Impact of bladder repair on postoperative outcomes in the surgical management of colovesical fistula: a systematic review and meta-analysis [version 1; peer review: awaiting peer review]

Дата публикации: 04-08-2026 07:51:21

Background Colovesical fistula is the most common type of enterovesical fistula and is associated with significant morbidity. Surgical management typically involves resection of the diseased bowel, with or without bladder repair. However, the necessity of routine bladder repair remains controversial. Methods A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. PubMed, Scopus, Web of Science, and the Cochrane Library were searched from inception to February 2026. Observational studies and case series including adult patients undergoing surgery for colovesical fistula were included. The primary outcome was postoperative urinary leak. A random-effects model was used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs). Results Twelve studies comprising patients with colovesical fistula were included. Meta-analysis of five studies demonstrated no significant difference in urinary leak between bladder repair and no repair groups (OR = 1.93, 95% CI: 0.42–8.81; I2 = 0%). Sensitivity analysis excluding mixed etiology studies showed consistent findings (OR = 2.02, 95% CI: 0.24–16.62; I2 = 10.6%). Fistula recurrence was rare across studies, while complications and length of hospital stay were variably reported and could not be pooled. Most studies had moderate risk of bias. Conclusions Bladder repair was not associated with reduced postoperative urinary leak in colovesical fistula surgery. A selective approach to bladder management may be sufficient in appropriately selected patients. Further prospective studies are needed to establish optimal surgical strategies.

Основное содержимое страницы с новостью.

Alshahrani SD, Al Shehri NK, Aboaly AM et al. Impact of bladder repair on postoperative outcomes in the surgical management of colovesical fistula: a systematic review and meta-analysis [version 1; peer review: awaiting peer review]. F1000Research 2026, 15:1284 (https://doi.org/10.12688/f1000research.186340.1)

Systematic Review

[version 1; peer review: awaiting peer review]

Saad Dhafer Alshahrani¹, Nora Khaled Al Shehri

https://orcid.org/0009-0007-1778-5122

², Ahmed Moustafa Aboaly

https://orcid.org/0009-0005-6940-6695

³, [...] Turki Saeed F Alshahrani⁴, Khaled Yahya A Hader

https://orcid.org/0009-0003-4923-5847

⁴, Hani Alasmari⁵, Razan Al-Hufayyan⁵, Hayam Almadani⁵, Zyad Khaloofah S. Alshehri⁵, Tasnim Abu Shaqah⁵, Ehab Sharyan

https://orcid.org/0009-0004-6297-1707

⁶, Feras Ibrahim A Alshehri⁷, Khalid Ali Bakri⁵, Atheer Ali Mobasher⁵

Saad Dhafer Alshahrani¹, Nora Khaled Al Shehri

https://orcid.org/0009-0007-1778-5122

², [...] Ahmed Moustafa Aboaly

https://orcid.org/0009-0005-6940-6695

³, Turki Saeed F Alshahrani⁴, Khaled Yahya A Hader

https://orcid.org/0009-0003-4923-5847

⁴, Hani Alasmari⁵, Razan Al-Hufayyan⁵, Hayam Almadani⁵, Zyad Khaloofah S. Alshehri⁵, Tasnim Abu Shaqah⁵, Ehab Sharyan

https://orcid.org/0009-0004-6297-1707

⁶, Feras Ibrahim A Alshehri⁷, Khalid Ali Bakri⁵, Atheer Ali Mobasher⁵

Author details Author details

¹ Department of Surgery, University of Bisha, Bishah, Aseer Province, Saudi Arabia
² Department of Urology, Aseer Health Cluster, Abha, Saudi Arabia
³ Intensive Care Unit, Armed Forces Hospitals Southern Region, Khamis Mushait, Aseer Province, Saudi Arabia
⁴ Faculty of medicine, King Khalid University, Abha, Saudi Arabia
⁵ Department of General Surgery, Aseer Central Hospital, Abha, Aseer Province, Saudi Arabia
⁶ Sana'a University Faculty of Medicine, Sana'a, Capital Municipality, Yemen
⁷ Batterjee Medical College for Sciences and Technology, Abha,, Aseer Province, Saudi Arabia

