URETERAL
OBSTRUCTION
SECONDARY
TO ILIAC ARTERY ANEURYSM
JOHN
F. REDMAN,
GILBERT
M.D.
S. CAMPBELL,
M.D.
From the Division of Urology, University Medical Center, Little Rock, Arkansas
of Arkansas
patient with an unusual unilateral ureter-al obstruction secondary to mechanical -A obstruction by a common iliac artery aneurysm in association with an abdominal-aortic aneurysm is presented. A diagnosis of ureteral obstruction should be suspected in a patient with flank or abdominal pain and an infra-umbilical (iliac) aneurysm. Treatment is directed toward the aneurysm. The aneurysma1 wall attachments to the ureter should be left undisturbed.
ABSTRACT
A fifty-seven-year-old white man was admitted to the University Hospital on March 10, 1974, for evaluation of a pulsating abdominal mass and low back pain. There was no history of hematuria or flank pain. On physical examination a large pulsating mass was palpable well below the costal margin. Distal pulses were excellent. Blood urea nitrogen was 19 mg. and serum creatinine 1.5 mg. per 100 ml. An excretory urogram demonstrated ureteropyelocaliectasis on the right side extending to the pelvic brim (Fig. 1A). The left side was within normal limits with no deviation of the ureter. On March 11, 1974, the patient underwent transperitoneal exploration of the aneurysm and
ureteral obstruction. A large aortic aneurysm measuring 15 cm. in its largest diameter was found to extend from just below the renal vessels to the bifurcation (Fig. 1B). The right common iliac artery had a second aneurysm which measured 8 cm. in its widest diameter. The left common iliac artery was minimally dilated. The right ureter was densely adherent to the wall of the right iliac artery aneurysm and was quite dilated proximally. The infrarenal aorta, left common iliac, and the right external and internal iliac arteries were occluded prior to making a longitudinal incision through the anterior wall of both aneurysms. After decompression of the aneurysms, the ureter immediately became flaccid. Because of the risk of denuding the ureter, the wall of the iliac aneurysm was left adherent to the ureter. A Dacron bifurcation graft was interposed from just distal to the renal vessels to just proximal to the iliac bifurcation in the bed of the two aneurysms.” Excretory urogram on April 19, 1974, showed some resolution of the ectatic changes, and an excretory urogram in October, 1974, showed complete restoration of the ectatic changes (Fig. 1C). Because of an allergic reaction during administration of the contrast medium, full dosage was not given; and, therefore, visualization of the ureter was poor.
212
UROLOGY
Ureteral obstruction secondary to periureteral fibrosis or compression in association with an abdominal-aortic aneurysm or iliac artery aneurysm is an unusual occurrence. Eighteen previous instances of aortic aneurysmal ureteral obstruction have been reported. l-l8 Six previous instances of iliac aneurysmal ureteral obstruction have been reported.7,‘8-21 A recent patient with a unilateral ureteral obstruction caused by an iliac artery aneurysm in association with an abdominal-aortic aneurysm is the basis for our report. Case Report
/ AUGUST 1975 / VOLUME
VI, NUMBER
2
AORllC ANEURYSM
COMMON ILIAC ANEURYSM \
Comment Ureteral obstruction caused by an aortic or iliac aneurysm is unusual. Rather than being a function of the size of the aneurysm itself, the obstruction usually is caused by a retroperitoneal fibrosis which encases the ureters. The fibrous tissue
UROLOGY
/ ACCUST
1975 / \‘OLUME
VI. NUMBER 2
FIGURE 1. (A) Preoperative excretory urogramjive hours following injection showing obstructive changes on right. (B) Drawing showing relationships of aneurysms and right ureter. (C) Oneyear postoperative excretory urogram (renal outline retouched) showing normal-appearing renal collecting structures.
formation has been described as occurring in two different ways: (1) the inflammatory changes usually seen in the wall of aneurysms may extend to the adventitia and perivascular structures, and (2) minute perforations of the arteriosclerotic plaques allow for leakage of blood retroperitoneally with resultant fibrosis. l2 Only occasionally
213
has the ureter been obstructed by the compression of the aneurysm alone.2’7 Crane7 and Kornfield and Jacobson 2o described cases similar to ours in which the ureter was compressed by an aneurysm of the terminal aorta and the left common iliac. In Labardini and Dow’s21 case the ureter was encased in an inflammatory mass consisting of a primary mycotic right common iliac artery aneurysm. With iliac artery aneurysms the ureteral obstruction is unilateral. Boontje, Groenewold, and Hekking” in reviewing a series of 14cases of ureteral obstruction secondary to aortic aneurysms found 9 to be bilateral. In almost all reported instances abdominal or flank pain was a presenting complaint. A pulsating abdominal mass was palpable in only half of the cases reported. 3-16 Failure to diagnose the aneurysm preoperatively may result in reoperation unless the surgeon is prepared to resect the aneurysm. In most instances treatment consists of resecting the aneurysm and freeing the ureter of all periureteral fibrosis. In our case, ureteral obstruction was due solely to compression of the ureter as it coursed over the common iliac artery aneurysm. The ureter immediately became flaccid with decompression of the aneurysm, and the ureter was found to be densely adherent to the wall of the aneurysm. Because of these findings and a wish not to endanger the ureteral vasculature, it was elected to leave the aneurysmal remnants attached to the ureter. Division of Urology 4301 West Markham Street Little Rock, Arkansas 72201 (DR REDMAN)
5.
