Diverticular disease, particularly affecting the sigmoid colon, poses a challenge for 10%–25% of individuals with this condition (1, 2). Complications arise in about 15% of diverticular disease cases (3–5). Among the management options for these complications, laparoscopic colectomy has become the leading choice globally for addressing symptomatic sigmoid diverticulitis (6–9).

One significant complication associated with diverticular disease is the occurrence of colovesical fistulas (CVFs) (Figure 1) happening in 4%–20% of cases and representing a substantial majority, around 60%–70%, of all CVF instances (10, 11). The causes of these fistulas are complex, involving the direct extension of a perforated diverticulum or erosion through the bladder wall (12, 13). This complexity is further influenced by the anatomical intricacies of the pelvis, physiological functions, and the distinct pressure gradient between the bowel and the bladder (14).

Clinical symptoms often manifest as lower urinary tract issues, with patients reporting problems such as pneumaturia, fecaluria, and recurrent urinary tract infections. These symptoms highlight the intricate pathological mechanism involved in CVF development (15). Traditionally, CVFs were considered a historical contraindication to minimally invasive approaches due to concerns about safety and feasibility (10). However, recent reports, such as those by Badic et al. (11), challenge this belief, emphasizing the safety and feasibility of laparoscopic management, even though there are higher conversion rates and associated morbidity.

Despite the growing literature on laparoscopic management of CVFs, there is still a significant gap in our understanding of the actual effectiveness and utility of the minimally invasive approach compared to open surgery (16). Adding to this challenge, recent studies may lack definitive conclusions as they often include a diverse group of patients with CVFs of varying causes, failing to distinguish between those secondary to diverticular disease and those arising from different factors (16).

This report aims to address these knowledge gaps by focusing on evaluating the adequacy and utility of laparoscopy in treating CVFs complicating diverticular disease, directly comparing it to open surgery. By examining this specific group of patients, our goal is to provide nuanced insights that can guide clinicians and surgeons in optimizing their approach to these intricate cases.

Between 2010 and 2020, 76 patients (29 males, 46 females) underwent surgery for colovesical fistula secondary to complicated diverticulitis. Of these, 40 underwent laparoscopic surgery (Group B), and 36 had open surgery (Group A). Most patients presented with pathognomonic signs of CVF.

Refer to Table 1 for an overview of demographic data. Comprehensive details on patient demographics are provided in Table 2.

In the realm of laparoscopic interventions for colovesical fistulas (CVF) complicating diverticular disease, our in-depth investigation emerges as a cornerstone, assuming even greater significance when situated within the broader landscape of existing research. The synthesis of insights from various studies, coupled with the recent systematic review by Cirocchi et al. (17), establishes a comprehensive foundation. Moreover, we incorporate crucial findings from three pivotal papers—by Badic et al. (11), N. L. Bertelson et al. (12) that not only enrich our understanding but also contribute essential perspectives to the ongoing discourse on this challenging condition.

Within our 76-patient cohort, evenly distributed between genders and categorized into Group A (undergoing open surgery) and Group B (undergoing laparoscopy), we robustly affirm the safety and efficacy of laparoscopy. Our emphasis on routine applicability in a homogeneous patient cohort underscores the potential versatility of the minimally invasive approach. Importantly, despite no significant differences in operative time, blood loss, and associated surgical procedures between the two groups, the laparoscopic approach showcases distinct advantages. These include reduced intraoperative blood loss (P = 0.04), diminished postoperative primary ileus (P = 0.003), lower postoperative morbidity (P < 0.0001), and a shorter median length of stay (P < 0.0001).

Crucially, our findings challenge historical perceptions regarding laparoscopy's time-intensive nature, with no significantly higher median operation times for laparoscopic resection compared to open surgery. The low conversion rate of 5%, notably lower than earlier studies, underscores the evolving landscape of laparoscopic techniques and the pivotal role of surgeon experience in mitigating conversion risks.

Cirocchi (17) and colleagues, through their systematic review, provide a panoramic view that likely encompasses diverse patient cohorts and procedural nuances across various studies. This collective evidence enriches our findings by offering nuanced insights into the evolving realm of laparoscopic interventions for CVF. Building upon this foundation, the insights presented by Badic et al. (11) in their paper, “Colovesical Fistula Complicating Diverticular Disease: A 14-Year Experience,” contribute a valuable 14-year experience in managing CVF. Their extensive retrospective analysis sheds light on long-term trends, challenges, and outcomes associated with laparoscopic interventions, thereby significantly broadening the temporal understanding of laparoscopic management for CVF.

