Diagnosis and treatment of arterial-ureteric fistula

Early diagnosis and management of arterio-ureteral fistulas: A literature review

OBJECTIVES

Arterio-ureteralfistula (AUF) is an infrequent but potentially life-threatening condition. The aim of this study was reviewing the literature to build a flow-chart useful for an early and effective diagnosis and treatment of this pathology.

MATERIALS AND METHODS

A literature search in PubMed was conducted. In addition, retrieved articles were cross-referenced. Data parameters included oncologic, vascular and urological history, diagnostics, treatment, and follow up were collected using a standard template by 2 independent reviewers.

RESULTS

A total of 140 cases of AUF out of 172 available in the literature at the time of the review, were considered. All patients presented gross hematuria. Chronic indwelling ureteral catheter (CIUC); history of pelvic surgery (HPS) and history of pelvic radiotherapy (HRT) were present respectively in 81%, 62.1%and 58.6% of the sample. The most predominant location of AUF was at the common iliac artery ureteral crossing. Angiography with provocative measures had the highest diagnostic sensitivity (50%) and endovascular treatment with stent-graft placement across the fistula is the current state of the art treatment choice.

CONCLUSIONS

Failure to diagnose can postpone a potentially life-saving targeted therapy and lead to complications. The identifi-cation of the Trifecta hematuria, history of pelvic surgery (HPS) and history of pelvic radiotherapy (HPR) would allow the identity-fication of patients at high risk of AUF, who may benefit from more sensitive early diagnostic investigations such as CT angiography and provocative angiography. The treatment of choice in case of AUF to date consist in endovascular prosthesis placement.

Arterioureteral fistula after radical cystectomy and ureterocutaneostomy: two case reports and a systematic literature review

Background

Arterioureteral fistula (AUF) is a rare, life-threatening condition wherein communication occurs between a ureter and the common, internal, or external iliac artery. The sensitivity of common clinical imaging examination for AUF is low, which leads to a delayed diagnosis and increased mortality. In addition, the increased use of ureteral stents contributes to the growing frequency of AUF.

Case presentation

Our two patients were 74 and 65 years old males respectively. They both had a medical history of bladder cancer and underwent radical cystectomy with ureterocutaneostomy. The patients underwent routine catheter exchange during over 1 year postradical cystectomy and subsequently experienced intermittent gross pulsatile haematuria. After a series of imaging examinations failed to identify the cause, the patients were ultimately diagnosed with AUF and treated with interventional radiotherapy, followed by broad-spectrum antibiotics. Positive effects were found.

Conclusions

The incidence of AUF is increased with the prolongation of survival in patients with related risk factors. This case report aims to highlight early diagnosis and management of AUF to lower the mortality.

External iliac artery pseudoaneurysm following treatment for arterio-ureteral fistula using a balloon-expandable stent-graft: A case report

Sepsis and bleeding can lead to life-threatening complications, such as stent-graft infection and pseudoaneurysm, after stent-graft implantation. An 83 year-old woman was admitted to our hospital for sepsis 14 months after treatment with a balloon-expandable stent-graft for an arterio-ureteral fistula (AUF) between the right external iliac artery and the right ureter. Blood cultures were positive for methicillin-resistant Staphylococcus aureus and Candida tropicalis. A giant infectious pseudoaneurysm (44 × 70 mm) at the distal edge of the stent-graft was suspected of having caused the sepsis. Although endovascular therapy (EVT) was planned to correct the pseudoaneurysm, the right iliac artery spontaneously became occluded from the ostium of the right common iliac artery to the common femoral artery 5 days after diagnosing the pseudoaneurysm; hence, EVT was not performed. Antibiotic administration was continued, and blood culture results were negative. Although EVT using a stent graft for AUFs is effective, data on the chronic phase outcomes are limited. Therefore, patients with AUFs treated using stent-grafts should be carefully followed up.

Midterm Results after Open Surgical and Endovascular Management of Arterioureteral Fistula

BACKGROUND

Arterioureteral fistula refers to the anomalous fistulous connection between the iliac artery and the ureter. It is often associated with pelvic malignancy, abdominal surgery, and radiation. As it is a potentially life-threatening condition, prompt diagnosis and management is essential.

