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Pyeloenteric Fistula Repair

For causes and diagnostic evaluation, see Pyeloenteric Fistula. These rare communications require an individualized plan based on renal function, obstruction, infection, bowel condition and operative fitness. Much of the procedure-specific literature consists of case reports and historical reviews; it does not support a fixed reconstructive algorithm or reliable pooled cure estimate.[2][5][6]

Stabilization and Planning​

Control sepsis and drain infected/obstructed systems promptly. Nephrostomy and/or ureteral stenting can decompress the collecting system, define anatomy and support kidney preservation. Manage fluid and electrolyte losses and provide nutritional support according to the patient's intake and gastrointestinal function. Parenteral nutrition is an option when needed, not an obligatory treatment for every pyeloenteric fistula.[1][3][16]

Plan with urology and the relevant gastrointestinal/colorectal team. Establish the bowel segment involved, remaining renal function, stone/obstruction burden, collections and possible malignancy. Diversion, reconstruction and nephrectomy should each have a defined purpose.[2]

Shackley's ten-patient complex entero-urinary referral series used staged drainage, sepsis/nutritional recovery and reconstruction. All fistulae were controlled, but only four patients had functional restoration and six required gastrointestinal and/or urinary diversion. Its mean five-month interval to reconstruction was descriptive. Neither this series nor an enterocutaneous-fistula study defines a mandatory four- or five-month wait for a renal-pelvis fistula, especially with uncontrolled infection.[1][4]

Selecting the Operation​

SituationReconstructive considerations
Severely damaged or nonfunctioning infected kidneyNephrectomy with bowel repair may provide source control when preservation is unsuitable. Historical spontaneous pyeloduodenal cases commonly involved chronic inflammatory renal disease.[5][6]
Useful renal function and correctable obstructionConsider urinary diversion followed by reassessment; selected patients may undergo fistula separation and renal-pelvis/bowel reconstruction. Stenting has been reported as an alternative to nephrectomy.[7]
Diseased bowel requiring resectionTreat the underlying bowel pathology and repair/reconstruct the urinary defect according to viability and anatomy; choose anastomosis or diversion according to contamination and operative risk.
Suspected malignancyStage the tumor and select the appropriate oncologic operation; a fistula is not itself a reason to prescribe simple or radical nephrectomy without defining tumor origin and extent.[13]
Prohibitive operative riskDrainage and selected endoscopic treatment may be considered after source control, with explicit contingency planning and acknowledgment of the limited evidence.[3][8]

Nephrectomy with Bowel Repair​

When nephrectomy is appropriate, define the relationship of the kidney, inflammatory mass and bowel before dividing the communication. Preserve healthy bowel where possible, assess the defect and repair or resect it according to tissue viability. Drain infected spaces and consider vascularized interposition when the separation or tissue quality warrants it. Closure method, number of layers and flap use are operative choices, not comparative-evidence requirements for every case.[5][6]

The classic 1983 review included 28 pyeloduodenal cases and favored nephrectomy with duodenal closure. That historical recommendation should be interpreted alongside remaining kidney function and later reports of successful kidney preservation.[5][7]

Kidney Preservation and Endoscopic Options​

  • Ureteral stent / nephrostomy: assess whether drainage adequately controls the leak and infection, then reassess the tract and underlying obstruction. A historical 40-patient upper-tract fistula series achieved success in 28 patients, but included several etiologies; 70% is not a pyeloenteric-specific closure rate.[7][14]
  • Endoscopic closure from the bowel side: Lee reported one debilitated patient treated with two sessions of clipping/endoloop ligation plus antibiotics and urinary drainage; contrast no longer leaked before discharge on day30. This is feasibility evidence, not a general alternative of proven equivalence to surgery.[3]
  • Percutaneous tract fulguration: Kim reported one successful case, assessed at six and 18 weeks. Tissue injury, urinary/enteric obstruction and ongoing infection need consideration; the report does not define a routine indication or energy protocol.[8]

Clips, suturing and sealants used for gastrointestinal defects require suitable tissue and drainage of associated cavities. Broader GI literature cannot establish pyeloenteric success rates or justify closing a tract over an undrained infection.[9][10]

Evidence and Follow-up​

Keep adjacent populations separate. Chen's Crohn's entero-urinary surgical cohort described urinary symptoms and bladder repair, while Ferguson studied bladder management after bowel resection. Their symptom-response and Foley-only findings do not establish treatment for a renal-pelvis defect.[11][12] Likewise, Bannon's 100-patient enteric/colonic reconstruction series and Owen's 153-patient enterocutaneous series cannot supply pyeloenteric cure rates or operative timing thresholds.[4][15]

