0022-534 7/92/1483-0863$03.00/0 Vol. 148, 863-864, September 1992 Printed in U.S. A.
THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
URETEROARTERIAL FISTULA: A CASE REPORT PAOLO PUPPO, MASSIMO PERACHINO, GIUSEPPE RICCIOTTI, NICOLA ZINICOLA AND PIERO EUGENIO PATRONE From the Departments of Urology and Vascular Surgery, S. Corona Hospital, Pietra Ligure, Italy
ABSTRACT
Ureteroarterial fistulas are rare, with less than 20 well documented cases reported. We report a case of a fistula between the left external iliac artery and the left ureter in a patient who underwent a previous operation for bladder cancer. The diagnostic and therapeutic approaches in these rare but high risk patients are discussed. KEY WORDS:
ureter, arteries, urinary fistula
Ureteroarterial fistulas are rare. To our knowledge, until 1984 fewer than 20 cases had been reported. Several causes had been advocated, including vascular pathology or previous vascular surgery, pregnancy, surgical trauma, radiotherapy, infection and indwelling ureteral catheters or stents. The prognosis normally is poor. We report a case of a fistula between the left external iliac artery and the left ureter in a patient who previously underwent an operation for bladder cancer. CASE REPORT
An 81-year-old white man was referred to our emergency department for massive hemorrhage from a cutaneous ureterostomy. The patient underwent radical cystectomy elsewhere 6 months previously for invasive bladder cancer and, probably in consideration of the advanced age, distal cutaneous ureteroureterostomy was performed. He previously underwent radiotherapy and 2, 8F indwelling ureterostomy catheters were present since the operation. Excretory urography, retrograde pyelography and ultrasonography only showed a large amount of clots in the left renal pelvis and ureter. Computerized tomography (CT) revealed a thin cleavage plane between the left ureter and the left external iliac artery, with extravasation of liquid at the crossing point (fig. 1). A detailed angiographic evaluation, including aortography and selective injections of the renal and common iliac arteries, demonstrated minimal extravasation of contrast material (fig. 2). At exploration the left external iliac artery was isolated and the fistula was recognized. The iliac artery was ligated and the graft prosthesis was not deemed helpful because of local infection. Therefore, a crossover femoral-to-femoral bypass was performed. Bilateral cutaneous ureterostomy at a higher position was established after resection of the distal portions of both ureters. The patient was discharged from the hospital 26 days postoperatively. He died of pulmonary complications 3 months later.
Treatment consisted of resection of the aneurysm and interposition of a monofilament knitted polypropylene graft. Toolin et al reported on a patient who had undergone pelvic exenteration for carcinoma of the uterine cervix, with a fistula between the right common iliac artery and the distal right ureter. 13 This patient had also received prior radiation therapy and was treated with an indwelling ureteral stent, which was present when the fistula developed. In this case diagnosis was made by arteriography. The lesion was treated successfully by embolization of the common iliac artery with Gianturco coils. In fact, a detrimental effect of irradiation is injury to the normal surrounding tissues, including the blood vessels, which was recognized as early as 1899 by Gassman. 15 Fonkalsrud et al studied the short-term and long-term effects of irradiation experimentally in dogs. 16 They postulated that the delayed changes in the media and adventitia of large arteries may be caused by injury to the vasa vasorum and may account for an increased incidence of rupture. The indwelling ureteral catheter may also have a role in the development of degenerative changes in the arterial and ureteral walls. In our case it is clear that the constant pulsation of the artery transmitted to an already damaged ureter (previous irradiation, fibrosis or surgical trauma) through a stiff intraluminal foreign body could produce necrosis. 13 Therefore, when ureteral stents or catheters are needed for long intervals, especially in irradiated patients, it is mandatory to use the softest and smallest stents consistent with the clinical needs of the patient. When an indwelling ureteral catheter or stent is present an uneventful IVP and ultrasound might be due to the fact that contrast medium extravasation is possible only in the presence of a favorable pressure gradient (from artery to ureter and not vice versa). In
DISCUSSION
In all previously reported cases of ureteroarterial fistulas a presumptive cause had been identified, including ureteral or vascular infection, previous irradiation, vascular surgery or disease, surgical trauma, pregnancy and the use of indwelling ureteral catheters or stents for extended periods. 1· 14 Ureteroarterial fistulas associated with primary vascular disease occur rarely. Such patients have gross hematuria secondary to spontaneous rupture of a renal artery aneurysm into the urinary tract, with a high mortality rate even after nephrectomy.1·3.5, 7• 8 Shultz et al described a fistula that formed between a right iliac artery aneurysm and a right ureteral stump. 5 This patient presented with pain on the right side and hematuria. Accepted for publication January 10, 1992.