Additionally, N. L. Bertelson et al.'s work in “Diverticular Colovesical Fistula: What Should We Really Be Doing?” (12) introduces a nuanced perspective on the current state of managing diverticular colovesical fistulas. By delving into the question of optimal practices, this paper addresses key considerations that not only inform but also complement our study. This valuable insight into the ongoing discourse on best practices enhances our understanding of how our findings align or diverge from current approaches. This multifaceted approach, incorporating insights from Cirocchi et al. (16), Bogdan Badic et al. (11), N. L. Bertelson et al. (12), contributes to a more comprehensive and nuanced understanding of laparoscopic interventions for CVF.

Delving into the systematic review by Cirocchi et al. (16), reveals a more nuanced exploration of parameters such as operative time, blood loss, conversion rates, and postoperative outcomes. By comparing our specific findings with this broader evidence base (18), a more comprehensive and nuanced understanding of laparoscopic benefits may emerge, thereby enhancing the applicability of these techniques in diverse clinical contexts.

The historical trajectory of laparoscopic resection for diverticular fistulizing disease, initiated in 1994 by Puente et al. (25). And subsequently reported by Hewett et al. (26) in 1995, underscores the initial challenges faced. Despite early promising experiences, the use of a mini-invasive technique for CVF caused by diverticular disease encountered obstacles due to the longer operative times of laparoscopy compared to open surgery and the high conversion rate (up to 60% in certain series) attributable to fibrosis and/or severe inflammation (16–32).

Our present study represents the largest series of laparoscopically treated CVF to date, distinguishing itself by exclusively including patients affected by CVF secondary to diverticular disease. Notably, there are few reports in the literature focusing exclusively on CVF by diverticulitis (33, 34), with most published studies encompassing fistulas of mixed etiology (35) or mixed diverticular fistula (16).

Furthermore, the inclusion of patients who were not previously selected, with a significant percentage (57.8%) having undergone previous abdominal operations, adds a real-world dimension to our study. The recent review by Keady and co-worker (10) on morbidity and mortality in the surgical management of CVF reported variable rates across studies. In our series, we observed an overall morbidity of 14.9%, significantly higher in the open surgery group. Remarkably, mortality was zero in the laparoscopic group, attributed to the high volume of laparoscopic operations performed and the adherence to standardized procedures by the same surgeons.

In contrast to previous reports (10, 11–34), the median operation time for laparoscopic resection for CVF was not significantly higher than the time for open surgery. Notably, the low conversion rate of 5% in the present cohort, considerably lower than rates reported in previous studies (10–16), reflects the evolving experience of surgeons and advancements in surgical techniques. Conversion was necessary in two patients due to severe fibrosis, impeding safe dissection. One of these patients presented with a concomitant colovaginal fistula, highlighting the complexity of cases. Engledow et al. (36) reported different rates of conversion over a period of 10 years (64% vs. 29%) based on surgeon experience. Accordingly, Kockerling et al. (37) concluded that laparoscopy, for fistulizing diverticular disease, should only be carried out by experienced laparoscopic surgeons.

The advantages of the laparoscopic approach in terms of intraoperative blood loss (P = 0.04), postoperative primary ileus (P = 0.003), and median hospitalization (P < 0.0001) further underscore its potential to offer the benefits of minimally invasive surgery to patients with CVF due to diverticular disease. This reaffirms and extends the findings proposed in previous studies (10–17).

In summary, our study, interwoven with insights from pivotal research and guided by a robust patient cohort, contributes significantly to the evolving discourse on laparoscopic interventions for CVF complicating diverticular disease. Through a comprehensive exploration of historical challenges, contemporary advantages, and nuanced comparisons, our findings provide valuable considerations for future research and clinical practice in the management of this challenging condition.

In the crucible of limitations, our study emerges unyielding, a force challenging the status quo in laparoscopic interventions for colovesical fistulas complicating diverticular disease. Amidst the retrospective constraints, our findings act as a catalyst for change, daring the medical community to break free from tradition. We beckon towards a future where innovation trumps limitations, urging a paradigm shift in the approach to colovesical fistula treatment.