Minimally invasive radiologic techniques in the treatment of uretero-enteric fistulas

Uretero-Colonic Fistula at a Previous Colon Anastomosis Site: A Case Report

Uretero-colonic fistulae are a rare disease resulting from pathologic connection between the ureter and colon, which can be difficult to diagnose. This case report reviews the case of an 83-year-old female with a history of ovarian cancer treated with surgery, radiation, and chemotherapy, who developed a uretero-colonic fistula at a previous colon anastomosis site, which was later diagnosed by ureteroscopy. She was treated with stent placement followed by loop colostomy and was discovered to have metastatic ovarian cancer. She received palliative care consultation and was advised to follow up as an outpatient with the oncology and urology services. Although uretero-colonic fistulae are treatable, treatment depends on patients' overall clinical picture.

Uretero-Jejunal Fistula: A Rare Cause of Acute Pyelonephritis

Penetrating peptic ulcers often lead to severe complications. The development of uretero-enteric fistulas is rare and can be challenging to diagnose and treat. Here, we present the case of a 41-year-old patient who previously underwent gastrojejunostomy for superior mesenteric artery syndrome and developed a peptic jejunal ulcer, leading to a uretero-jejunal fistula and finally causing acute pyelonephritis. The patient was managed with a multidisciplinary approach including medical therapy and endoscopic and radiologic interventions.

URETERO-COLONIC FISTULA SECONDARY TO A FOREIGN BODY INGESTION: LAPAROSCOPYC APPROACH IN A PEDIATRIC PATIENT

INTRODUCTION

The most common causes of uretero-colonic fistulas are penetrating injury, iatrogenic trauma, and ureteric lithiasis.^1,2,3 Spontaneous uretero-colonic fistula is a rare complication of foreign body ingestion. Most pass through the gastrointestinal tract without problems and less than 1% produces perforation.⁴ Fish bones are among the most frequently reported foreign bodies to have caused a perforation and children are considered a risk group for foreign body ingestion.^4,5 The aim of this video was to report an unprecedented case of a uretero-colonic fistula secondary to foreign body ingestion in a pediatric patient treated using a laparoscopic approach.

MATERIAL AND METHODS

Clinical case of a 3-year-old female patient who consulted because of a febrile UTI.

RESULTS

On ultrasound hydronephrosis and a linear echogenic image were detected in the ureteral lumen. CT scan showed a high-density image in the mid ureter. A ureteral calculus was suspected. Retrograde pyelography revealed a narrowed ureteral segment. During flexible ureteroscopy a foreign body was released from the ureteral wall using laser holmium. A postoperative 3D CT scan detected the remaining fragment of the foreign body. A laparoscopic approach was decided on to remove it. A uretero-colonic fistula was identified. It was dissected and the foreign body was removed from the ureter and the sigmoid colon. The colon wall defect was repaired and a terminal uretero-ureteral anastomosis was performed with separate stitches. A 5 fr double-J ureteral stent was left in place for 4 weeks. Analysis of the foreign body revealed an organic composition compatible with a fish bone. After a 2-year follow-up, the patient remains asymptomatic with no residual hydronephrosis on ultrasound.

CONCLUSION

Uretero-colonic fistula can be treated using a minimally invasive laparoscopic approach. To our knowledge, this is the first report in the literature of a uretero-colonic fistula secondary to a foreign body in a child.

Tandem ureteral stents in the management of double-J stent dysfunction in gynecological malignancies

PURPOSE

The goal of this study was to determine the efficacy and safety of tandem ureteral stent placement in the management of malignant ureteral obstruction (MUO) refractory to single ureteral double-J stent drainage in women with gynecological malignancies.

MATERIALS AND METHODS

A retrospective study was performed on 14 women (mean age, 54.5±9.6 [SD] years; range: 38-70 years) who had tandem stent placement following failed single ureteral double-J stent placement from 2012 to 2017. Survival analyses were performed with Kaplan-Meier method.

RESULTS

Twenty-nine successful procedures were performed on 19 ureters (19 primary stent placement and 9 exchange procedures). Technical success of primary tandem stent placement was 95% (19/20 procedures). Mean follow-up was 180.1±173.7 (SD) days (range: 62-616 days). Median estimated survival of the patients was 118 days (Q1: 261, Q3: 95; range: 62-616 days). Primary stent failure rate was 25% and assisted stent failure rate was 21.4%. There was no significant difference among survival of patients with and without tandem stent failure. Mean estimated primary stent patency and assisted stent patency were 171.4±13.8 (SD) days and 409.9±59.8 (SD) days, respectively. Four patients underwent 1 to 3 stent exchanges. Median exchange time was 181 days (Q1: 151, Q3: 191, range: 141-214 days) and technical success rate was 100%. Grade 2 and 3 complication rates were 25% and 3.6%, respectively.

CONCLUSION

Tandem ureteral stent placement is a feasible, safe and effective procedure for the management of failed ureteral double-J stent placement in women with gynecological malignancies.

Spontaneous uretero-sigmoid fistula secondary to calculus

A 25-year-old man was referred to the urology department after a subacute history of left back pain, burning micturition associated with pneumaturia and fecaluria. Ultrasonography was performed showing hydronephrosis, and plain film radiography demonstrated a long vertical left pelvic calculi. Uro-computed tomography (CT) combined with a water enema CT showed a 10 cm long calculus with the cranial extremity fistulating the sigmoidal wall. Surgical treatment included left nephroureterectomy and sigmoidectomy with a colorectal anastomosis. Postoperative course was uneventful.

Ureteroenteric Fistula Revealed by 99mTc-DTPA Renal Scan

A 55-year-old woman with a history of cervical carcinoma, status post hysterectomy and radiation therapy 8 years prior, presented worsening back pain for 9 months. The patient underwent a Tc-DTPA renal scan, which showed that a vertically linear tracer distribution was seen alongside the right ureter. Ureteroenteric fistula was confirmed and repaired by surgery.