Saad Dhafer Alshahrani
Roles: Conceptualization, Data Curation, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Review & Editing

Nora Khaled Al Shehri
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Software, Validation, Visualization, Writing – Original Draft Preparation

Ahmed Moustafa Aboaly
Roles: Formal Analysis, Investigation, Methodology, Project Administration, Validation, Visualization, Writing – Original Draft Preparation

Turki Saeed F Alshahrani
Roles: Formal Analysis, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Writing – Original Draft Preparation

Khaled Yahya A Hader
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Software, Validation, Visualization, Writing – Original Draft Preparation

Hani Alasmari
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Visualization, Writing – Original Draft Preparation

Razan Al-Hufayyan
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation

Hayam Almadani
Roles: Data Curation, Investigation, Methodology, Project Administration, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation

Zyad Khaloofah S. Alshehri
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation

Tasnim Abu Shaqah
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation

Ehab Sharyan
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Resources, Software, Validation, Writing – Original Draft Preparation

Feras Ibrahim A Alshehri
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation

Khalid Ali Bakri
Roles: Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation

Atheer Ali Mobasher
Roles: Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS AWAITING PEER REVIEW

Abstract

Background

Colovesical fistula is the most common type of enterovesical fistula and is associated with significant morbidity. Surgical management typically involves resection of the diseased bowel, with or without bladder repair. However, the necessity of routine bladder repair remains controversial.

Methods

A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. PubMed, Scopus, Web of Science, and the Cochrane Library were searched from inception to February 2026. Observational studies and case series including adult patients undergoing surgery for colovesical fistula were included. The primary outcome was postoperative urinary leak. A random-effects model was used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs).

Results

Twelve studies comprising patients with colovesical fistula were included. Meta-analysis of five studies demonstrated no significant difference in urinary leak between bladder repair and no repair groups (OR = 1.93, 95% CI: 0.42–8.81; I² = 0%). Sensitivity analysis excluding mixed etiology studies showed consistent findings (OR = 2.02, 95% CI: 0.24–16.62; I² = 10.6%). Fistula recurrence was rare across studies, while complications and length of hospital stay were variably reported and could not be pooled. Most studies had moderate risk of bias.

Conclusions

Bladder repair was not associated with reduced postoperative urinary leak in colovesical fistula surgery. A selective approach to bladder management may be sufficient in appropriately selected patients. Further prospective studies are needed to establish optimal surgical strategies.

Keywords

Colovesical fistula, bladder repair, urinary leak, colorectal surgery, systematic review

Corresponding authors: Saad Dhafer Alshahrani, Nora Khaled Al Shehri, Ehab Sharyan, Atheer Ali Mobasher Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2026 Alshahrani SD et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Alshahrani SD, Al Shehri NK, Aboaly AM et al. Impact of bladder repair on postoperative outcomes in the surgical management of colovesical fistula: a systematic review and meta-analysis [version 1; peer review: awaiting peer review]. F1000Research 2026, 15:1284 (https://doi.org/10.12688/f1000research.186340.1) First published: 04 Aug 2026, 15:1284 (https://doi.org/10.12688/f1000research.186340.1) Latest published: 04 Aug 2026, 15:1284 (https://doi.org/10.12688/f1000research.186340.1)

Introduction

Enterovesical fistulas are abnormal communications between the gastrointestinal tract and the urinary bladder that are associated with significant morbidity, particularly due to recurrent urinary tract infections and urosepsis.¹^–³ Among these, colovesical fistula represents the most common subtype, most frequently involving the sigmoid colon because of its close anatomical relationship to the bladder.¹ Patients typically present with pneumaturia, fecaluria, and recurrent urinary infections, and in severe cases, the condition may progress to sepsis and renal impairment.⁴

Diverticular disease is the leading cause of colovesical fistula, accounting for nearly 80% to 90% of cases.⁵ Although diverticulitis is often uncomplicated, approximately 1% to 4% of patients develop fistula formation as a complication.⁶ Malignancy represents the second most common etiology, responsible for 10% to 20% of cases, followed by inflammatory bowel diseases such as Crohn’s disease, which is associated with fistula formation in approximately 2% to 5% of affected patients.¹^,⁷ Overall, colovesical fistulas are relatively uncommon, accounting for approximately 1 in 3000 hospital admissions, with a clear male predominance.⁸

