John J. Bauer, M.D. www.flinturology.com Urology Services, Inc. G-1121 West Hill Rd. Flint, Michigan 48507 Tel: 810.232.8888 Fax: 810.232.9190 Email: jbauer@flinturology.com [map]

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Contents
General information
Pre-operative instructions
Risks and Complications
Detailed Surgery Description
Family waiting instructions
Post-operative instructions

Printing tip: If you want to print only one portion of this entire document, you should be able to do this depending on your software. To print a selection, highlight the section you want to print using your mouse, then click on print, and then in the print menu, choose "selection."

Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary.

A vesicoenteric fistula is a connection between the bladder and any bowel structure. This can include the small intestines, sigmoid colon or rectum. The three most common causes of this entity are: Colonic Diverticulitis, Crohn�s Disease (inflammation of the small and large intestines), and Colon Cancer. The symptoms usually encountered are: chronic urinary tract infections, gas bubbles during urination, bowel movements with urine in them, feces in the urine, foul smelling urine and a host of irrative bladder symptoms. The definitive diagnosis is a CAT scan that shows air in the bladder. The treatment of this condition is to treat the other diseases that cause them (mentioned above) and see if the fistula resolves spontaneously. Surgery is used to remove the connection and usually entails removal of a section of bowel and a small bladder cuff. A separate tissue is then placed between the two structures to prevent refistulization.

Your pre-operative appointments

Before your surgery, you will be seen by the physician and the anesthesiologist, and when applicable, there is a pre-admission appointment with the hospital. Click here to read more details about these appointments, referred to as the Pre-Operative Work-Up.

Change In Health Status

Notify your surgeon if you experience any significant change in your health status: develop a cold, influenza, a bladder infection, diarrhea, or other infection, before your surgery.

Pre-Operative Medication Instructions

Unless specifically instructed otherwise by your surgeon or anesthesiologist, please observe the following guidelines for taking your medicines before surgery:

1. One Week Prior to Surgery:
   - STOP all aspirin and all aspirin-containing medicines (e.g., Anacin, Excedrin, Pepto-Bismol). Check any cold or pain medication bottles to make certain aspirin is not contained. See additional list at Blood Thinners.

2. Two Days Prior to Surgery:
   - STOP all nonsteroidal anti-inflammatory medications (e.g., etodolac [Lodine], fenoprofen [Nalfon], ibuprofen [Advil, Motrin, Nuprin], ketorolac [Toradol], maproxen [Aleve], meclofenarnate [Meclomen], mefenamic acid [Ponstel], naproxen [Anaprox, Naprosyn].

3. Day Before Your Surgery:
   Start the pre-operative Bowel Prep (cleansing procedure) appropriate for this surgery, as described below:

   Your procedure involves the bowel and therefore needs the most thorough cleaning protocol. It will be ordered by your physician and it may require hospital admission the day before.

   • Reglan 20mg Tablet, one tablet 1 hour before Golytely
     - To be taken every 1-2 hours if nauseated
   • 1 Gallon of Colyte or Golytely to begin no later than 4:00PM the day before surgery
     - Drink one cup every 15 minutes over 3-4 hours
   • 1or 2-Bottles of Magnesium Citrate if diarrhea is not clear
   • Ducolax 5 mg, take 4 tablets one hour after Golytely is finished
   • Neomycin 500mg, take 2 tablets at 8:00PM, 9:00PM and 12:00 Midnight
     -If surgery is in the afternoon, take 2 tablets at 7:30 AM the day of surgery
   • Flagyl 500mg, take 1 tablet at 8:00PM, 9:00PM and 12:00 Midnight
     - If surgery is in the afternoon, take 1 tablet at 7:30 AM the day of surgery
   • Phenergan 25mg, take one tablet every 4 hours if nauseated
   • Restoril 30mg, take one tablet in the evening for sleep
   • Cefotetan 2gm IVPB, in the pre-op holding area
   • Gentamycin 100mg IVPB, in the pre-op holding area
   • Flagyl 1gm IVPB, in the pre-op holding area
   • 2-Fleets Enemas or Neomycin Enemas
     • Night before
     • Morning of the surgery

4. On the Morning of your Surgery:
   • DO NOT TAKE digitalis medicines (e.g., Crystodigin, Digoxin, Lanoxin).
   • DO NOT TAKE oral antidiabetes medicines (e.g., chlorpropamide [Diabinese], glyburide [DiaBeta, Glynase, Micronase], glypizide [Glucotrol], tolazamide [Tolinase], tolbutamide [Orinase].
   • DO TAKE one-half of your usual morning. INSULIN dose. DO NOT TAKE your morning INSULIN dose if you are driving a great distance the morning of surgery or if your surgery is scheduled for the afternoon.
   • DO TAKE, with a small sip of water, ALL of your other usual morning doses of regularly prescribed medicines. Use your asthma inhalers and bring them with you to the hospital.

