Scand J Urol Nephrol26: 307-309, 1992
URETERO-ILIAC FISTULA-A RARE CAUSE OF HEMATURIA Case Report Johannes Eberle, Siegfried Uberreiter and Giinther Janetschek From the Departmrnt of Uro1og.v. Innsbnrck. L~tiiLwsityHospital, Austria
Scand J Urol Nephrol Downloaded from informahealthcare.com by UB Wuerzburg on 10/29/14 For personal use only.
(Submitted June 28, 1991. Accepted for publication October 10, 1991)
Abstract. Fistulation between the ureter and iliac artery is a rare cause of hematuria. Like our case, most of the cases reported so far, originate from traumatic or iatrogenic lesions. This condition should be considered in patients with massive hematuria and underlying predisposing factors. Key words: hematuria, uretero-iliac fistula. ureteral stenting, blood vessel prosthesis.
Several isolated cases of fistulation between the ureter and iliac vessels have been reported in literature (1, 2, 10, 1 1 ). The presumptive causes include mycotic aneurysm, spontaneous rupture in atherosclerotic disease, irradiation for pelvic malignancy and ureterolithotomy (6). More recently, however, these lesions have commonly been reported in connection with vascular surgery (aortofemoral bypass, resection of abdominal aortic aneurysm) (7) and routine application of ureteral stents (3, 4, 5 ) . Thus, persistent hematuria in a patient with a characteristic clinical history should alert the physician to the possibility of uretero-arterial fistula.
raphy yielded no evidence of any pathological communication between the artery and the ureter. Five weeks later the patient was re-admitted with a bladder tamponade. He presented with persistent microscopic hematuria. but was otherwise asymptomatic. At that time a uretero-arterial fistula could be demonstrated by rctrograde ureterography at the level of the bifurcation of the pelvic vessels (Fig. 2). The contrast medium, which was applied under pressure, passed into the vascular system (Fig. 3). Surgical repair included a cross-over bypass with graft interposition as well as nephrcctomy.
DISCUSSION During the past ten years nearly 20 cases of fistulation between the ureter and the bifurcation of the pelvic vessels have been reported. The most interesting cases among them were a pathological communication between the ureter and the iliac vein (9), and a congenital arterio-
CASE REPORT A 65-year-old man was referred to our hospital for
recurrent gross hematuria. He had had a reconstruction of the right pelvic vessels (dacron patch) few years before and was still on anticoagulant medication. One year before the onset of hematuria he suffered several renal colics on the right side. At that time the right upper urinary tract was found to be obstructed, but because of irreversible damage to the right kidney no further measures were taken. Repeated urinanalyses were negative, and there was no microscopic hematuria. On admission a non-functional hydronephrotic kidney on the right side was found associated with a partially thrombotic aneurysm of the right common iliac artery (Fig. I ) . Pelvic arteriog21 -928263
Fig. I . Computed tomography demonstrating partially thrombotic aneurysm of the right common iliac artery. Scand .I L i o l Ncplrrol 26
Scand J Urol Nephrol Downloaded from informahealthcare.com by UB Wuerzburg on 10/29/14 For personal use only.
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J. Eberle et al.
Fig. 2. Retrograde ureterography showing ureterohydronephrosis. Fig. 3. Contrast medium passing into the vascular system.
venous malformation of the iliac vessels with secondary fistulation (8). All patients presented with gross hematuria (or rather “hematuria without urine”) which was generally painless. In some cases the hemorrhage was so profuse that it was potentially fatal, some patients however had only microscopic hematuria recurring intermittently for several weeks or months. Gross hematuria is often associated with an obstruction of the upper urinary tract on the same side or to anticoagulant medication after vascular surgery. The main problem in these cases is the diagnostic verification of a suspected fistula. As reported in literature, arteriography is not always helpful. In our patient arteriography also failed to demonstrate the fistula. Therefore ante- and retrograde radiographic examination of the ureter is essential. Visualization may be facilitated by occluding the ureter with a balloon catheter. Ureteroscopy may be helpful in patients presenting with microscopic hematuria. The therapeutic procedure depends on the local findings and previous surgical measures. Aneurysm resulting in ureteral obstruction reScand J Urol Nephrol26
quires resection followed by ureterolysis. It is essential to place the vascular graft behind the ureter, possibly with an omental or peritoneal graft in between. When placing indwelling stents-especially for long-term drainage-the vascular condition of the patient (e.g. severe atherosclerosis, aneurysm) has to be taken into consideration and the stent should be adapted to the anatomical situation.