Surgical management remains the definitive treatment in most patients, particularly those with diverticular or malignant etiologies.⁹ Standard operative management typically involves resection of the diseased bowel segment with or without direct bladder repair. However, there is considerable variability in intraoperative and postoperative bladder management. In some cases, the bladder defect is sutured, while in others, no repair is performed and healing is facilitated by urinary catheter drainage alone.⁹^,¹⁰ This variability reflects the lack of consensus regarding the necessity of bladder repair, particularly when no obvious bladder defect is identified intraoperatively.¹¹

Postoperative outcomes in patients undergoing surgery for colovesical fistula are variable. Reported morbidity rates range from 8% to 49%, with mortality rates up to 1.5% in large series of diverticular disease.⁴ Importantly, urinary leak following bladder repair appears to be uncommon, raising questions about whether routine bladder repair is necessary in all cases. In addition, practices such as duration of catheterization and the use of cystography vary widely among institutions.¹²

Despite the clinical relevance of this issue, current evidence remains limited and heterogeneous, and clear guidelines for bladder management in colovesical fistula surgery are lacking. Therefore, this systematic review and meta-analysis aims to evaluate the impact of bladder repair versus no bladder repair on postoperative outcomes, particularly urinary leak, to inform surgical decision-making and optimize patient care.

Methods

Study design

This study was conducted as a systematic review and meta-analysis to evaluate the impact of bladder repair versus no bladder repair in the surgical management of colovesical fistula. The review was designed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and the Cochrane Handbook for Systematic Reviews of Interventions.¹³^,¹⁴

The research question was structured using the PICO framework: Population (P) included adult patients (≥18 years) with colovesical fistula undergoing surgical treatment; Intervention (I) was bladder repair, including suturing, oversewing, or partial cystectomy; Comparison (C) was no bladder repair, such as catheter drainage alone or conservative bladder management; and Outcomes (O) included postoperative urinary leak and fistula recurrence as primary outcomes, with secondary outcomes including complications, length of hospital stay, and reoperation rates.

Search strategy

A comprehensive literature search was performed using PubMed, Scopus, Web of Science, and the Cochrane Library from database inception to February 2026. The search strategy combined terms related to colovesical fistula and bladder management, including “colovesical fistula,” “enterovesical fistula,” “bladder repair,” and “bladder management,” along with surgical terms. In addition, Google Scholar was used to identify potentially relevant gray literature and studies not indexed in the selected databases. To ensure feasibility and relevance, the first four pages of Google Scholar results were screened, as the platform ranks studies by relevance and typically displays the most pertinent results first. The reference lists of included studies were also manually screened to identify additional eligible articles. The complete database-specific search strings are provided in Supplementary File 1.

Inclusion and exclusion criteria

Studies were included if they met the following criteria: observational studies (retrospective or prospective cohorts), randomized controlled trials (if available), or case series including at least 10 patients; adult patients (≥18 years) diagnosed with colovesical fistula; and studies reporting surgical management with clear documentation of bladder repair and/or no bladder repair strategies. Eligible studies were required to report at least one relevant outcome, including urinary leak, recurrence, complications, or length of hospital stay, and to be published in English.

Studies were excluded if they were case reports or small case series (<10 patients), review articles, editorials, or conference abstracts without original data; involved non-surgical management only; included mixed fistula types without extractable data specific to colovesical fistula; or lacked a clear description of bladder management strategy.

Study selection

All identified citations were imported into Rayyan for organization and duplicate removal.¹⁵ Screening was conducted in two stages, beginning with title and abstract screening followed by full-text assessment of potentially eligible studies. Multiple reviewers independently evaluated all studies according to predefined inclusion and exclusion criteria. Any discrepancies were resolved through discussion and consensus. The study selection process is summarized in a PRISMA flow diagram.

