Case Study: Robotic-Assisted Surgery to Repair Colovesical Fistula

A 60-year-old male underwent robotic-assisted colorectal surgery at UPMC Montefiore in April 2025.

Back in July 2024, the Somerset County resident presented with fecaluria (he was passing stool in his urine). He saw his local doctor and underwent a CT scan, cystoscopy, colonoscopy, and a visit with a general surgeon before receiving his diagnosis of a colovesical fistula, which is an abnormal connection between the colon and the bladder.

“These fistulas put you at risk for urinary tract and chronic infections and should be repaired, says Kellie E. Cunningham, MD, a surgeon and robotic-assisted surgery lead in the UPMC Division of Colon and Rectal Surgery.

The patient’s colonoscopy helped determine the cause was likely diverticular related and not due to a mass or cancer. The patient wanted surgery close to home and underwent his initial procedure with Taesun Moon, DO, general surgeon, at UPMC Somerset.

Dr. Moon needed to perform an open-style surgery since the patient’s sigmoid colon was very inflamed and abnormal, and there was also murky abdominal fluid. The surgeon resected the diseased part of the patient’s intestine and gave him a colostomy bag. During the procedure, a urologist found and repaired the connection to the bladder.

The patient had an indwelling stent and foley catheter for a few weeks. During recovery, he was admitted back to the hospital with complications from a pelvic abscess. He received antibiotics and his ureteral stent was removed.

In January 2025, the patient wanted his colostomy bag reversed. Dr. Moon performed an endoscopy to make sure his colon and rectum were healthy. After the procedure, the patient noted that he was passing air in his urine, which was suspicious for a recurrent fistula between his bladder and bowel.

Advanced Colorectal Surgery in Pittsburgh

Dr. Moon referred the patient to Dr. Cunningham in Pittsburgh, where she performed a flexible sigmoidoscopy to evaluate his rectum for length and quality of the tissue.

“The results of this office-based procedure dictate if the rectum is healthy for a reconnection and if I should counsel the patient regarding a possible temporary loop ileostomy as part of the colostomy closure surgery,” she says.

Later that day, the patient was passing air in his urine again.

“That was even more evidence that something wasn’t quite right,” adds Dr. Cunningham, who scanned him and found radiographic evidence of a connection between the patient’s rectal stump and his bladder.

The patient now had two problems: a recurrent colovesical fistula and an end colostomy that he wanted reversed. Dr. Cunningham recommended a robotic-assisted surgical approach to address both.

“I've been doing these robotic-assisted minimally invasive operations for several years. Being able to complete these robotically depends on how much adhesive disease is left over from the first procedure, how much space there is to work, and if you can recognize normal anatomy without challenges. If any of those factors are in play, it's safer to do an open procedure,” says Dr. Cunningham, who also recommended the procedure for faster healing.

She performed the robotic-assisted surgery, beginning with five poke-hole incisions. Dr. Cunningham revised the patient’s rectum, resecting the rectal stump dehiscence, which had caused the recurrent fistula. A urologist also assisted to assess the patient’s bladder and insert ureteral stents.

Due to copious inflammation in his pelvis and the need to perform a low rectal transection to correct the fistula, Dr. Cunningham elected to divert him with a temporary ileostomy, which he will have for about three months.

The Benefits of Minimally Invasive Colorectal Surgery

“Healing for him is going to be remarkably different than his open procedure,” says Dr. Cunningham. “In addition to expedited wound healing, minimally invasive surgery has many benefits, including expedited recovery and decreased hernia and infection risk.”

The patient is a machinist who does heavy lifting.

“With a laparotomy incision, we must give patients eight-week restrictions on heavy lifting but with minimally invasive procedures, the restraint gets lifted far sooner and there’s less of a hernia risk,” says Dr. Cunningham. “Hopefully, he can go back to work sooner.”

To refer a patient or learn more about the UPMC Division of Colon and Rectal Surgery, call 412-647-1705.