6. 7. 8.
9. 10.
11.
12.
13.
14.
15.
16.
17.
18.
19. References DUCKANOFF, A.: Ruptur eines Aneurysmas der abdominal Aorta, die eine akute Nierenerkrankung Nachahmte, Ztscher. f. Urol. Chir. 40: 34 (1934). JAMES, T. G. I. : Uraemia due to aneurysm of abdominal aorta, Br. J. Urol. 7: 157 (1935). SCHLOSS, W. A., and KAPLAN, B. J.: Spontaneous extravasation from the ureter secondary to aneurysm of the abdominal aorta, N. Engl. J. Med. 249: 802 (1953). SHUMACKER, H. B., JR., and GARRETT, R.: Obstruc-
214
20.
21.
22
tive uropathy from abdominal aortic aneurysm, Surg. Gynecol. Obstet. 100: 758 (1955). DE WEERD, J. H., RINGER, M. G., JR., POOL, T. L., and GAMBILL, E. E.: Aortic aneurysm causing bilateral ureteral obstruction: report of case, J, Urol. 74: 78 (1955). JELLINEK, E. H.: Aneurysm of abdominal aorta with anuria, Lancet 2: 922 (1956). CRANE, J. F.: LTV&era1 involvement by aortic aneurysm, J. Ural. 79: 403 (1958). PEARLMAN, C. K., and MACKEY, J. R., JR.: Anuria resulting from abdominal aneurysm, ibid. 83: 184 (1960). COTTLER, Z. R., and IMMERGUT, S.: Obstruction of solitary kidney by aortic aneurysm, ibid. 86: 510 (1961). ALBERS, D. D., and BETTAGLIO, A.: Ureteral obstruction from an unsuspected aortic aneurysm: case report, ibid. 85: 249 (1961). SPITTELL, J. A., JR., and HUNT, J. C.: Abdominal aortic aneurysm and the kidney, Med. Clin. North Am. 50: 1021 (1966). LABARDINI, M. M., and RATLIFF, R. K.: The abdominal aortic aneurysm and the ureter, J. Urol. 98: 590 (1967). WAGENKNECHT, L. V., and MADSEN, P. 0. : Bilateral ureteral obstruction secondary to aortic aneurysm, ibid. 103: 732 (1970). ABBOTT, D. L., SKINNER, D. G., YALOWITZ, P. A., and MULDER, D. G.: Retroperitoneal fibrosis associated with abdominal aortic aneurysm: an approach to management, ibid. 109: 987 (1973). FREIDEL, W. E., SMITH, T. R., and HERMAN, J. R. : Anuria caused by peri-aneurysmal retroperitoneal fibrosis, ibid. 110: 516 (1973). BOONTJE, A. H., GROENEWOLD, H., and HEKKING, J. H. : Ureteral obstruction secondary to abdominal aortic aneurysm, J. Cardiovas. Surg. 15: 606 (1974). NEISTADT, A., JONES, T., and ROB, C.: Vascular system involvement by idiopathic retroperitoneal fibrosis, Surgery 59: 950 (1966). GOODWIN, W. E., and SHUMACKER, H. B., JR.: Aneurysm of the hypogastric artery producing urinary tract obstruction: report of a case, J. Urol. 57: 839 (1947). RIVES, H. F., and COOK, E. N.: Ureteral obstruction caused by aneurysm of iliac artery, Minn. Med. 29: 143 (1946). KORNFIELD, H. J., and JACOBSON, M. E.: Ureteral obstruction: an unusual complication of iliac aneurysm, J. Kan. Med. Sot. 59: 252 (1955). LABARDINI, M. M., and Dow, R. W.: Primary mycotic aneurysm of the right common iliac artery. Condition producing hydonephrosis and hydroureter and duodenal fistula, Arch. Surg. 96: 373 (1968). and CREECH, O., JR. : Endo-aneurysmorrhaphy treatment of aortic aneurysm, Ann. Surg. 164: 935 (1966).