METHODS

We performed a retrospective analysis of patients treated for arterioureteral fistula in a single-vascular institution from January 2013 to March 2019. Preoperative assessment included physical and laboratory examinations and medical history, with diagnosis established through computed tomography angiography, digital subtraction angiography, or ureteroscopy. Parameters analyzed included perioperative mortality and morbidity as well as treatment durability during midterm follow-up.

RESULTS

Nine patients with ten arterioureteral fistulas were included in the study. Macroscopic hematuria was the main presenting symptom, with 2 patients admitted due to hemorrhagic shock. Endovascular treatment was carried out in 6 patients. In 4 cases, single stent-graft deployment inside the common iliac artery was performed, in one case in combination with plugging of the internal iliac artery. One patient underwent implantation of an iliac-branched device, whereas in another patient coiling of the internal iliac artery sufficed for management of the fistula. Open surgical repair was carried out in three cases. Perioperative mortality was zero; one patient had prolonged hospital stay due to superficial wound infection. Recurrent hematuria and stent-graft infection were observed during follow-up in three patients after endovascular repair, all of them treated through open surgery with no further complications. One patient developed an enterocutaneous fistula after open repair during follow-up and required redo surgery.

DISCUSSION

Arterioureteral fistula is a challenging clinical scenario demanding prompt diagnosis and management. Open surgery remains the treatment of choice in cases of preexisting vascular reconstruction or manifest infection. Endovascular techniques offer a viable solution in significantly comorbid patients or in patients presenting with acute, life-threatening bleeding. Rigorous follow-up is required regardless of treatment modality due to the considerable rate of reinterventions.

Ureteral Arterial Fistula - A Role for Open Operation in the 21st Century

BACKGROUND

Ureteral arterial fistula is a rare and challenging clinical entity. The diagnosis and management of ureteral arterial fistula present a unique disease process that requires a dual specialty approach, involving both vascular and urologic surgeons. There are different options for repair, including both open and endovascular techniques.

METHODS AND RESULTS

A 78-year-old male presented to the emergency department (ED) in septic shock secondary to a urinary tract infection and was admitted to the intensive care unit (ICU) for further management and resuscitation. The patient had previously undergone radical cystoprostatectomy with ileal conduit creation in 2011 for recurrent bladder cancer. Following creation of his ileal conduit, he required long-term indwelling ureteral stents bilaterally due to recurrent stricturing at the ureteroneocystostomy with stent exchanges performed 2-3 times per year due to frequent urinary tract infections. During his hospitalization for sepsis, the urology service performed an exchange of his left indwelling ureteral stent. However, pulsatile bleeding was observed from the junction of the ileal conduit and left ureter. The stent was replaced at the bedside, and the bleeding ceased. Vascular surgery consultation and a computed tomography angiogram (CTA) gave support to the diagnosis of a ureteral arterial fistula. A plan was developed to exchange the stent in the operating room with vascular surgery assistance. It was determined that a definitive open repair with excision of the fistula would be the most appropriate course.

CONCLUSIONS

In the setting of hemodynamically significant bleeding, we recommend an endovascular approach to obtain hemostasis. However, an open approach provides both reconstruction and infectious resistance in an already soiled field. Open repair may provide a more definitive reconstruction.

Endovascular and open surgical options in the treatment of uretero-arterial fistulas

Objective

To report and analyze the indications and results of endovascular and open surgical treatment for uretero-arterial fistula.

Methods

We retrospectively reviewed the clinical data of 25 consecutive patients with uretero-arterial fistulas admitted to our hospital from 2011 to 2020. Endpoints were technical success, freedom from open conversion, stent-graft/graft-related complications, and 30-day and one-year mortality.

Results

The study included 25 patients (68% female, n = 17) with 27 uretero-arterial fistulas by bilateral pathologies in two patients. The mean age was 61 ± 11 years (range 35–80). The most common predisposing factors for uretero-arterial fistula were history of pelvic operations for malignancy in 21 patients (84%), radiotherapy in 21 patients (84%), previous pelvic vascular bypass in 2 patients (8%), and iliac aneurysms in 2 patients (8%). On average, the period between the primary pelvic surgery and the diagnosis of uretero-arterial fistulas was 46 months (range 7–255). Twenty patients (80%) underwent endovascular treatment of the uretero-arterial fistulas. The primary technical success of the endovascular treatment was 95%, and the freedom from open conversion was 40% at six months and 30% at one year. Thirteen uretero-arterial fistulas (48%) underwent delayed open conversion due to recurrent bleeding in six cases (46%), stent-graft infection in three cases (23%), or pelvic abscess in four cases (31%). Primary open surgery was applied for five (20%) patients. After a mean follow-up of 34 months, early (<30 days) mortality was 8% (2/25), one-year mortality 16% (4/25), and overall mortality was 24% (6/25).