Pre-Operative Diet Instructions

Unless specifically instructed otherwise by your surgeon or anesthesiologist, patients of all ages must observe the following diet restrictions before surgery:

1. Eight hours before the Scheduled Start of your Surgery:
   DO NOT EAT any solid foods, including juices with pulp (e.g., orange juice, nectars), lozenges, candy, chewing gum, and mints. DO NOT DRINK full liquid, such as milk, cream, and jello. You may continue to drink up to eight ounces of clear liquids until SIX hours before the scheduled start of your surgery. Clear liquids include Water, clear juices (e.g., apple, grape), black tea and black coffee.
2. Six hours before the Scheduled Start of your Surgery:
   DO NOT TAKE anything by mouth except for your usual medicines; follow the Preoperative medication instructions above.
3. Exceptions:
   DO NOT TAKE anything by mouth for eight hours, except for your usual medicines, if you are pregnant, morbidly obese, or are diagnosed with diabetes, renal failure, or stomach acid reflux with heartburn.

Patients undergoing operative or diagnostic procedures involving sedation are required to refrain from eating, drinking or taking anything by mouth for a stated period prior to their surgery or procedure. The reason for this is to prevent complications caused by nausea or vomiting while you are unconscious. Should you vomit while in the unconscious state, the risk exists that the vomit may enter into your lungs causing serious complications such as pneumonia. These complications may result in an extension of your hospitalization following your surgical procedure. It is for this reason patients are often instructed to have nothing by mouth after midnight the night prior to your operation unless otherwise instructed by an anesthetist.

Pre-Operative Cleaning Instructions (bathing and showering instructions)

Pre-operative showers are to be taken the night before and the morning of surgery just prior to your arrival. All adults are required to take a shower using either a Betadine or Hibiclens Surgical Scrub antibacterial soap. The reason is to remove as much bacteria from your skin as possible prior to your surgery. If you are allergic to these products please notify your physician or nurse. Perform your shower as follows:

1. Generously lather your body, scrub well, and rinse. Give particular attention to the area were the incision will be made for your procedure.
2. Following the morning shower, do not apply creams, body oils, lotions, perfumes, deodorants, makeup, lipstick, nail polish or any other cosmetic product to the skin or nails.
3. Do not use Hibiclens on your face. You may use any other antibacterial soap for the face.
4. Children under 5 years of age are to be given a bath using an over the counter antibacterial soap.

On The Day Of Surgery

• Take your medicines as instructed above.
• You may brush your teeth; rinse your mouth, but do not swallow the water.
• Leave all jewelry (including wedding and all other rings) and valuables (including money and credit cards) at home.
• If you wear contact lenses, glasses or hearing aids, please bring a case or container, and solution for contacts, to protect them while you are in surgery.
• Wear a minimum amount of makeup, and no mascara. Please remove the nail polish from both index fingers.
• Please bring a copy of your current medical problem list from you primary care physician (family medicine/internist).
• Minors (anyone less than 18 years old) must be accompanied by a parent or legal guardian to sign the operative consent fount

The anesthesiologist will discuss with you the anesthetic most appropriate for your medical condition and procedure prior to surgery.

After your surgery you must be escorted/driven home by a responsible adult. You may take a taxi car or shuttle if accompanied by a responsible adult who can stay with you after the driver departs.

Time To Arrive For Your Surgery

During your Pre-Admission Interview, our Registered Nurse will provide you with the correct time to arrive for check-in prior to your surgery.

ARRIVAL TIME:
WHERE TO ARRIVE:

The risks and complications for this surgery are described in the "Counseling and Pre-Op Note" that you will need to sign before the surgery. The main content of that note is listed below.

Indications:

Patient is a male/female with inflammatory bowel disease, diverticulitis, colon cancer or previous abdominal surgery that was diagnosed with a vesicle fistula to either small bowel or colon noted on CT scan/cystoscopy/barium enema/ small bowel follow through.

Alternatives:

Options include prolonged complete urinary diversion (Foley catheter, suprapubic catheter or bilateral percutaneous renal drainage) and/or complete bowel rest with total parenteral nutrition with observation.

Risks/Complications:

The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.

The specific risks of this procedure include, but are not limited to: bowel anastomosis leakage, peritonitis, abscess, sepsis, bowel obstruction, ileus, failure of the procedure with additional corrective surgeries may be necessary, damage to ureter requiring stent placement/removal at a later date with cystoscopy or reconstructive surgery and prolonged catheterization of the bladder,

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.