UROLOGY
/
AUGUST 1975 /
VOLUME VI, NUMBER 2
OBSTRUCTION
SECONDARY
TO ILIAC ARTERY ANEURYSM
JOHN
F. REDMAN,
GILBERT
M.D.
S. CAMPBELL,
M.D.
From the Division of Urology, University Medical Center, Little Rock, Arkansas
of Arkansas
patient with an unusual unilateral ureter-al obstruction secondary to mechanical -A obstruction by a common iliac artery aneurysm in association with an abdominal-aortic aneurysm is presented. A diagnosis of ureteral obstruction should be suspected in a patient with flank or abdominal pain and an infra-umbilical (iliac) aneurysm. Treatment is directed toward the aneurysm. The aneurysma1 wall attachments to the ureter should be left undisturbed.
ABSTRACT
A fifty-seven-year-old white man was admitted to the University Hospital on March 10, 1974, for evaluation of a pulsating abdominal mass and low back pain. There was no history of hematuria or flank pain. On physical examination a large pulsating mass was palpable well below the costal margin. Distal pulses were excellent. Blood urea nitrogen was 19 mg. and serum creatinine 1.5 mg. per 100 ml. An excretory urogram demonstrated ureteropyelocaliectasis on the right side extending to the pelvic brim (Fig. 1A). The left side was within normal limits with no deviation of the ureter. On March 11, 1974, the patient underwent transperitoneal exploration of the aneurysm and
ureteral obstruction. A large aortic aneurysm measuring 15 cm. in its largest diameter was found to extend from just below the renal vessels to the bifurcation (Fig. 1B). The right common iliac artery had a second aneurysm which measured 8 cm. in its widest diameter. The left common iliac artery was minimally dilated. The right ureter was densely adherent to the wall of the right iliac artery aneurysm and was quite dilated proximally. The infrarenal aorta, left common iliac, and the right external and internal iliac arteries were occluded prior to making a longitudinal incision through the anterior wall of both aneurysms. After decompression of the aneurysms, the ureter immediately became flaccid. Because of the risk of denuding the ureter, the wall of the iliac aneurysm was left adherent to the ureter. A Dacron bifurcation graft was interposed from just distal to the renal vessels to just proximal to the iliac bifurcation in the bed of the two aneurysms.” Excretory urogram on April 19, 1974, showed some resolution of the ectatic changes, and an excretory urogram in October, 1974, showed complete restoration of the ectatic changes (Fig. 1C). Because of an allergic reaction during administration of the contrast medium, full dosage was not given; and, therefore, visualization of the ureter was poor.
212
UROLOGY
Ureteral obstruction secondary to periureteral fibrosis or compression in association with an abdominal-aortic aneurysm or iliac artery aneurysm is an unusual occurrence. Eighteen previous instances of aortic aneurysmal ureteral obstruction have been reported. l-l8 Six previous instances of iliac aneurysmal ureteral obstruction have been reported.7,‘8-21 A recent patient with a unilateral ureteral obstruction caused by an iliac artery aneurysm in association with an abdominal-aortic aneurysm is the basis for our report. Case Report
/ AUGUST 1975 / VOLUME
VI, NUMBER
2
AORllC ANEURYSM
COMMON ILIAC ANEURYSM \
Comment Ureteral obstruction caused by an aortic or iliac aneurysm is unusual. Rather than being a function of the size of the aneurysm itself, the obstruction usually is caused by a retroperitoneal fibrosis which encases the ureters. The fibrous tissue
UROLOGY
/ ACCUST
1975 / \‘OLUME
VI. NUMBER 2
FIGURE 1. (A) Preoperative excretory urogramjive hours following injection showing obstructive changes on right. (B) Drawing showing relationships of aneurysms and right ureter. (C) Oneyear postoperative excretory urogram (renal outline retouched) showing normal-appearing renal collecting structures.
formation has been described as occurring in two different ways: (1) the inflammatory changes usually seen in the wall of aneurysms may extend to the adventitia and perivascular structures, and (2) minute perforations of the arteriosclerotic plaques allow for leakage of blood retroperitoneally with resultant fibrosis. l2 Only occasionally
213
has the ureter been obstructed by the compression of the aneurysm alone.2’7 Crane7 and Kornfield and Jacobson 2o described cases similar to ours in which the ureter was compressed by an aneurysm of the terminal aorta and the left common iliac. In Labardini and Dow’s21 case the ureter was encased in an inflammatory mass consisting of a primary mycotic right common iliac artery aneurysm. With iliac artery aneurysms the ureteral obstruction is unilateral. Boontje, Groenewold, and Hekking” in reviewing a series of 14cases of ureteral obstruction secondary to aortic aneurysms found 9 to be bilateral. In almost all reported instances abdominal or flank pain was a presenting complaint. A pulsating abdominal mass was palpable in only half of the cases reported. 3-16 Failure to diagnose the aneurysm preoperatively may result in reoperation unless the surgeon is prepared to resect the aneurysm. In most instances treatment consists of resecting the aneurysm and freeing the ureter of all periureteral fibrosis. In our case, ureteral obstruction was due solely to compression of the ureter as it coursed over the common iliac artery aneurysm. The ureter immediately became flaccid with decompression of the aneurysm, and the ureter was found to be densely adherent to the wall of the aneurysm. Because of these findings and a wish not to endanger the ureteral vasculature, it was elected to leave the aneurysmal remnants attached to the ureter. Division of Urology 4301 West Markham Street Little Rock, Arkansas 72201 (DR REDMAN)
5.