Conclusions

Uretero-arterial fistula is a late complication of prior pelvic surgery, radiation, and indwelling ureteral stents. Endovascular treatment remains an effective and less invasive modality in controlling the related life-threatening arterial bleeding of the uretero-arterial fistula. Open surgical treatment is still required for patients with local sepsis, previously failed endovascular treatment or infected stent-grafts.

Endovascular treatment of arterio-ureteral fistula with new-generation balloon-expandable stent graft using a 7-French system

Arterio-ureteral fistulas are relatively rare, but a potentially life-threatening condition because of the possible massive bleeding. An 82-year-old woman with a history of hysterectomy and irradiation for uterine cancer was treated with ureteric stents for recurrent bilateral ureteral stenosis. During the adjustments of the stent, removing the right ureteric stent immediately resulted in massive hematuria. Computed tomography showed that the right ureter coursed above and seemed to be connected to the right external iliac artery. From the clinical history and computed tomography findings, an arterio-ureteral fistula between the right external iliac artery and right ureter was strongly suspected. The GORE^® VIABAHN^® VBX Stent Graft was deployed from the common iliac artery to the external iliac artery via a 7-French femoral system, followed by post-dilatation. The patient did not develop any complications or recurrence of hematuria after the procedure during the 11-month follow-up. The VBX is a useful device, with a low- profile device and a size-adjustable balloon-expandable stent that depended on the individual vessel size for post-dilatation. However, there are several concerns, such as risk of infection, stent thrombosis/stenosis, and chronic outcome while using stent grafts for treatment. Patients with arterio-ureteral fistulas who were treated using stent grafts should be carefully followed up.

A Bleeding Uretero-Arterial Fistula: Open Repair After Unsuccessful Endovascular Treatment

INTRODUCTION

Uretero-arterial fistula (UAF) poses major challenges in management and diagnosis due to the rarity of this condition and associated high morbidity/mortality rates.

METHODS

We describe a case of a UAF associated with previous aorto-biiliac grafting, ureteric stenting and right nephrectomy because of chronic pielonephritis and complicated by surgical site infection. This case illustrates a very complex pathology, with a challenging diagnosis and multiple treatment options.

RESULTS

A 72 year-old woman was referred to Vilnius Vascular Unit for open UAF repair. The patient had a history of open abdominal aortic aneurysm repair using a bifurcated graft 25 years ago. The right ureter was injured during the operation and a rigid indwelling ureteric stent was inserted. Six months prior to referral, she underwent a right nephrectomy due to a chronic pyelonephritis, complicated by surgical site infection, which was still present at the time of admission. Initial CTA demonstrated bilateral iliac aneurysms, but no signs of UAF. A further CTA revealed a UAF between the right ureteral stump and the right common iliac artery (CIA) para-anastomotic aneurysm. After unsuccessful attempts to embolize the UAF using both coils and glue, the patient was referred to Vilnius Vascular Unit for open repair. Left axillo-bifemoral bypass reconstruction was performed followed by UAF repair and bifurcated graft explantation. Follow-up after 2 years showed no recurrence of haematuria, good function of the remaining kidney and patent axillo-bifemoral bypass with no signs of infection around the prosthetic aortic stump.

CONCLUSIONS

Uretero-arterial fistula is a uncommon condition in everyday clinical practice. The rarity of this condition may lead to delayed or missed diagnosis which can result in life-threating consequences. A multidisciplinary approach involving urologists, vascular surgeon and radiologist are crucial to both the diagnosis and managment of this rare entity.

Ureteroarterial fistula treated by endovascular stent placement

A 69-year-old woman with changes secondary to pelvic radiotherapy presents repeated episodes of massive hematuria associated with double J catheter replacements. After several imaging tests, an uretero-arterial fistula is confirmed by angiography and treated with a coated stent. Uretero-arterial fistula poses a diagnostic challenge, requiring a multidisciplinary approach through clinical suspicion and interventional procedures.