To view the actual printable form for this surgery, click here: Counseling Note for Vesicoenteric Fistula Repair. To print the document, simply select print after you have opened the page. You can use that copy to sign before your surgery.

Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary.

Indications: Patient with a Vesicoenteric fistula

Sample Procedure Dictation:

Patient was given a continuous epidural anesthetic with supplemental general anesthesia. He was placed in the supine position and then was prepped and draped in the usual standard sterile fashion. A 24 French Foley catheter was placed per urethra with good return of urine; balloon was inflated to 30 cc with sterile saline. A midline incision was made from the below the umbilicus to the symphysis pubis coagulating all bleeders as they where encountered. The rectus fascia was divided the length of the incision. The Space of Retsius was developed bluntly to expose the bladder and obturator fossa. The obturator lymph nodes were palpated. All nodes were normal in character and not sent for frozen section. All bleeders and lymphatics were bovied or clipped as they were encountered. The bladder was then entered in a vertical manner from the dome to the bladder neck with bovie coagulation, using 0-chromic stay sutures for traction. The ureteral orifices were noted to be intact with good efflux. A 2-0 vicryl suture was placed at the apex of the incision at the bladder to prevent tearing of the bladder neck, this suture was tagged with a clamp and used to start the closure of the bladder later in the case. The ureters were intubated with 5 Fr feeding tubes to avoid injury of the ureters during the ileal bowel resection. The Vesicoenteric fistula could be identified easily. The pre-peritoneal space was identified, and the peritoneum was entered taking care to avoid any injury to the bowel. We then placed a Buckwalter self-retaining retractor to expose the abdominal cavity. The ileum was inspected and the area of induration and fistula was identified. The bladder fistula and 1 cm of normal margin were resected using the bovie. The bladder and the ileal segment were separated easily and the bladder defect in the area of the resected fistula was closed in a two-layer fashion using running 2-0vicryl sutures after the ureteral stents were removed. A 24 Fr three-way hematuria catheter was placed per urethra and the balloon was filled with 10 cc of normal saline. The vertical bladder incision was closed in a two-layer fashion with running 2-0 vicryl sutures. The bladder was then filled with normal saline by gravity and checked for leakage. The areas of leakage were closed with figure eight 2-0 vicryl sutures until no leakage occurred at a 350 cc volume. A 10mm Jackson-Pratt drain was placed through a separate stab incision in the pelvis. The operative site was inspected for possible bleeders, which were clipped if found.

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This fistula tract and the surrounding induration necessitated a bowel resection. Approximately 10 cm of Ileum proximal to the ileocecal valve and bounding the area of the fistula tract was tagged with 3-0 GI silk sutures. The mesentery was then delicately dissected from the ileum near the sutures to allow a GIA stapler to be placed. The mesentery was then incised in a sequential manner using Kelly clamps and 3-0 silk free ties. Large feeding vessels were avoided during this process to avoid vascular compromise. The wound was then draped off with sterile towels and the bowel segment was then divided using the GIA stapler. This segment of involved ileum was then removed and sent for permanent section analysis. The two remaining ends of the ileum were then re-anastomosed using the GIA/TIA stapler in a standard side-to-side manner. The staple line was then reinforced and everted with 3-0 silk sutures. The anastomosis was inspected with bowel contents milked through without leakage. The mesentery was closed with 3-0 vicryl sutures to prevent internal herniation.

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or
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The fistula tract and surrounding induration of the ileum did not necessitate a bowel resection. The fistula tract was excised and the ileum was primarily closed with a two-layer closure with 3-0 vicryl and 2-0 GI silk sutures to imbricate the first layer closure. ---------------

A segment of omentum was mobilized and placed between the bladder and bowel closures to prevent re-fistulization. The abdomen was irrigated with 2 liters of Ancef irrigation fluid. The fascia was then closed in a running fashion with #2-vicryl suture. The subcutaneous tissue was irrigated with saline and the skin was closed with staples. Xerofoam gauze was placed over the incision and bandaged. The JP drain was secured with 3-0 nylon sutures to the abdominal wall. These and the Foley were securely tapped. The Foley was set-up with CBI at a rate of 150cc/hr. The patient was then awaken from anesthesia without complications and transferred to the Recovery Room (RR). The patient arrived to the RR in stable condition and without complications.

To the family and friends of patients undergoing surgery.

SCHEDULED STARTING TIME OF SURGERY:

ESTIMATED LENGTH OF SURGERY:

You should plan to check in at the waiting area information desk as soon as your family member or friend has left for the Operating Room. This is the only way we can talk to you afterwards, or on occasion; reach you to give you updates on the operation's progress. If the surgery is scheduled for many hours, you can leave to eat or do other things, but you should let the information desk know that you are going to leave the area, where you are going, and how long you might be gone so that we might reach you if need be. You should be in the area before the elected time of the end of the operation.