6. 7. 8.
9. 10.
11.
12.
13.
14.
15.
16.
17.
18.
19. References DUCKANOFF, A.: Ruptur eines Aneurysmas der abdominal Aorta, die eine akute Nierenerkrankung Nachahmte, Ztscher. f. Urol. Chir. 40: 34 (1934). JAMES, T. G. I. : Uraemia due to aneurysm of abdominal aorta, Br. J. Urol. 7: 157 (1935). SCHLOSS, W. A., and KAPLAN, B. J.: Spontaneous extravasation from the ureter secondary to aneurysm of the abdominal aorta, N. Engl. J. Med. 249: 802 (1953). SHUMACKER, H. B., JR., and GARRETT, R.: Obstruc-
214
20.
21.
22
tive uropathy from abdominal aortic aneurysm, Surg. Gynecol. Obstet. 100: 758 (1955). DE WEERD, J. H., RINGER, M. G., JR., POOL, T. L., and GAMBILL, E. E.: Aortic aneurysm causing bilateral ureteral obstruction: report of case, J, Urol. 74: 78 (1955). JELLINEK, E. H.: Aneurysm of abdominal aorta with anuria, Lancet 2: 922 (1956). CRANE, J. F.: LTV&era1 involvement by aortic aneurysm, J. Ural. 79: 403 (1958). PEARLMAN, C. K., and MACKEY, J. R., JR.: Anuria resulting from abdominal aneurysm, ibid. 83: 184 (1960). COTTLER, Z. R., and IMMERGUT, S.: Obstruction of solitary kidney by aortic aneurysm, ibid. 86: 510 (1961). ALBERS, D. D., and BETTAGLIO, A.: Ureteral obstruction from an unsuspected aortic aneurysm: case report, ibid. 85: 249 (1961). SPITTELL, J. A., JR., and HUNT, J. C.: Abdominal aortic aneurysm and the kidney, Med. Clin. North Am. 50: 1021 (1966). LABARDINI, M. M., and RATLIFF, R. K.: The abdominal aortic aneurysm and the ureter, J. Urol. 98: 590 (1967). WAGENKNECHT, L. V., and MADSEN, P. 0. : Bilateral ureteral obstruction secondary to aortic aneurysm, ibid. 103: 732 (1970). ABBOTT, D. L., SKINNER, D. G., YALOWITZ, P. A., and MULDER, D. G.: Retroperitoneal fibrosis associated with abdominal aortic aneurysm: an approach to management, ibid. 109: 987 (1973). FREIDEL, W. E., SMITH, T. R., and HERMAN, J. R. : Anuria caused by peri-aneurysmal retroperitoneal fibrosis, ibid. 110: 516 (1973). BOONTJE, A. H., GROENEWOLD, H., and HEKKING, J. H. : Ureteral obstruction secondary to abdominal aortic aneurysm, J. Cardiovas. Surg. 15: 606 (1974). NEISTADT, A., JONES, T., and ROB, C.: Vascular system involvement by idiopathic retroperitoneal fibrosis, Surgery 59: 950 (1966). GOODWIN, W. E., and SHUMACKER, H. B., JR.: Aneurysm of the hypogastric artery producing urinary tract obstruction: report of a case, J. Urol. 57: 839 (1947). RIVES, H. F., and COOK, E. N.: Ureteral obstruction caused by aneurysm of iliac artery, Minn. Med. 29: 143 (1946). KORNFIELD, H. J., and JACOBSON, M. E.: Ureteral obstruction: an unusual complication of iliac aneurysm, J. Kan. Med. Sot. 59: 252 (1955). LABARDINI, M. M., and Dow, R. W.: Primary mycotic aneurysm of the right common iliac artery. Condition producing hydonephrosis and hydroureter and duodenal fistula, Arch. Surg. 96: 373 (1968). and CREECH, O., JR. : Endo-aneurysmorrhaphy treatment of aortic aneurysm, Ann. Surg. 164: 935 (1966).
UROLOGY
/
AUGUST 1975 /
VOLUME VI, NUMBER 2