Data extraction

Data extraction was performed independently by reviewers using a standardized data collection form. Extracted data included study characteristics (author, year, country, study design), patient demographics, etiology of fistula, sample size, and details of bladder management strategies (repair versus no repair). Outcome data were extracted for urinary leak, fistula recurrence, postoperative complications, length of hospital stay, reoperation, and mortality. Where necessary, data were extracted separately for repair and no-repair groups. Any discrepancies in data extraction were resolved through discussion among reviewers.

Quality assessment

The methodological quality and risk of bias of included studies were assessed using the ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions) tool.¹⁶ This tool evaluates bias across seven domains, including confounding, selection of participants, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes, and selection of reported results. Each domain was rated as low, moderate, serious, or critical risk of bias. Assessments were performed independently by reviewers, with disagreements resolved by consensus.

Statistical analysis

All statistical analyses were conducted using R (version 4.3.3) with the meta and metafor packages. Meta-analysis was performed for outcomes with sufficient and comparable data across studies. A random-effects model was applied to account for anticipated clinical and methodological heterogeneity among studies. Dichotomous outcomes, including postoperative urinary leak, were analyzed using odds ratios (ORs) with 95% confidence intervals (CIs). A continuity correction was applied where necessary to account for zero-event studies.

Statistical heterogeneity was assessed using the I² statistic and Cochran’s Q test. I² values were interpreted as low (<25%), moderate (25–50%), or substantial (>50%) heterogeneity. A sensitivity analysis was conducted by excluding studies with mixed etiologies to evaluate the robustness of the pooled estimates and assess the impact of potential clinical heterogeneity. Meta-analysis for recurrence, complications, and length of hospital stay was not performed due to insufficient and heterogeneous data across studies, including low event rates and lack of stratified reporting. For these outcomes, a narrative synthesis was conducted to summarize findings across studies.

Assessment of publication bias was not performed because the number of included studies was below the minimum recommended threshold for reliable evaluation.¹⁷ Funnel plot–based methods and statistical tests for asymmetry, such as Egger’s regression and Begg’s rank correlation, are known to have low statistical power and may produce misleading results when applied to fewer than 10 studies.¹⁷^,¹⁸ In accordance with established methodological recommendations, no formal assessment of publication bias was undertaken.

Results

Study selection.

A total of 446 records were identified through database searching, of which 186 duplicates were removed, leaving 260 records for title and abstract screening. After screening, 245 records were excluded based on predefined criteria, primarily due to non-original study design, irrelevant population, or lack of surgical focus. Fifteen full-text articles were assessed for eligibility, of which three were excluded due to lack of extractable outcome data or unclear bladder management strategy. Figure 1 illustrates the study selection process according to the PRISMA guidelines. Ultimately, 12 studies were included in the systematic review.¹⁹^–³⁰

Figure 1. PRISMA 2020 flow diagram of study selection for the systematic review.

Caption: The diagram summarizes the identification, screening, eligibility assessment, and final inclusion of studies evaluating bladder repair versus no bladder repair in the surgical management of colovesical fistula.

Study characteristics

Table 1 summarizes the characteristics, population, and bladder management strategies of the included studies. The majority of studies were retrospective cohort designs conducted across various countries, including the USA, Europe, and Asia. Sample sizes ranged from 19 to 89 patients, with most studies focusing on colovesical fistula secondary to diverticulitis. Bladder management strategies varied widely, with some studies performing routine bladder repair, while others adopted a conservative approach without repair. The type of repair also differed, ranging from simple suturing to partial cystectomy. Overall, this heterogeneity reflects variability in surgical practice and clinical decision-making across institutions.