Incidence, management, and sequelae of ureteric obstruction in women with cervical cancer

PURPOSE

Hydronephrosis due to ureteric obstruction (UO) is stage-defining at cervical cancer presentation but may occur after primary staging. We aimed to determine the incidence and review the presentation and management of UO in women with cervical cancer attending our center. Particular attention was paid to the evolving role of interventional radiology (IR) in management.

METHODS

Women with a new diagnosis of cervical cancer between January 2012 and December 2016 formed the cohort that was retrospectively reviewed from the oncology database and patient records.

RESULTS

There were 310 women diagnosed with cervical cancer; 240 were stages I/II and 70 were stages III/IV. Primary treatments were chemoradiotherapy (n = 168; 54.2%), surgery (n = 121; 39.0%), and palliative care alone (n = 21; 6.8%). UO occurred in 74 (23.9%); present at primary staging in 53 (71.6%) and arising after staging in 21 (28.4%). Primary interventions for hydronephrosis were IR (n = 50; 67.6%), cystoscopic stenting (n = 19; 25.7%), bowel urinary conduit construction (n = 2; 2.7%), and none (n = 3; 4.1%). For those who attended IR, the mean number of IR procedures was 2.2, range 1-7. Maximum serum creatinine was 303 μmol/L for women with UO at primary staging compared with 252 μmol/L for UO after staging (P = 0.267). Thirty-eight women experienced substantial morbidity related to UO. Stage-adjusted mortality risk was 2.3 times higher for UO cases compared with those without UO.

CONCLUSIONS

UO is associated with substantial morbidity and survival disadvantage in cervical cancer and may present after primary cancer staging. We recommend renal biochemistry during routine follow-up. A majority of cervical cancer-associated UO cases are managed with IR in our center.

Endovascular Management of Ureteroarterial Fistula: Single Institution Experience and Systematic Literature Review

Background:

Ureteroarterial fistula (UAF) represents an uncommon complication after urological surgery; however, this is a well-documented condition in patients with predisposing risk factors. The aim of the present study is to report and analyze the endovascular management of a series of patients with UAF, treated in authors’ hospital, and to report and analyze the same data concerning patients retrieved from a systematic literature review.

Methods:

Authors conducted a retrospective analysis of prospectively collected data and a systematic literature review. The research was carried out through PubMed database searching the following keywords: “uretero arterial fistula” and “uretero iliac fistula.” It includes only articles reporting the endovascular management.

Results:

Forty-six articles were included in the present study for a total of 94 patients. Risk factors were as follows: chronic indwelling ureteral stents, pelvic surgery, radiotherapy, iliac artery pseudo-aneurysm, and chemotherapy. All patients had gross hematuria at presentation. Stent graft placement was performed in 89 patients, embolization in 5 patients, and iliac internal artery embolization combined with stent graft placement was performed in 24 patients. Four postprocedural complications were observed (4.2%). During a median follow-up of 8 months, 10 complications related to UAF were observed (10.6%): rebleeding (7 cases) and stent thrombosis (3 cases). Two patients died for causes related to UAF (2.1%): rebleeding (1) and retroperitoneal abscess (1).

Conclusion:

Based on the present data, endovascular treatment is feasible and safe with low postprocedural complications and mortality rate. Considering the increase in surgery and radiotherapy performed, UAF should be always debated in patients with massive hematuria.

Arterioureteral fistula: an unusual clinical case

Arterioureteral fistulas (AUFs) are abnormal communications between a major artery and the mid to distal ureter. It is a rare but potentially life-threatening condition that is seldom recognised. We present a case of a 66-year-old man who was admitted to the surgical ward owing to infection of an aortic bifemoral bypass graft. During admission, the patient developed persistent haematuria with considerable loss of haemoglobin. He was submitted to urgent surgical exploration of the graft. An ascending pyelography performed at the beginning of the surgery clearly shows a communication between the left ureter and the vascular graft. Open surgical exploration was undertaken, the fistulised section of the ureter resected and an end-to-end ureteroplasty was performed. The vascular graft was removed and the patient later submitted to left supracondylar amputation. Urinary drainage remained intact.