Systematic Review of the Management of Ureteroarterial Fistulas After Ileal Conduit Urinary Diversion

OBJECTIVE. No studies or guidelines exist to direct management of ureteroarterial fistula (UAF) after ileal conduit urinary diversion in which the possible risks and complications associated with stent-graft infection from the conduit flora must be reconciled with those of open surgical repair. This study seeks to characterize the clinical presentation, pathogenesis, and optimal diagnostic and therapeutic management of this entity through a systematic review of the literature. MATERIALS AND METHODS. A systematic search of the English-language literature using the PubMed, Scopus, and ScienceDirect databases was performed: 264 abstracts were identified. From those abstracts, 32 studies comprising 40 patients with 43 UAFs were selected for analysis. Data points including demographics, clinical presentation, UAF specifications, procedural details, postprocedural complications, and clinical outcomes were reviewed. RESULTS. Predisposing factors included female sex, chronic ureteral stent placement, and past surgical intervention and irradiation for pelvic malignancy. Fistulization was overwhelmingly unilateral (95.0% of patients) and included the common iliac artery (90.7% of UAFs). Combined endovascular and endoureteral modalities presented similar outcomes compared with surgical approaches in terms of UAF-related mortality (7.1% vs 13.3%, respectively) and complication rates (28.6% vs 26.7%) during a similar median follow-up period (9.5 vs 14.0 months). Endovascular stent-graft infections were present in 14.3% of cases and represented a leading indication for reintervention after endovascular management (50.0%). CONCLUSION. Short- and intermediate-term outcomes of combined endovascular and endoureteral techniques compare favorably with those of surgical approaches in the treatment of UAF after ileal conduit urinary diversion. Although there is a relatively low stent-graft infection rate, close follow-up within the first year after the procedure is required given the propensity of complications to develop during this window. The use of postprocedural antibiotics is uncertain but is likely prudent.

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.