Table 1. Characteristics of included studies and bladder management strategies in the surgical treatment of colovesical fistula.StudyStudy DesignCountrySample size & populationEtiologySettingAge (Mean/Median)Bladder repair (n)No repair (n)Type of repairKey surgical details Mileski et al., 1987Retrospective cohortUSA34 (27 inflammatory CVF)Diverticulitis/Crohn’sNot specifiedMean 61Not clearly separatedNot clearTwo-layer closureMulti-stage vs single-stage Walker et al., 2002CohortUK19 CVF patientsMixed (diverticular, cancer, trauma)Coloproctology unitMedian 64019NoneFoley drainage only Ferguson et al., 2008Retrospective cohortUSA74 EVF patientsDiverticulitis + Crohn’sNot specifiedMean 54.32450Suture ± omentumCatheter drainage in no-repair Melchior et al., 2009Retrospective cohortGermany49 CVF patientsDiverticulitisSingle-center Median ~ 66–73490Two-layer closureRoutine repair Niebling et al., 2016Retrospective cohortNetherlands31 CVF patientsDiverticulitisSingle-center Mean 61.1310Oversewing + omentumStandard repair Dolejs et al., 2018Retrospective cohortUSA89 CVF patientsDiverticulitisAcademic centerNot reported6623Simple vs partial excisionSurgeon vs urologist Bertelson et al., 2018Retrospective cohortUSA78 CVF patientsDiverticulitisMulti-institution Median 533444Simple vs complex repairDebridement + closure El-Haddad et al., 2018Retrospective cohortEgypt40 CVF patientsDiverticulitisTertiary centerMean 58.1MajorityMinimal no-repairMinimal → cystectomyVariable approaches Tomizawa et al., 2019Retrospective cohortJapan39 CVF patientsDiverticulitisSurgical departmentMedian 60039NoneLaparoscopic, no repair Holland et al., 2022Prospective studyUSA24 CVF patientsDiverticulitisCommunity systemMean 67.5816Simple suturesEarly catheter removal Stapler et al., 2023Retrospective cohortUSA73 CVF patientsDiverticulitisNot specifiedNot reported1459Suture repairEarly vs late catheter van der Beeke et al., 2025Retrospective cohortNetherlands55 CVF patientsDiverticulitisTeaching hospitalNot reported~2233Simple vs complexRepair only if defect found

Primary outcome: urinary leak

Figure 2 presents the forest plot comparing urinary leak between bladder repair and no bladder repair groups. Across five studies, the pooled analysis using a random-effects model demonstrated no statistically significant difference in urinary leak between the two approaches (OR = 1.93, 95% CI: 0.42–8.81). Individual studies showed wide confidence intervals, reflecting small sample sizes and low event rates. Heterogeneity was negligible (I² = 0.0%), indicating consistency across studies despite clinical variability.

Figure 2. Forest plot comparing postoperative urinary leak between bladder repair and no bladder repair in patients undergoing surgery for colovesical fistula.

Caption: The figure presents pooled odds ratios (ORs) with 95% confidence intervals (CIs) from the included comparative studies using a random-effects model. An OR > 1 favors no bladder repair, whereas an OR < 1 favors bladder repair with respect to lower urinary leak risk. Square sizes are proportional to study weight, and the diamond represents the pooled effect estimate.

Sensitivity analysis

Figure 3 shows the sensitivity analysis performed after exclusion of the mixed etiology study by Ferguson et al.²¹ The pooled estimate remained non-significant (OR = 2.02, 95% CI: 0.24–16.62), with low heterogeneity (I² = 10.6%). The direction and magnitude of the effect were consistent with the primary analysis, confirming the robustness of the findings and suggesting that inclusion of mixed populations did not substantially influence the overall results.

Figure 3. Sensitivity analysis forest plot for postoperative urinary leak after exclusion of the mixed-etiology study by Ferguson et al. (2008).

Secondary outcomes

Table 2 summarizes the secondary outcomes across included studies. Fistula recurrence was rare, with most studies reporting zero events or very low recurrence rates, regardless of bladder management strategy. Due to the low incidence and lack of comparative data, meta-analysis was not feasible. Postoperative complications were variably reported, ranging from 7.7% to 46%, with no clear association between bladder repair and complication rates. Length of hospital stay was inconsistently reported, with values generally ranging between 4 and 14 days. Reoperation and mortality were infrequently reported and showed no consistent pattern across studies. Overall, the heterogeneity and limited reporting of these outcomes precluded quantitative synthesis.

