Ureteral injuries during vascular surgery

Urological complication following aortoiliac graft: case report and review of the literature

CONTEXT

Ureteral stenosis and ureterohydronephrosis may be serious complications of aortoiliac or aortofemoral reconstructive surgery.

CASE REPORT

A 62-year-old female patient presented with a six-month history of left lumbar pain. She was a smoker, and had mild chronic arterial hypertension and Takayasu arteritis. She had previously undergone three vascular interventions. In two procedures, Dacron prostheses were necessary. Excretory urography showed moderate left ureterohydronephrosis and revealed a filling defect in the ureter close to where the iliac vessels cross. This finding was compatible with ureteral stenosis, and the aortoiliac graft may have been the reason for this inflammatory process. The patient underwent laparotomy, which showed that there was a relationship between the ureteral stenosis and the vascular prosthesis. Segmental ureterectomy and end-to-end ureteroplasty with the ureter crossing over the prosthesis anteriorly were performed. There were no complications. The early and late postoperative periods were uneventful. The patient evolved well and the results from a new excretory urogram were normal. We concluded that symptomatic ureterohydronephrosis following aortoiliac graft is a real complication and needs to be quickly diagnosed and treated by urologists.

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.

Fatal recurrent ureteroarterial fistulas after exenteration for cervical cancer

BACKGROUND

Ureteroarterial fistula (UAF) is a rare occurrence. It can be difficult to diagnose with a high mortality. We report a case of a recurrent UAF.

CASE

A 38-year-old women diagnosed with cervical cancer had undergone pelvic exenteration for severe radiation-induced necrosis with a vesicovaginal and rectovaginal fistula after primary radiation therapy. Hemorrhage into the urinary tract necessitated surgical intervention and vascular repair with a femoral-femoral bypass. Although these measures were effective, the patient died 6 months later following an acute hemorrhage into her conduit. Arteriogram revealed a second UAF.

CONCLUSION

When urinary tract bleeding occurs in patients previously diagnosed with a gynecologic malignancy and treated with radiation therapy and extensive surgery with urinary diversion, UAF should be considered in the differential diagnoses.

Ureteric injuries: diagnosis, management, and outcome

OBJECTIVES

To define the current causes and the optimal methods of early diagnosis and management of ureteric injuries, both iatrogenic (excluding endourologic) and traumatic, and to determine the outcome of these injuries and which identifiable factors affect this outcome.

METHODS

A retrospective analysis was performed of all the 35 patients who sustained 40 ureteric injuries over a 5-year period (1991-1996). The methods used for diagnosis and management were reviewed. The outcome was assessed in terms of preservation of renal function.

RESULTS

The study group was composed of 28 patients with 32 iatrogenic injuries and 7 patients with 8 injuries caused by external trauma. Gynecologic procedures accounted for 63% (20 of 32) of the iatrogenic injuries, whereas motor vehicle crashes accounted for 75% of the external injuries (6 of 8 injuries). The successful diagnostic rate for direct inspection (intraoperatively), intravenous urogram, retrograde pyelogram, and anterograde pyelogram were 33% for the former two and 100% for the latter two. Treatment consisted of primary open repair in 26 cases, a staged procedure in 7 cases, and endoscopic stenting in 5 cases. Of 36 cases with follow-up, complications developed in 9 cases (25%), 7 cases of which were corrected surgically. Overall incidence of nephrectomy was 8%, and the factors that seemed to affect the outcome adversely were pediatric age (< or =12 years), injury to upper ureter, delay in recognition, the presence of a urinoma, and/or associated organ injury.

CONCLUSION

Iatrogenic trauma is the leading cause of ureteric injuries. The single controllable factor adversely affecting the outcome of this rather uncommon injury seems to be delayed diagnosis. Wound inspection and intravenous urogram are not reliable for early and accurate diagnosis, and a retrograde pyelogram or an anterograde pyelogram may be needed. Uncontrollable factors adversely affecting the outcome include young age, injury to upper ureter, and associated injuries all seen in association with external trauma rather than iatrogenic injuries.

Hematuria and death secondary to aortoureteric fistula

Ureteroarterial fistulae are extremely rare after previous vascular surgery. Eight cases have been described in the English literature. This is the first example of a vascular communication between the aorta and the ureter. All previous cases were ureteroiliac fistulae. Known hydronephrosis in the presence of prior vascular grafting and heavy hematuria should alert the clinician to the possibility of a ureteroarterial fistula.

