Fistulous Complications Following Radical Cystectomy for Bladder Cancer: Analysis of a Large Modern Cohort: Beyond the Abstract

Fistula formation is a rare and poorly described complication following radical cystectomy (RC) with urinary diversion. Given the relative paucity of information available in the literature on these complications, we sought to identify patients who experienced any type of fistulous complication and analyze the risk factors for formation as well as their management outcomes.

We performed a retrospective review of 1041 patients who underwent RC for bladder cancer at our institution. Patients who experienced fistulae of any type were identified, and risk factors, management strategies, and outcomes were analyzed. Patients underwent initial conservative management and those who failed underwent surgical repair. We performed analyses to identify predictors of fistula formation as well as the need for surgical repair.

Thirty-one (3%) patients experienced fistula formation, with a median time to fistula presentation of 31 days. Entero-diversion was the most common fistula type (55%), followed by entero-cutaneous (29%), and diversion-cutaneous (13%). On multivariable analyses, a history of radiation therapy (OR 3.1, p = 0.03) and orthotopic neobladder (OR 3.1, p = 0.04) were both predictors of fistula formation. Conservative management without surgical repair was successful in 42% of patients. There were no predictors of failing conservative management. Of those requiring surgical repair, success was achieved in a single operation in all but one (94%).

Our series looked at fistulous complications in a more in-depth fashion than prior studies. While the occurrence of fistulae was higher in our series (3%) than reported in the literature (0.3-2.6%), in our opinion, this is simply explained by a few key factors:

1) First, and maybe most importantly, many authors report 30- or 90-day complication rates while we reported on a cohort with a median follow-up of 11.4 months. This has significant implications on the observation rate of this rare complication, as 10 (~32%) of our patients who experienced fistula formation did so after 90 days, and three (~10%) after one year.
2) Second, we reported on fistulae of all morphologies and involving all urinary diversion types, while many previous reports have looked only at fistulae involving small bowel and orthotopic neobladders. This broadened definition captures a larger group of complications that may not be included in a standard investigation (including entero-diversion, entero-cutaneous, diversion-cutaneous, diversion-vaginal, entero-vaginal, colo-vaginal, colo-diversion, and uretero-enteric).
3) Lastly, the heterogeneous nature of fistulous complications, as outlined above, limits standardized reporting in institutional or national datasets.

For these reasons, we believe that fistulous complications are underreported and occur in “the real world” more frequently than the literature would lead one to believe.

In summary, fistulous complications are rare after RC. They generally occur within the first few months after the procedure, and are most commonly between the urinary diversion and small bowel. A history of abdominopelvic radiation therapy and an orthotopic neobladder are risk factors for fistula formation. While there are no identifiable risk factors for those who fail conservative management, surgical repair of fistulae is generally met with a high success rate in a single operation.

Written By: Zachary L. Smith, M.D. The University of Chicago Medicine Department of Surgery, Section of Urology @ZacharySmithMD Email:

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