Table 2. Postoperative outcomes reported in studies comparing bladder repair versus no bladder repair in colovesical fistula surgery.StudyLeak (Repair)Leak (No Repair)RecurrenceComplicationsLOSReoperationMortality Mileski et al., 1987Not reportedNot reported1 caseHigher in staged surgery21–57 daysNot clear1 death Walker et al., 2002—0/1905/19 (26%)Median 14 daysNot reported1/19 Ferguson et al., 20080/240/500Not clearly reportedNot reportedNot reported0 Melchior et al., 20090/49—04/49 (8.2%)Not reported00 Niebling et al., 20160/31—09/31 (29%)Not reportedNot reported1/31 Dolejs et al., 20183/662/23146% overall6–9 daysNot reportedNot reported Bertelson et al., 20182/340/44Not reported37%Not reportedNot reportedNot reported El-Haddad et al., 2018——2/4032.5%Not reportedNot reported3/40 Tomizawa et al., 2019—0/3903/39 (7.7%)Median 8 daysNot reportedNot reported Holland et al., 20221/80/1603/24 (12.5%)Mean 4.3 daysNot reportedNot reported Stapler et al., 2023Not separatedNot separatedNot reported25–33% compositeLOS ≥7 days (reported)Included in compositeNot reported van der Beeke et al., 20252/4 (complex), 0/18 (simple)1/33032.7%Median 5 days3.6%Not reported

Risk of bias assessment

Figure 4 presents the risk of bias assessment of the included studies using the ROBINS-I tool. Most studies were judged to have a moderate risk of bias, primarily due to confounding and the retrospective nature of the data. Bias due to confounding was the most prominent concern, reflecting the lack of adjustment for important clinical variables such as disease severity and surgical decision-making. Other domains, including intervention classification and outcome measurement, were generally low risk. Only one study was rated as low overall risk of bias, while several studies were classified as serious risk due to multiple methodological limitations.²⁸ These findings indicate that the overall quality of evidence is moderate and should be interpreted with caution.

Figure 4. Risk of bias assessment of included studies using the ROBINS-I tool.

Caption: Risk of bias was assessed across seven ROBINS-I domains: bias due to confounding (D1), selection of participants (D2), classification of interventions (D3), deviations from intended interventions (D4), missing data (D5), measurement of outcomes (D6), and selection of the reported result (D7), in addition to the overall risk-of-bias judgment for each study. Green indicates low risk of bias, yellow indicates moderate risk of bias, and red indicates serious risk of bias.

Discussion

This systematic review and meta-analysis evaluated the role of bladder repair in the surgical management of colovesical fistula and demonstrated no significant reduction in postoperative urinary leak with routine bladder repair. The pooled analysis showed comparable leak rates between repair and no-repair strategies, and this finding remained stable in sensitivity analysis after exclusion of mixed etiology cohorts. These results suggest that routine bladder repair may not be necessary in all cases, particularly when no clear bladder defect is identified intraoperatively.

The pathophysiology of colovesical fistula provides a plausible explanation for these findings. In most cases, particularly those related to diverticular disease, fistula formation results from localized inflammation and adherence between the colon and bladder rather than a large structural defect in the bladder wall.⁵ Once the diseased bowel segment is resected and the inflammatory process is controlled, the bladder often demonstrates a strong intrinsic capacity for healing under low-pressure conditions achieved with catheter drainage. This may explain the low incidence of urinary leak reported across studies, even in the absence of formal bladder repair.³¹

The predominance of diverticular disease as the underlying etiology further supports a conservative approach to bladder management. Diverticular disease accounts for up to 80% to 90% of colovesical fistulas and is generally associated with favorable postoperative outcomes following bowel resection.⁵ In this context, aggressive bladder intervention such as partial cystectomy or extensive suturing may not confer additional benefit and could potentially increase operative complexity. Conversely, malignancy-related fistulas often require more extensive resection, including bladder repair or partial cystectomy, due to direct tumor invasion and the need for oncological clearance.³² This highlights the importance of tailoring surgical management to the underlying etiology rather than adopting a uniform approach.

Another important consideration is the variability in intraoperative identification of bladder defects. Several studies have reported that the fistula opening is not always clearly visualized during surgery, even with adjunctive techniques such as bladder filling with methylene blue.²¹^,²²^,²⁴^,²⁵^,²⁸ In such cases, surgeons may elect not to perform bladder repair, relying instead on postoperative catheter drainage to facilitate healing. The present findings support the safety of this approach, as the absence of repair did not result in increased leak rates.