The information deck will overhead page you or the "family of" when they receive the recovery call to let you know that the surgery has been completed. The overhead page system works ONLY on the Surgical Waiting Area and not throughout the hospital or the cafeteria.

We will plan to see you in the surgical waiting area after we have safely completed the early phases of the post-anesthesia recovery in the "Recovery Room" or PAR (Post Anesthesia Recovery). This may take up to an hour after the initial call. Sometimes, especially if another case is ready to start, we will call and talk to you. If for some reason, we have not come or called within 30 minutes, please ask the information desk to page us.

Your family member will be in the Recovery Room for 1-2 hours. This is standard recovery time, although the times vary with each individual. For example, spinal anesthetics take longer to "wear off," local anesthetics are much shorter acting. Under no circumstances are family members or friends allowed in the recovery room. The information deck will inform you of the patient's return to the room as soon as they receive the information that the patient has left recovery. At that time, they will give you the room number and direct you to the correct wing and floor.

Activity

1. No heavy lifting (more than 15 lbs.) for 4 weeks (1 week for an implant).
2. No driving for 3 weeks (1 week for an implant). We also discourage riding in a car since the vibrations and movement may cause bleeding.
3. Use the stairs infrequently. Take one step at a time, and have assistance available.
4. No long trips for 3 weeks.
5. No cutting the lawn, shoveling snow, raking leaves, etc., for 4 weeks.
6. No sexual activity for 6 weeks after surgery.
7. No manipulation of the prosthesis
8. Showers after the bandages are removed (48 hrs) are okay. It is okay to wash the wound, do not rub the wound just pat dry it. Avoid tub baths or swimming in a pool for 1 week.
9. Regular light activity is encouraged several times daily. We encourage walking. Do not be a couch potato.
10. If discomfort returns then reduce activity, take it easy, and more gradually resume activities.

Diet

1. Drink plenty of fluids. We recommend 24-32 oz over your usual daily fluid intake. Limit fluids after 6 PM. Avoid tea, coffee (including decaf) and pop.
2. Resume a regular diet at home. Take high calorie supplements if appetite is poor.
3. If you have a special diet secondary to Diabetes, Renal Disease, Liver Disease, etc. you may resume eating when tolerated.

Medication

1. Please take the medications as prescribed by your doctor. Start them on day of discharge, and please complete the entire prescription. Take pain medication only as needed. Try Tylenol or Motrin for milder pain. You will typically be discharged with your old medications and new pain medication, antibiotics and stool softeners
2. Resume all medications you normally took before surgery, unless instructed otherwise. Do not take blood thinners or aspirin products for 1-2 weeks or as directed.
3. If there is a problem taking or getting the medication, call us.

Catheter and Wound Care

1. Do not remove the dressing from the wound unless instructed. If you are home with a bandage, it is usually removed after 48 hrs.
2. Your sutures will dissolve over time and do not need to be removed. Your steri-strips will fall off over a two-week period; please let them fall off on their own rather than removing them. You can trim the edges of the steri-strips that have rolled up onto themselves if they bother you.
3. You may cover the wound with gauze if there is mild drainage.
4. If the wound becomes red, inflamed, or has excessive drainage, please contact your doctor immediately.
5. If you notice pus coming from any wound, please call your physician.
6. Expect some spotting or bleeding from your incision for the next 1-week, if it progressively worsens then please call your physician.
7. If you have a catheter in place, wash around it gently with soap and water. Keep the catheter taped to your thigh or abdomen to avoid inadvertent jerking or pulling. Do not disconnect the catheter from the drainage bag unless directed by your doctor. You may apply Bacitracin ointment at the point the catheter enters your body.

Bowel Movements

1. Do not strain when having a bowel movement. Expect irregular bowel habits after surgery until fully recovered. Increase fiber in your diet.
2. You may need to use a stool softener or laxative. Try Colace (Docusate Sodium), Metamucil or Milk of Magnesia at your local pharmacy.

When to Contact your Doctor

1. Excessive bleeding or passage of large clots. Also if you feel your bladder is not draining or if you are unable to urinate.
2. Fevers greater than 101º F, excessive chills.
3. Nausea and vomiting or inability to keep down fluids.
4. If you have any questions or concerns that are not covered by this handout.
5. Significant tenderness or swelling in the legs, chest pain, shortness of breath.
6. If it is a serious emergency, go the Emergency Room or call 911.
7. Please call the office to arrange your follow-up appointment.

Contacting Your Physician

Dr. Bauer can be contacted by calling the number listed at the top of the page. You may also call the hospital to have them contact us. Please do not hesitate to call with any questions or concerns.

Frequently Asked Questions after surgery

This section is under construction.