REFERENCES Baum M. Baum R, Plaine L, Bosniak M. Computed tomography in the diagnosis of a fistula between the ureter and iliac artery. J Comput Assist Tomogr 1987; 1 1: 7 19-72 1. Joost J, Bartsch G, Weimann S, Neurer G. Ilioureteric fistula. Br J Urol 1981; 53: 477. Kar A. Angwafo F, Jhunjhunwala S. Ureteroarterial and ureterosigmoid fistula associated with polyethylene indwelling ureteral stents. J Urol 1984; 132: 755-757.
Levine R, Pollack H, Banner M. Transient ureteral obstruction after ureteral stenting. AJR 1982: 138: 323-327.
Uretero-iliacjistula
formation: a cause of massive hematuria and ureteral obstruction. J Urol 139: 355-356. 9. Teuton M, Viner N. Zuckermann H, Butler D. Ureteroiliac vein fistula associated with a polyethylene indwelling ureteral stent. J Urol 1987; 137: 975-976. 10. Toolin E, Pollack H, McLean G, Banner M, Wein A. Ureteroarterial fistula: a case report. J Urol 1984; 132: 553-554. 1 1 . Wheatley J, Ansley J , Smith R, Trulock T, Campbell D. Ureteroarterial fistula. Urology 1981; 18: 498-502.
Scand J Urol Nephrol Downloaded from informahealthcare.com by UB Wuerzburg on 10/29/14 For personal use only.
5. Nelson H, Fried F. Iliac artery-ureteral fistula associated with Gibbons’ Catheter: a case report and review of the literature. J Urol 1981; 125: 878-880. 6. Nicita G, Lunghi F, Diligenti L, Ferrarese D, Fiorelli C, Turini D. Arteriovesical fistula after ureterolithotomy: a case report and review of the literature. J Urol 1978; 120: 370-371. 7. Schapira H, Li R, Gribetz M, Wulfsohn M. Brendler H. Ureteral injuries during vascular surgery. J Urol 1981; 125: 293-297. 8. Sharma S, Goswami A, Sharma G, Malkondiah G, Khanna S. Congenital iliac arteriovenous mal-
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Scand J Urol Nephrol26
URETERO-ILIAC FISTULA-A RARE CAUSE OF HEMATURIA Case Report Johannes Eberle, Siegfried Uberreiter and Giinther Janetschek From the Departmrnt of Uro1og.v. Innsbnrck. L~tiiLwsityHospital, Austria
Scand J Urol Nephrol Downloaded from informahealthcare.com by UB Wuerzburg on 10/29/14 For personal use only.
(Submitted June 28, 1991. Accepted for publication October 10, 1991)
Abstract. Fistulation between the ureter and iliac artery is a rare cause of hematuria. Like our case, most of the cases reported so far, originate from traumatic or iatrogenic lesions. This condition should be considered in patients with massive hematuria and underlying predisposing factors. Key words: hematuria, uretero-iliac fistula. ureteral stenting, blood vessel prosthesis.
Several isolated cases of fistulation between the ureter and iliac vessels have been reported in literature (1, 2, 10, 1 1 ). The presumptive causes include mycotic aneurysm, spontaneous rupture in atherosclerotic disease, irradiation for pelvic malignancy and ureterolithotomy (6). More recently, however, these lesions have commonly been reported in connection with vascular surgery (aortofemoral bypass, resection of abdominal aortic aneurysm) (7) and routine application of ureteral stents (3, 4, 5 ) . Thus, persistent hematuria in a patient with a characteristic clinical history should alert the physician to the possibility of uretero-arterial fistula.
raphy yielded no evidence of any pathological communication between the artery and the ureter. Five weeks later the patient was re-admitted with a bladder tamponade. He presented with persistent microscopic hematuria. but was otherwise asymptomatic. At that time a uretero-arterial fistula could be demonstrated by rctrograde ureterography at the level of the bifurcation of the pelvic vessels (Fig. 2). The contrast medium, which was applied under pressure, passed into the vascular system (Fig. 3). Surgical repair included a cross-over bypass with graft interposition as well as nephrcctomy.
