Erosion of the ureter by ileofemoral arterial prosthesis

A systematic review of management of uretero-arterial fistula

OBJECTIVE

Uretero-arterial fistula (UAF) is lethal condition. However, there is no consensus regarding diagnosis and treatment of UAF owing to its rarity. The aim of this paper was to present an actual case of UAF and to systematically review the symptoms, risk factors, diagnosis, and treatment of this condition.

METHODS

The case study included a 52-year-old woman who showed a massive hemorrhage during urinary stent replacement. For the systematic review of articles on UAF, those written in English and published from 1939 to 2020 were searched on PubMed using the keywords "uretero-arterial fistula," "arterio-ureteral fistula," and "hematuria".

RESULTS

We included 121 articles and 235 patients (mean age, 66.0 years; women, 139 [59.1%]) in this review. UAF occurred most frequently in the common iliac artery (112 patients [47.7%]). Almost all patients (232 patients [98.7 %]) complained of hematuria. The risk factors for UAF were pelvic surgery (205 patients [87.2%]), long-term use of urinary stents (170 patients [72.3%]), oncologic radiotherapy (107 patients [45.5%]), and malignancy (159 patients [67.7%]). Although computed tomography (CT) can detect various useful findings such as extravasation, pseudoaneurysm, hydronephrosis, and opacification of ureters, it was diagnostically useful in only one-third of the cases. Angiography was useful in diagnosing UAF in 124 (66.3%) of the 187 patients (80.0%) who underwent this procedure. With regard to treatment, endovascular approaches have been widely used in recent years because their invasiveness is lesser than that of open surgical repair. In the era of endovascular therapy, the indications for open surgical repair include ureteral-intestinal fistula, abscess formation, and graft infection after endovascular therapy.

CONCLUSIONS

CT was recommended as the first examination in patients with risk factors for UAF because of its usefulness. Subsequently, angiography should be considered because UAF can be treated using an endovascular approach following diagnostic angiography. Diagnosis and treatment of UAF can often be difficult; therefore, the important first step of diagnosis is suspecting UAF and employing a multidisciplinary approach.

Operative Management of Crossover Femoral-femoral Graft Erosion into Bladder: A Case Report

Erosion of vascular grafts is not uncommon as seen in the recent literature. There have been many case reports documenting the work up and management of erosion of these grafts into bowel. We report a case of a crossover femoral-femoral graft that eroded into the anterior bladder wall and was incidentally found as an adherent bladder stone during cystoscopy. We demonstrate the importance of having a high level of clinical suspicion for eroding vascular grafts when preoperative imaging shows close proximity of graft to bladder.

Arterio-ureteral fistula--a systematic review

OBJECTIVE

To review published reports on arterio-ureteral fistula.

METHOD

Literature search.

RESULTS

Eighty cases were identified. Primary fistulas were mainly seen in combination with aortoiliac aneurysmal disease. Secondary fistulas were seen after pelvic cancer surgery, often with radiation, fibrosis and ureteral stenting or after vascular surgery with synthetic grafting. The dominating symptom is massive haematuria, often with circulatory impairment. The clue to a rapid and correct diagnosis is a high degree of suspicion. Most frequently diagnosis has been obtained through angiography or pyelography. When there is a ureteral stent manipulation it will often provoke bleeding and lead to diagnosis. The fistula must be excluded and a vascular reconstruction made. Most frequently this has been obtained through occlusion of the fistula and an extra-anatomic reconstruction (femoro-femoral crossover). Recently stent-grafting has been successfully used but follow-up is short.

CONCLUSION

Arterio-ureteral fistula is rare and should be suspected in patients with complicated pelvic surgery and massive haematuria, especially where rigid ureteral stents have been placed.

Autologous vein-covered stent for the endovascular management of an iliac artery-ureteral fistula: case report and review of the literature

Iliac artery-ureteral fistula is a rare entity that is being reported with increasing frequency. Patients with iliac artery-ureteral fistulas can be divided into two distinct groups on the basis of the factors that predispose them to having these fistulas. In group I the fistula is associated with degenerative iliac artery disease or previous arterial reconstructive surgery. Patients in group II have undergone some combination of the following procedures: pelvic extirpative surgery for malignancy, urinary diversion, radiation therapy, and ureteral stenting. The diagnosis of an iliac artery-ureteral fistula can be elusive even with the use of multiple imaging methods. Direct operative repair is technically demanding and is associated with high mortality rates. In recent years, treatment has shifted toward percutaneous embolization of the iliac artery and extraanatomic lower extremity vascular reconstruction for group II patients. In this report, the 24 group II patients with iliac artery-ureteral fistulas who previously have been described are reviewed, and a new endovascular treatment for this entity that uses a stented vein graft is detailed.

Arterioureteral fistula after extended resection of pelvic tumors: report of three cases and review of the literature

Arterioureteral fistulas are rare. Three patients with arterioureteral fistulas complicating extended resection of pelvic tumors associated with bilateral cutaneous ureterostomy in the right lower quadrant are reported. In one case, the fistula involved the left ureter, the right common iliac artery, and the inferior mesenteric artery. Pathological iliac artery, pelvic cancer, or operated ureteral stones are often incriminated in the genesis of ureteroarterial fistulas. Insertion of a ureteral catheter has been found to be the main promoting factor. The common iliac artery is involved frequently. Clinical presentation is often limited to gross hematuria, whereas complementary investigations have not proved to be sensitive. Surgical treatment is often complex, but must be undertaken early, even in the absence of absolute proof of diagnosis, in order to preclude uncontrollable massive hemorrhage.

Arterial-ureteral fistula: case study with review of published reports

Arterial-ureteral fistula, a rare cause of gross hematuria, may be associated with life-threatening hemorrhage if not rapidly diagnosed and treated. Recently, a patient at the Hunter H. McGuire Veterans Administration Medical Center developed an arterial-ureteral fistula at the site of the confluence of the external iliac artery and a superior mesenteric artery bypass graft. Review of the world's literature revealed 31 additional reported cases of arterial-ureteral fistulas. This current case is only the second one reported in which the diagnosis was made with arteriography. Several common features of arterial-ureteral fistulas were present in this case: a history of ureteral obstruction and urinary tract infections, upper urinary tract disease, and previous vascular surgery. The condition is usually associated with either prior upper urinary tract instrumentation or vascular surgery, and an antecedent period of intermittent hematuria, followed by life-threatening hematuria, is common. A high index of suspicion and early surgical intervention are required for successful management. The major surgical challenges are to establish unobstructed urinary drainage and restore vascular continuity. Exclusion of prosthetic material from potentially infected areas is mandatory.