omentum was sutured over the renal pelvis.
CASE REPORT
E. S., a 69-year-old woman, was hospitalized for abdominal pain and vomiting 9 days in duration. There were no other
Fm. l. Plain x-ray of renal areas shows bilateral calculi symptoms or significant history. On physical examination she was ill and dehydrated but afebrile, with a dull tender firm mass with an ill-defined edge occupying the left side of the abdomen. Sigmoidoscopy revealed urine in the rectum. Laboratory investigations included hemoglobin 12 gm. per dl., total white cell count 15,300 per cu. mm. and blood urea 88 mg. per 100 ml. A mid stream urine specimen was sterile but with marked pyuria. Blood cultures yielded a Proteus organism. The bladder mucosa was erythematous on cystoscopy. An abdominal x-ray showed an absent left psoas margin, calculi in the left kidney and a staghorn calculus in the right kidney (fig. 1). Extravasation of contrast medium from the left renal pelvis was seen on excretory urography (IVP) and barium tracked from at least 4 diverticula of the descending colon into the same cavity (fig. 2). Attempts to defunctionalize the fistula by draining the left renal pelvis via a ureteral catheter left in situ for 48 hours were unsuccessful because of blockage. At operation a large inflammatory mass of transverse and descending colon was encountered and a right transverse double barreled colostomy was performed. The abdominal mass disappeared in 2 weeks. Three months later, after x-rays had shown that the fistula Accepted for publication July 1, 1977.
Fm. 2. Barium enema. Note that barium has left colon via diverticula and is passing towards renal calculi.
4
Convalescence was uneventful and the colostomy was closed 2 months later. The patient has been in excellent health in the subsequent 2 years. COMMENT
This case is unusual because the fistula was demonstrated on IVP, thus indicating that the affected kidney had moderate function. Since the patient had bilateral renal calculous dis847
848
UNDERWOOD
ease the standard treatment of nephrectomy and closure of the colonic defect was inappropriate. 3 Brust and Morgan4 described a renocolic fistula from a pericolic abscess with a colonic adenocarcinoma and Husted 5 reported such a fistula from diverticular disease. Both of their patients, as in this case, had pre-existing renal calculous disease. Meyers has shown that perinephritis produces radiographic abnormalities in the colon and it appears that atrophy of perinephric fat is necessary before a renocolic fistula can develop. 6 Thus, chronic renal disease is an essential prerequisite for a renocolic fistula, whether the final impetus is provided by renal or bowel disease. Mr. J. Burke allowed me to report on his patient. Dr. Jean Dow provided the x-rays.
REFERENCES
1. Abeshouse, B. S.: Renal and ureteral fistula of visceral and
2. 3. 4. 5. 6.
cutaneous types: report of four cases. Urol. & Cutan. Rev., 53: 641, 1949. Bissada, N. K., Cole, A. T. and Fried, F. A.: Reno-alimentary fistula: an unusual urological problem. J. Urol., 110: 273, 1973. Arthur, G. W. and Morris, D. G.: Reno-alimentary fistulae. Brit. J. Surg., 53: 396, 1966. Brust, R. W., Jr. and Morgan, A. L.: Renocolic fistula secondary to carcinoma of the colon. J. Urol., 111: 439, 1974. Husted, J. W.: An unusual case of pyelonephritis: nephrocolic fistula o:wing to a ruptured colonic diverticulum. J. Urol., 111: 724, 1974. Meyers, M. A.: Colonic changes secondary to left perinephritis: new observations. Radiology, 111: 525, 1974.