863
FIG. 1. CT with contrast medium extravasation (arrow) shows close relationship between left ureter and left external iliac artery.
864
PUPPO AND ASSOCIATES
mentioned (radiation, infection, stents, arterial disease and pregnancy) are also at risk for this problem and must be treated carefully to minimize the possibility of fistula formation. REFERENCES
FIG. 2. Angiographic study did not allow for diagnosis
our patient the indwelling ureteral catheter was supposed to act as a valve. Therefore, we believe that in all patients who present with hematuria and 1 or more of the aforementioned presumptive causes it is important to suspect the possibility of fistula formation, and to perform CT and detailed angiographic studies. In conclusion, we believe that when urinary diversion is performed after cystectomy in high risk patients it always seems better to perform an ileal conduit or, when this is not possible, cutaneous ureterostomy in the high position. To avoid such a life-threatening complication, however, it should be clear that patients with an intact ureter and bladder plus the risk factors
1. Wheatley, J. K., Ansley, J. D., Smith, R. B., III, Trulock, T. S. and Campbell, D.: Ureteroarterial fistula. Urology, 18: 498, 1981. 2. Davidson, 0. W. and Smith, R. P.: Uretero-arterial fistula. Report of a case. J. Urol., 42: 257, 1939. 3. Cowen, R.: Uretero-arterial fistula. J. Urol., 73: 801, 1955. 4. Whitmore, W. F., Jr.: Uretero-arterial fistula and ureterovaginal fistula: report of a case. Urologia, 21: 184, 1954. 5. 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. 6. Schapira, H. E., Li, R., Gribetz, M., Wulfsohn, M.A. and Brendler, H.: Ureteral injuries during vascular surgery. J. Urol., 125: 293, 1981. 7. Reiner, R. J., Conway, G. F. and Threlkeld, R.: Ureteroarterial fistula. J. Urol., 113: 24, 1975. 8. Burt, R. L., Johnston, F. R., Silverthorne, R. G., Lock, F. R. and Dickerson, A. J.: Ruptured renal artery aneurysm in pregnancy: report of a case with survival. Obst. Gynec., 7: 229, 1956. 9. 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. 10. Nelson, H. N. and Fried, F. A.: Iliac artery-ureteral fistula associated with Gibbons' catheter: a case report and review of the literature. J. Urol., 125: 878, 1981. 11. Schoenberg, H. W. and Mikuta, J. J.: Technique for preventing urinary fistulas following pelvic exenteration and ureteroileostomy. J. Urol., 110: 294, 1973. 12. Dorfman, L. E. and Thomford, N. R.: Unusual ureteral injury following aorto-iliac by-pass graft: case report. J. Urol., 101: 25, 1969. 13. Toolin, E., Pollack, H. M., McLean, G. K., Banner, M. P. and Wein, A. J.: Ureteroarterial fistula: a case report. J. Urol., 132: 553, 1984. 14. Grillo, N., Seno, S. and Vedovato, F.: Fistola arterioureterale dopo TEA ed arterioplastica con patch in Gore-Tex. Min. Angiol., 14: 233, 1989. 15. Gassman, A.: Zur Histologie der Roentgenulcere. Fortschr. Geb. Roentgenstr., 2: 199, 1899. 16. Fonkalsrud, E. W., Sanchez, M., Zerubavel, R. and Mahoney, A.: Serial changes in arterial structure following radiation therapy. Surg., Gynec. & Obst., 145: 395, 1977.
THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
URETEROARTERIAL FISTULA: A CASE REPORT PAOLO PUPPO, MASSIMO PERACHINO, GIUSEPPE RICCIOTTI, NICOLA ZINICOLA AND PIERO EUGENIO PATRONE From the Departments of Urology and Vascular Surgery, S. Corona Hospital, Pietra Ligure, Italy
ABSTRACT
Ureteroarterial fistulas are rare, with less than 20 well documented cases reported. We report a case of a fistula between the left external iliac artery and the left ureter in a patient who underwent a previous operation for bladder cancer. The diagnostic and therapeutic approaches in these rare but high risk patients are discussed. KEY WORDS:
ureter, arteries, urinary fistula
Ureteroarterial fistulas are rare. To our knowledge, until 1984 fewer than 20 cases had been reported. Several causes had been advocated, including vascular pathology or previous vascular surgery, pregnancy, surgical trauma, radiotherapy, infection and indwelling ureteral catheters or stents. The prognosis normally is poor. We report a case of a fistula between the left external iliac artery and the left ureter in a patient who previously underwent an operation for bladder cancer. CASE REPORT
An 81-year-old white man was referred to our emergency department for massive hemorrhage from a cutaneous ureterostomy. The patient underwent radical cystectomy elsewhere 6 months previously for invasive bladder cancer and, probably in consideration of the advanced age, distal cutaneous ureteroureterostomy was performed. He previously underwent radiotherapy and 2, 8F indwelling ureterostomy catheters were present since the operation. Excretory urography, retrograde pyelography and ultrasonography only showed a large amount of clots in the left renal pelvis and ureter. Computerized tomography (CT) revealed a thin cleavage plane between the left ureter and the left external iliac artery, with extravasation of liquid at the crossing point (fig. 1). A detailed angiographic evaluation, including aortography and selective injections of the renal and common iliac arteries, demonstrated minimal extravasation of contrast material (fig. 2). At exploration the left external iliac artery was isolated and the fistula was recognized. The iliac artery was ligated and the graft prosthesis was not deemed helpful because of local infection. Therefore, a crossover femoral-to-femoral bypass was performed. Bilateral cutaneous ureterostomy at a higher position was established after resection of the distal portions of both ureters. The patient was discharged from the hospital 26 days postoperatively. He died of pulmonary complications 3 months later.
Treatment consisted of resection of the aneurysm and interposition of a monofilament knitted polypropylene graft. Toolin et al reported on a patient who had undergone pelvic exenteration for carcinoma of the uterine cervix, with a fistula between the right common iliac artery and the distal right ureter. 13 This patient had also received prior radiation therapy and was treated with an indwelling ureteral stent, which was present when the fistula developed. In this case diagnosis was made by arteriography. The lesion was treated successfully by embolization of the common iliac artery with Gianturco coils. In fact, a detrimental effect of irradiation is injury to the normal surrounding tissues, including the blood vessels, which was recognized as early as 1899 by Gassman. 15 Fonkalsrud et al studied the short-term and long-term effects of irradiation experimentally in dogs. 16 They postulated that the delayed changes in the media and adventitia of large arteries may be caused by injury to the vasa vasorum and may account for an increased incidence of rupture. The indwelling ureteral catheter may also have a role in the development of degenerative changes in the arterial and ureteral walls. In our case it is clear that the constant pulsation of the artery transmitted to an already damaged ureter (previous irradiation, fibrosis or surgical trauma) through a stiff intraluminal foreign body could produce necrosis. 13 Therefore, when ureteral stents or catheters are needed for long intervals, especially in irradiated patients, it is mandatory to use the softest and smallest stents consistent with the clinical needs of the patient. When an indwelling ureteral catheter or stent is present an uneventful IVP and ultrasound might be due to the fact that contrast medium extravasation is possible only in the presence of a favorable pressure gradient (from artery to ureter and not vice versa). In
DISCUSSION
In all previously reported cases of ureteroarterial fistulas a presumptive cause had been identified, including ureteral or vascular infection, previous irradiation, vascular surgery or disease, surgical trauma, pregnancy and the use of indwelling ureteral catheters or stents for extended periods. 1· 14 Ureteroarterial fistulas associated with primary vascular disease occur rarely. Such patients have gross hematuria secondary to spontaneous rupture of a renal artery aneurysm into the urinary tract, with a high mortality rate even after nephrectomy.1·3.5, 7• 8 Shultz et al described a fistula that formed between a right iliac artery aneurysm and a right ureteral stump. 5 This patient presented with pain on the right side and hematuria. Accepted for publication January 10, 1992.