Postoperative management strategies also vary considerably, particularly with respect to the duration of catheterization and the use of routine cystography prior to catheter removal. Emerging evidence suggests that early catheter removal may be safe in selected patients, with low rates of urinary complications.¹² Given the low incidence of urinary leak observed in this review, prolonged catheterization and routine imaging may not be necessary in all cases, although further prospective data are needed to define optimal protocols.

From a clinical perspective, avoiding unnecessary bladder repair may offer several advantages. It may reduce operative time, limit the need for urological intervention, and decrease the risk of bladder-related complications. In addition, a simplified surgical approach may facilitate minimally invasive techniques, which have been increasingly adopted in the management of colovesical fistula with favorable outcomes.³³

Overall, the findings of this study contribute to an evolving paradigm in the surgical management of colovesical fistula, where individualized decision-making based on intraoperative findings and underlying etiology is emphasized. Rather than routine bladder repair, a selective approach appears to be safe and effective in appropriately selected patients, particularly those with benign disease and no identifiable bladder defect.

Limitations

This study has several limitations that should be considered when interpreting the findings. First, all included studies were observational in nature, with the majority being retrospective cohorts, which introduces an inherent risk of selection bias and confounding. Surgical decision-making regarding bladder repair was not standardized and was often based on intraoperative findings and surgeon preference, limiting comparability between groups. Second, sample sizes in individual studies were relatively small, and the overall number of studies included in the meta-analysis was limited, which may reduce the statistical power to detect small differences between treatment strategies.

Third, important clinical variables such as fistula size, degree of inflammation, and intraoperative findings were inconsistently reported and could not be accounted for in the analysis. Additionally, heterogeneity in surgical techniques, postoperative management protocols, and definitions of outcomes, particularly urinary leak and complications, may have influenced the results. Fourth, several outcomes of interest, including recurrence, complications, and length of hospital stay, could not be quantitatively synthesized due to limited and non-stratified data, restricting the scope of meta-analysis.

Finally, publication bias could not be formally assessed due to the small number of included studies, and the possibility of selective reporting cannot be excluded. Despite these limitations, this study provides a comprehensive synthesis of the available evidence and offers clinically relevant insights into the management of colovesical fistula.

Conclusion

This systematic review and meta-analysis found that bladder repair was not associated with a significant reduction in postoperative urinary leak compared with no bladder repair in patients undergoing surgery for colovesical fistula. The consistency of findings across analyses supports the safety of a selective approach to bladder management, particularly in cases of benign disease where no obvious bladder defect is identified intraoperatively. These results suggest that routine bladder repair may be unnecessary in many patients and that simple catheter drainage may be sufficient to allow bladder healing under low-pressure conditions. Adopting a tailored, etiology-driven strategy may help reduce operative complexity without compromising outcomes. Further prospective, well-designed studies are warranted to confirm these findings and to establish standardized guidelines for bladder management in colovesical fistula surgery.

Software availability

Software available from: The statistical analyses were performed using R (version 4.3.3), available from https://cran.r-project.org/.

Source code available from: https://github.com/mohamedbakl/colovesical-fistula-meta-analysis

Archived source code at time of publication: https://doi.org/10.5281/zenodo.21456272

License: MIT License.

Data availability statement

Underlying data

No underlying data are associated with this article.

Extended data

OSF: Impact of bladder repair on postoperative outcomes in the surgical management of colovesical fistula: a systematic review and meta-analysis. https://doi.org/10.17605/OSF.IO/DER37.³⁴

License: CC BY 4.0 International.

The project contains the following extended data:

- Supplementary File 1. Complete search strategies for PubMed, Scopus, and Web of Science.
- Supplementary File 2. PRISMA 2020 checklist
- Supplementary File 3. ROBINS-I assessment
- Supplementary File 4. R code

Acknowledgements

We would like to express our gratitude to Shohob Research Services Center for their efforts in training the research team and supervising the research process until the completion of this study.

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© 2026 Alshahrani SD et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Impact of bladder repair on postoperative outcomes in the surgical management of colovesical fistula: a systematic review and meta-analysis [version 1; peer review: awaiting peer review]

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