Ureteroarterial fistula: case report and review of the literature

Ureteroarterial fistulae are rare. We report 2 cases of this clinical problem. Ureteroarterial fistulae can occur in association with prolonged ureteral stenting, radiation therapy, vascular pathology, and prior pelvic or vascular surgery. Identification of a fistula is often difficult and requires the physician to be highly alert and vigilant. Diagnostic and therapeutic options for a ureteroarterial fistula are discussed.

Iatrogenic ureteral injuries: a 20-year experience in treating 165 injuries

PURPOSE

We reviewed the causes, treatment and morbidity associated with iatrogenic ureteral injuries.

MATERIALS AND METHODS

From 1972 to 1992 the charts of all patients with the diagnosis of iatrogenic ureteral injury were reviewed and 156 injuries were identified.

RESULTS

Urological, gynecological and general surgical procedures accounted for 70 (42%), 56 (34%) and 39 (24%) injuries, respectively. Of the injuries 91% occurred in the lower third, 7% in the middle third and 2% in the upper third of the ureter, respectively. Among the urological lesions 77% were identified at injury compared to only 33% of the nonurological cases. Nonurological and urological ureteral injuries detected postoperatively required 1.8 and 1.6 procedures, respectively, compared to only 1.2 procedures in both groups (p < 0.0006 and p < 0.013) when the injuries were detected immediately at operation.

CONCLUSIONS

Endourological procedures are the most common cause of iatrogenic ureteral injuries. When identified at injury and treated properly such injuries seldom lead to loss of renal function.

Late complications after aortic surgery

The incidence of false aneurysms, anastomotic stenoses, and ureteric obstruction is reported to be low in patients who have undergone aortic surgery. The use of intravenous peripheral digital subtraction angiography (IVDSA) with completion excretory urography (CEU) may provide a more sensitive means of long-term detection of these complications. The aim of this study was to (1) establish the incidence of anastomotic aneurysms, anastomotic stenoses, and ureteric obstruction after aortic surgery; (2) identify local and systemic factors that predispose to these complications; and (3) evaluate IVDSA as a single radiologic investigation to diagnose these complications. Forty-four patients who had undergone aortic surgery 1 to 12.3 years previously agreed to undergo IVDSA and CEU. False aneurysms were found at 10 distal anastomoses (none at the aorta), for an anastomotic incidence of 11.2% and a patient incidence of 15.9%. Endarterectomy and the femoral artery as a site of distal anastomosis were important factors in the development of anastomotic aneurysms, as were detected radiologically at eight aortic anastomosis (18%). There were no distal anastomotic stenoses. Hypercholesterolemia was more common in this group (62.5%) than in the overall group (21.2%). Three asymptomatic ureteric obstructions were diagnosed in two patients, both of whom had emergency surgery for ruptured aortic aneurysms. The higher incidence of anastomotic aneurysms, anastomotic stenoses, and asymptomatic ureteric obstruction sound merits careful follow-up. IVDSA with CEU may be a simple and effective method of detection.

Vascular surgery-associated ureteral injury: zebras do exist

This report describes a case of direct ureteral injury sustained during retroperitoneal vascular surgery. The diagnosis was delayed and treatment was complicated by infection. To address the patient's problem initially and then to consolidate our impressions, a literature review was undertaken. The conclusions from this review suggest that direct ureteral injury during vascular surgery is rare but most common during redo surgery, is just as likely to be missed as discovered during surgery, and when missed may be so for months. The diagnostic delay is caused by a varied and often misleading presentation, and a ureteral contrast study is the ultimate diagnostic tool. In these delayed cases the typical ureteral treatment is a stented ureteroureterostomy or nephrectomy. In the present case the patient was otherwise healthy; therefore an aggressive attitude to renal salvage was taken. This is a unique case of ileal conduit replacement of the damaged ureter for this specific situation. Five years after repair, renal function is stable without infectious complications. The current literature would suggest that the vascular graft may be left undisturbed if the urine is sterile. If infection is present, graft removal appears the standard of care and was successful in the present case.

Ureteroarterial fistula: a case report

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.

Ureteral injury in abdominal vascular reconstructive surgery

Iatrogenic ureteral injuries in vascular reconstructive surgery are rarely reported. We present a case of ureteral transection during repair of an aortic aneurysm in a patient with a previously placed aortobifemoral graft. In reported series of surgical ureteral injuries, 17 of 381 injuries occurred during vascular procedures. A review of the literature and management scheme for ureteral complications in the presence of prosthetic vascular grafts is presented in light of current endourologic materials and techniques.

