We present the case of a 60-year-old male patient with a history of recurrent acute sigmoid diverticulitis episodes. Comorbidities were limited to suspected obstructive sleep apnea (OSAS). The patient did not exhibit pneumaturia, fecaluria, or recurrent urinary tract infections. Colonoscopy revealed sigmoid diverticulosis, while contrast-enhanced abdominal CT demonstrated a large sigmoid diverticulum adhered to the posterior bladder wall, suggestive of a pre-fistulous state.
Given the clinical presentation, we opted for surgical intervention, performing a robot-assisted hemicolectomy using the Da Vinci system. The surgery involved ligation of the inferior mesenteric artery and vein, followed by the mobilization of the left colon up to the splenic flexure. Subsequent meticulous dissection was carried out to separate the sigmoid colon from the bladder, to which it was tenaciously adhered. This revealed a diverticulum that had eroded the bladder wall down to the muscular layer. We resected the diverticulum from the sigmoid colon, leaving a portion adhered to the bladder wall.
The rectum was resected up to the peritoneal reflection using a linear stapler. To remove the remaining diverticulum fragment adhered to the bladder wall, the bladder was filled with a solution of physiological saline and methylene blue, facilitating safer dissection and visualization of potential suture lines. The fragment was cautiously dissected from the bladder wall, with no evidence of fistulas. The bladder wall was subsequently reinforced with a continuous suture using Stratafix PDS 2/0.
Following the removal of the surgical specimen, a termino-terminal colorectal anastomosis was created using a circular stapler. Postoperatively, the patient experienced an uneventful recovery, maintaining a urinary catheter until the 5th postoperative day with no signs of hematuria or fecaluria. Following catheter removal, diuresis was normal and spontaneous.
This case highlights the successful management of a complicated sigmoid diverticulum with robotic-assisted surgery, emphasizing the importance of meticulous dissection and bladder wall reinforcement in such cases.