863
FIG. 1. CT with contrast medium extravasation (arrow) shows close relationship between left ureter and left external iliac artery.
864
PUPPO AND ASSOCIATES
mentioned (radiation, infection, stents, arterial disease and pregnancy) are also at risk for this problem and must be treated carefully to minimize the possibility of fistula formation. REFERENCES
FIG. 2. Angiographic study did not allow for diagnosis
our patient the indwelling ureteral catheter was supposed to act as a valve. Therefore, we believe that in all patients who present with hematuria and 1 or more of the aforementioned presumptive causes it is important to suspect the possibility of fistula formation, and to perform CT and detailed angiographic studies. In conclusion, we believe that when urinary diversion is performed after cystectomy in high risk patients it always seems better to perform an ileal conduit or, when this is not possible, cutaneous ureterostomy in the high position. To avoid such a life-threatening complication, however, it should be clear that patients with an intact ureter and bladder plus the risk factors
1. Wheatley, J. K., Ansley, J. D., Smith, R. B., III, Trulock, T. S. and Campbell, D.: Ureteroarterial fistula. Urology, 18: 498, 1981. 2. Davidson, 0. W. and Smith, R. P.: Uretero-arterial fistula. Report of a case. J. Urol., 42: 257, 1939. 3. Cowen, R.: Uretero-arterial fistula. J. Urol., 73: 801, 1955. 4. Whitmore, W. F., Jr.: Uretero-arterial fistula and ureterovaginal fistula: report of a case. Urologia, 21: 184, 1954. 5. 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. 6. Schapira, H. E., Li, R., Gribetz, M., Wulfsohn, M.A. and Brendler, H.: Ureteral injuries during vascular surgery. J. Urol., 125: 293, 1981. 7. Reiner, R. J., Conway, G. F. and Threlkeld, R.: Ureteroarterial fistula. J. Urol., 113: 24, 1975. 8. Burt, R. L., Johnston, F. R., Silverthorne, R. G., Lock, F. R. and Dickerson, A. J.: Ruptured renal artery aneurysm in pregnancy: report of a case with survival. Obst. Gynec., 7: 229, 1956. 9. 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. 10. Nelson, H. N. and Fried, F. A.: Iliac artery-ureteral fistula associated with Gibbons' catheter: a case report and review of the literature. J. Urol., 125: 878, 1981. 11. Schoenberg, H. W. and Mikuta, J. J.: Technique for preventing urinary fistulas following pelvic exenteration and ureteroileostomy. J. Urol., 110: 294, 1973. 12. Dorfman, L. E. and Thomford, N. R.: Unusual ureteral injury following aorto-iliac by-pass graft: case report. J. Urol., 101: 25, 1969. 13. Toolin, E., Pollack, H. M., McLean, G. K., Banner, M. P. and Wein, A. J.: Ureteroarterial fistula: a case report. J. Urol., 132: 553, 1984. 14. Grillo, N., Seno, S. and Vedovato, F.: Fistola arterioureterale dopo TEA ed arterioplastica con patch in Gore-Tex. Min. Angiol., 14: 233, 1989. 15. Gassman, A.: Zur Histologie der Roentgenulcere. Fortschr. Geb. Roentgenstr., 2: 199, 1899. 16. Fonkalsrud, E. W., Sanchez, M., Zerubavel, R. and Mahoney, A.: Serial changes in arterial structure following radiation therapy. Surg., Gynec. & Obst., 145: 395, 1977.