DISCUSSION During the past ten years nearly 20 cases of fistulation between the ureter and the bifurcation of the pelvic vessels have been reported. The most interesting cases among them were a pathological communication between the ureter and the iliac vein (9), and a congenital arterio-
CASE REPORT A 65-year-old man was referred to our hospital for
recurrent gross hematuria. He had had a reconstruction of the right pelvic vessels (dacron patch) few years before and was still on anticoagulant medication. One year before the onset of hematuria he suffered several renal colics on the right side. At that time the right upper urinary tract was found to be obstructed, but because of irreversible damage to the right kidney no further measures were taken. Repeated urinanalyses were negative, and there was no microscopic hematuria. On admission a non-functional hydronephrotic kidney on the right side was found associated with a partially thrombotic aneurysm of the right common iliac artery (Fig. I ) . Pelvic arteriog21 -928263
Fig. I . Computed tomography demonstrating partially thrombotic aneurysm of the right common iliac artery. Scand .I L i o l Ncplrrol 26
Scand J Urol Nephrol Downloaded from informahealthcare.com by UB Wuerzburg on 10/29/14 For personal use only.
308
J. Eberle et al.
Fig. 2. Retrograde ureterography showing ureterohydronephrosis. Fig. 3. Contrast medium passing into the vascular system.
venous malformation of the iliac vessels with secondary fistulation (8). All patients presented with gross hematuria (or rather “hematuria without urine”) which was generally painless. In some cases the hemorrhage was so profuse that it was potentially fatal, some patients however had only microscopic hematuria recurring intermittently for several weeks or months. Gross hematuria is often associated with an obstruction of the upper urinary tract on the same side or to anticoagulant medication after vascular surgery. The main problem in these cases is the diagnostic verification of a suspected fistula. As reported in literature, arteriography is not always helpful. In our patient arteriography also failed to demonstrate the fistula. Therefore ante- and retrograde radiographic examination of the ureter is essential. Visualization may be facilitated by occluding the ureter with a balloon catheter. Ureteroscopy may be helpful in patients presenting with microscopic hematuria. The therapeutic procedure depends on the local findings and previous surgical measures. Aneurysm resulting in ureteral obstruction reScand J Urol Nephrol26
quires resection followed by ureterolysis. It is essential to place the vascular graft behind the ureter, possibly with an omental or peritoneal graft in between. When placing indwelling stents-especially for long-term drainage-the vascular condition of the patient (e.g. severe atherosclerosis, aneurysm) has to be taken into consideration and the stent should be adapted to the anatomical situation.
REFERENCES Baum M. Baum R, Plaine L, Bosniak M. Computed tomography in the diagnosis of a fistula between the ureter and iliac artery. J Comput Assist Tomogr 1987; 1 1: 7 19-72 1. Joost J, Bartsch G, Weimann S, Neurer G. Ilioureteric fistula. Br J Urol 1981; 53: 477. Kar A. Angwafo F, Jhunjhunwala S. Ureteroarterial and ureterosigmoid fistula associated with polyethylene indwelling ureteral stents. J Urol 1984; 132: 755-757.
Levine R, Pollack H, Banner M. Transient ureteral obstruction after ureteral stenting. AJR 1982: 138: 323-327.
Uretero-iliacjistula
formation: a cause of massive hematuria and ureteral obstruction. J Urol 139: 355-356. 9. Teuton M, Viner N. Zuckermann H, Butler D. Ureteroiliac vein fistula associated with a polyethylene indwelling ureteral stent. J Urol 1987; 137: 975-976. 10. Toolin E, Pollack H, McLean G, Banner M, Wein A. Ureteroarterial fistula: a case report. J Urol 1984; 132: 553-554. 1 1 . Wheatley J, Ansley J , Smith R, Trulock T, Campbell D. Ureteroarterial fistula. Urology 1981; 18: 498-502.
Scand J Urol Nephrol Downloaded from informahealthcare.com by UB Wuerzburg on 10/29/14 For personal use only.
5. Nelson H, Fried F. Iliac artery-ureteral fistula associated with Gibbons’ Catheter: a case report and review of the literature. J Urol 1981; 125: 878-880. 6. Nicita G, Lunghi F, Diligenti L, Ferrarese D, Fiorelli C, Turini D. Arteriovesical fistula after ureterolithotomy: a case report and review of the literature. J Urol 1978; 120: 370-371. 7. Schapira H, Li R, Gribetz M, Wulfsohn M. Brendler H. Ureteral injuries during vascular surgery. J Urol 1981; 125: 293-297. 8. Sharma S, Goswami A, Sharma G, Malkondiah G, Khanna S. Congenital iliac arteriovenous mal-
309
Scand J Urol Nephrol26
![[Segmental and congenital absence of the inferior vena cava: a rare cause of hematuria, report of a case].](/assets/img/hold.png)