Follow recovery of renal function, infection, drainage and nutritional status, and document anatomical closure when removing supportive drainage or when symptoms persist. A quiet tract alone does not establish unobstructed renal drainage. Long-term management also addresses the original stone, inflammatory or malignant disease.[2][14]

References​

1. Shackley DC, Brew CJ, Bryden AA, et al. "The staged management of complex entero-urinary fistulae." BJU Int. 2000;86(6):624–629. doi:10.1046/j.1464-410x.2000.00871.x

2. Yu NC, Raman SS, Patel M, Barbaric Z. "Fistulas of the genitourinary tract: a radiologic review." Radiographics. 2004;24(5):1331–1352. doi:10.1148/rg.245035219

3. Lee KN, Hwang IH, Shin MJ, et al. "Pyeloduodenal fistula successfully treated by endoscopic ligation without surgical nephrectomy: case report." J Korean Med Sci. 2014;29(1):141–144. doi:10.3346/jkms.2014.29.1.141

4. Owen RM, Love TP, Perez SD, et al. "Definitive surgical treatment of enterocutaneous fistula: outcomes of a 23-year experience." JAMA Surg. 2013;148(2):118–126. doi:10.1001/2013.jamasurg.153

5. Rodney K, Maxted WC, Pahira JJ. "Pyeloduodenal fistula." Urology. 1983;22(5):536–539. doi:10.1016/0090-4295(83)90237-6

6. Gentile PA, Gualtieri L, Izzo S, et al. "Une liaison dangereuse: spontaneous pyeloduodenal fistula." Dig Dis Sci. 2023;68(4):1106–1111. doi:10.1007/s10620-023-07828-1

7. Desmond JM, Evans SE, Couch A, Morewood DJ. "Pyeloduodenal fistulae: a report of two cases and review of the literature." Clin Radiol. 1989;40(3):267–270. doi:10.1016/s0009-9260(89)80194-1

8. Kim SC, Weiser AC, Nadler RB. "Nephroenteric fistula treated with fulguration of the fistulous tract." J Endourol. 2000;14(5):443–445. doi:10.1089/end.2000.14.443

9. Willingham FF, Buscaglia JM. "Endoscopic management of gastrointestinal leaks and fistulae." Clin Gastroenterol Hepatol. 2015;13(10):1714–1721. doi:10.1016/j.cgh.2015.02.010

10. Cereatti F, Grassia R, Drago A, Conti CB, Donatelli G. "Endoscopic management of gastrointestinal leaks and fistulae: what option do we have?" World J Gastroenterol. 2020;26(29):4198–4217. doi:10.3748/wjg.v26.i29.4198

11. Chen Y, Cao L, Qiu J, et al. "Surgical management and outcome of entero-urinary fistula complicating Crohn's disease: a single center study." World J Surg. 2023;47(12):3365–3372. doi:10.1007/s00268-023-07196-x

12. Ferguson GG, Lee EW, Hunt SR, Ridley CH, Brandes SB. "Management of the bladder during surgical treatment of enterovesical fistulas from benign bowel disease." J Am Coll Surg. 2008;207(4):569–572. doi:10.1016/j.jamcollsurg.2008.05.006

13. Chen CH, Cheng HL, Tong YC, Pan CC. "Spontaneous pyeloduodenal fistula: an unusual presentation in advanced renal transitional cell carcinoma." Urology. 2002;60(2):345. doi:10.1016/s0090-4295(02)01749-1

14. Maillet PJ, Pelle-Francoz D, Leriche A, Leclercq R, Demiaux C. "Fistulas of the upper urinary tract: percutaneous management." J Urol. 1987;138(6):1382–1385. doi:10.1016/s0022-5347(17)43648-2

15. Bannon MP, Heller SF, Rivera M, et al. "Reconstructive operations for enteric and colonic fistulas: low mortality and recurrence in a single-surgeon series with long follow-up." Surgery. 2019;165(6):1182–1192. doi:10.1016/j.surg.2019.01.020

16. Kumpf VJ, de Aguilar-Nascimento JE, Diaz-Pizarro Graf JI, et al. ASPEN-FELANPE Clinical Guidelines: Nutrition Support of Adult Patients With Enterocutaneous Fistula. JPEN J Parenter Enteral Nutr. 2017;41:104–112. doi:10.1177/0148607116680792. Nutritional route evidence concerns ECF, not a validated pyeloenteric protocol.