0022-5347/78/1203-0370$02.00/0 Vol. 120, September Printed in U .SA.
THE JOURNAL OF UROLOGY
Copyright © 1978 by The Williams & Wilkins Co.
ARTERIOVESICAL FISTULA AFTER URETEROLITHOTOMY: A CASE REPORT AND REVIEW OF THE LITERATURE GIULIO NICITA, FRANCESCO LUNGHI, LUIGI MAGI DILIGENT!, DOMENICO FERRARESE, CARLO FIORELLI AND DAMIANO TURIN! From the Departments of Urology and Radiology, University of Florence and S. M. N uova Hospital, Florence, Italy
A case is reported of massive recurrent hematuria after ureterolithotomy caused by a fistula between a branch of the hypogastric artery and the bladder. tion of the right kidney showed pyonephrosis and nephrectomy was done. Convalescence was uneventful.
T. N., a 52-year-old man, was hospitalized on March 8, 1973 with fever, chills and right flank pain. Purulent material and 2 uric stones had been removed surgically from the right juxtavesical ureter 3 weeks previously. Convalescence had been uneventful. Blood chemistry tests were normal, except for erythrocyte sedimentation rate and leukocytosis. Escherichia coli strain
Hematuria owing to a fistula between the iliac vessels and the urinary tract is rare and in most cases it is of traumatic 1
A, inferior vesical artery is not recognizable. Gluteal, pudenda! and obturator arteries stem from common trunk. B, at level with inferior portion of sacroiliac synchondrosis is oval radiopaque spot persistently opacified for overflowing of contrast medium outside arterial wall. Clots cause non-homogeneous opacification of bladder.
as well as a Proteus strain were present in the urine. An excretory urogram was normal on the left side, while a delayed slight opacification of the distended calices appeared on the right side. A right retrograde ureterogram was unsuccessful and the patient had massive hematuria 2 days later. Within the next few days hematuria recurred, requiring 6 units of blood. Further cystoscopy was unsuccessful owing to the massive hemorrhage. On March 11 renal angiography showed only reduced right renal vascularization and pelvic angiography revealed spreading of the contrast medium outside 1 of the vessels in the pelvis (see figure). Surgical exploration revealed a large mass of infected clots outflowing into the bladder through a hole a few millimeters in diameter in t:he right paravesical space and iliac fossa. Ligature of the right hypogastric artery, suture of the vesical hole and drainage of the obturator fossa were done. Explora-
Accepted for publication November 11, 1977.
or iatrogenic origin.2--u Less frequently it is caused by spontaneous rupture of an aneurysm of the common iliac artery (see table). 7 • 8 In our patient 1 of the branches of the hypogastric artery was interrupted, which was the cause of severe hematuria through a hole in the vesical wall. The fact that the hemorrhage recurred was owing to the plugging effect of a mass of intravesical and juxtavesical clots. We have formulated a different hypothesis. Attempted ureteral catheterization may have caused the lesion in the vesical wall and the small artery, thus creating a hematoma that later emptied into the bladder. A septic process supplied by the primary urinary infection may have caused necrosis of the vesical and arterial walls. During the previous ureterolithotomy a vesical branch of the hypogastric artery may have been injured partially and later it may have broken completely in the septic ambient that favored necrosis of the bladder wall. In these cases angiography is helpful in the detection of the site and extent of the lesion as well as in the planning of operation. Also, during angiography pelvic embolization can be attempted and, thus, an operation may be avoided.
ARTERIO'\TJ~SIC.A.. L FI3~'::JLi1- AF'TER Uii~TEROLITHOTO:C~1Y
Causes and syinpto1ns of iliac artery pathology inuoluing the loiaer urinary tract ·---~----··
Common iliac artery (arterioureteral fistula) Hydronephrosis for iliac aneurysm, nephrectomy Rupture of iliac aneurysm
Shultz and associates' Rennick and associates 8
Rupture of iliac aneurysm Ureterolithotomy Ureterolithotomy
Taylor and Reinhart' Cowen 6 Arap and associates'
Pelvic operation Pelvic operation Common iliac artery (artery·bladder fistula) Post.traumatic Rous and Andronaco' Hypogastric artery Goodwin, W. E. and Shumacker, H. B., Jr.: J. Urol., 57: 839, U nruptured aneurysm 1947 Anderson, E. E. and Silver, D.: J. Urol., 97: 90, 1967 Unruptured aneurysm Unruptured aneurysm Markowitz, A. M. and Norman, J. C.: Ann. Surg., 154: 777, 1961 Unruptured aneurysm Frank, I. N., Thompson, H. T., Rob, C. and Schwartz, S. I.: Arch. Surg., 83: 956, 1961 Markowitz and Norman Ruptured aneurysm Ruptured aneurysm Frank and associates Ruptured aneurysm Wirthlin, L. S. and Warshaw, A. L.: Surgery, 73: 629, 1973
Urinary tract obstruction and massive hematuria into distal ureteral stump
Whitmore' Reiner and associates 3
Gross hematuria into bladder
No symptoms or bladder neck obstruction and rectal symptoms
Bleeding from rectum
Although hypogastric artery aneurysms present urological symptomatology they rarely empty into the urinary tract.
L Rous, S. N. and Andronaco, J. T.: Post.traumatic aneurysm of the iliac artery with rupture directly into bladder: a case report and review of the literature. J. Urol., 108: 722, 1972. 2. Shultz, M. L., Ewing, D. D. and Lovett, V. F.: Fistula between iliac aneurysm and distal stump of ureter with hematuria: a case report. J. Urol., 112: 585, 1974. 3. Reiner, R. J., Conway, G. F. and Threlkeld, R.: Ureteroarterial fistula. J. Urol., 113: 24, 1975. 4. Whitmore, W. F., Jr.: Uretero-arterial fistula and uretero·vagi·
nal fistula: report of case. Urologia, 21: 184, 1954. 5. Arap, S., Nardy, 0. W., Goes, G. M., Azevedo, J. R. and de Campos Freire, J. G.: Fistula ureteroarterial. Rev. Paulista Med., 67: 352, 1965. 6. Cowen, R.: Uretero.arterial fistula. J. Urol., 73: 801, 1955. 7. Taylor, W. N. and Reinhart, H. L.: Mycotic aneurism of common iliac artery with rupture into right ureter. Report of a case. J. Urol., 42: 21, 1939. 8. Rennick, J. M., Link, D. P. and Palmer, J. M.: Spontaneous rupture of an iliac artery aneurysm into a ureter: a case report and review of the literature. J. Urol., 116: 111, 1976.