Uretero-iliac fistula--a rare cause of hematuria. Case report

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.

Ureteral obstruction after abdominal aortic surgery

Obstructive uropathy following abdominal aortic surgery can no longer be considered a rarity. Early hydronephrosis, developing in the first postoperative year, occurs in 10% to 20% of patients; it usually runs a benign, self-limiting course. The incidence of delayed ureteral obstruction, which develops or persists after the first postoperative year, is unknown because it is asymptomatic in most cases. Although spontaneous resolution is possible, it seems that this late form is more likely to persist. The diagnosis of postoperative hydronephrosis is not an indication for urologic intervention. This should seldom be necessary; it should be reserved only for patients with evidence of worsening obstruction or deteriorating renal function. Early and particularly, delayed hydronephrosis seems to be a marker for present or impending graft complications, such as infection or false aneurysms. A prolonged follow-up is therefore mandatory whenever the diagnosis is established as it may improve long-term survival and limb salvage. The need for routine screening for this condition remains to be established. With the availability of noninvasive methods, such a task could be easily accomplished.

Ureteral obstruction and ureteral fistulas after aortofemoral or aortoiliac bypass surgery

Ureteral injury after aortofemoral or aortoiliac bypass surgery has seldom been described in the literature considering the large number of bypass operations performed. Some causative factors, such as the position of the bypass, are obvious while others are less clear. However, no attempt has been made to unify criteria to establish a management protocol. Of 154 cases of ureteral units with ectasia reviewed ureteral fistulas were present in 19. Radiological ureteral obstruction appears to precede fistula formation. Symptoms, time of diagnosis and treatment according to the predominant etiology have been discussed. Etiological (in varying degrees of importance), clinical and diagnostic criteria, together with a management and therapeutic protocol in which early and late lesions are clearly differentiated were established, while bearing in mind that not all radiological obstruction patterns correspond to true ureteral lesions.

Ureteroarterial fistula: case report and review of literature

A fistula developed between the left common iliac artery and the distal left ureter of an 83-year-old woman who had undergone aortofemoral bypass grafting many years previously and in whom a Double-J stent was in place for 3 weeks while she was awaiting extracorporeal shock wave lithotripsy. Exsanguinating hemorrhage into the urinary tract necessitated emergency nephrectomy and vascular repair. Although these measures were successful temporarily, the patient died 6 weeks later of repeat myocardial infarction and acute renal failure. The increasing frequency of ureteral stent use and of an operation on the iliac arteries is expected to increase the frequency of these potentially catastrophic fistulas.

Ureteral injuries complicating vascular surgery: is repair indicated?

We have managed 8 patients who sustained an iatrogenic ureteral injury during either placement or revision of a vascular graft. Primary repair was performed in all 5 patients diagnosed at injury. Persistent extravasation necessitating nephrectomy occurred in 2 of these patients. The diagnosis was delayed in 3 patients. Two patients underwent successful ureteral reconstruction and 1 required nephrectomy. Graft complications did not occur. Ureteral repair is recommended as the preferred method to manage ureteral injuries associated with vascular reconstruction.

Ureteral leak around an aortic bifurcation graft: complication of ureteral stenting

Aortoiliac bypass surgery has a 2 to 20 per cent incidence of ureteral injury causing postoperative hydronephrosis frequently without symptoms. We describe a patient in whom a ureteral stricture developed 12 days after placement of an aortic bifurcation graft. Treatment consisted of ureteral dilation and stenting following which a ureteral leak developed around the bifurcation graft from the stented dilation site, presumably from pressure necrosis of the ureter caught between the pulsating graft and the ureteral stent. The patient did well with external nephrostomy drainage. We conclude that ureteral stenting of patients suffering from significant aortoiliac disease should be approached with great caution, using the softest stent material available.

Ureteroarterial fistula: a case report

We report on a patient with a fistula between the right common iliac artery and the distal right ureter who had undergone pelvic exenteration for carcinoma of the uterine cervix. The patient also had received prior radiation therapy and was being treated with an indwelling ureteral stent at the time the fistula developed. Diagnosis was made by an occlusive ureterogram and the lesion was treated successfully with embolization of the common iliac artery.