Silent arterio-ureteral fistula: Diagnosis and endovascular management

We report a patient with history of recurrent invasive rectal adenocarcinoma complicated by obstructive uropathy requiring nephro-ureteral catheter placement. Two years later during a regular catheter exchange, the patient developed unusually bloody urine raising suspicion for possible vascular injury. CT angiogram and conventional angiogram were negative. However, an antegrade nephrostogram revealed a fistulous communication between the right ureter and the right internal iliac artery. Subsequently, the artery was sacrificed using detachable coils. We discuss the rare encounter of a silent arterio-ureteral fistula, the value of antegrade nephrostogram as a diagnostic tool, and the management options in such scenario.

Radiation-Related Fractures after Radical Radiotherapy for Cervical and Endometrial Cancers: Are There Any Differences?

In this study, we reviewed CT/MRI scans and studied the rates of radiation-related fractures in subjects treated for cervical cancer (CC, 63 subjects) by radical radiotherapy (RT) and in subjects treated for endometrial cancer (EC, 64 subjects) by radical surgery and RT. The differences between bone density measured in L1 on pretreatment CT, age and body mass index (BMI) were evaluated. Despite significant differences in RT total dose, age, BMI, etc., between both groups, the rate of radiation-related fractures was similar: 28.6% of CC versus 26.6% of EC subjects. CC subjects with fractures were significantly older (62.4 ± 10.1 vs. 49.0 ± 12.4 years; p < 0.001), and their bone densities were significantly lower (106.3 ± 40.0 vs. 168.2 ± 49.5 HU; p < 0.001); no difference in BMI was found. EC subjects with fractures were without significant difference in age but had significantly lower bone densities (103.8 ± 29.0 vs. 133.8 ± 42.3 HU; p = 0.009) and BMIs (26.1 ± 4.9 vs. 31.8 ± 6.9 kg/m2; p = 0.003). Bone density strongly correlated with age (r = -0.755) only in CC subjects. Subjects with fractures from both groups had similarly low bone densities (106.3 ± 40.0 vs. 103.8 ± 29.0 HU; p = 0.829); however, no correlation between bone density and BMI was found. The rate of radiation-related fractures in both groups was clearly associated only with low pretreatment bone density, reflecting osteoporosis.

Successful, staged management of an iliac artery to ileal urinary conduit fistula

Fistula formation between the iliac artery and an ileal conduit is a rare pathology. A 39-year-old female patient presented with intermittent hematuria from her ileal conduit for 4 days, which progressed to massive hemorrhage on the ward. Her background includes stage 4A squamous cell carcinoma of the cervix treated with pelvic chemoradiotherapy and brachytherapy, recurrent obstructive uropathy requiring bilateral nephrostomies and bilateral ureteral stenting. Twelve months before this presentation, she had been treated for an iliac artery-ileal conduit fistula with a covered stent to the left common iliac artery. After initial fluid resuscitation, the bleeding was managed with endovascular placement of a covered stent. She subsequently underwent definitive vascular reconstruction with removal of the common iliac artery stents, an aortoiliac bypass using a vein graft, and repair of the ileal conduit electively. This case demonstrates the management of a rare clinical pathology and highlights the importance of close surveillance after endovascular procedures.

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.

[Uretero-iliac artery fistula as a urological emergency]

Uretero-iliac artery fistulae represent a urological emergency with considerable mortality. We present 2 cases of a uretero-iliac artery fistula. Nowadays, minimally-invasive endovascular therapy seems to be the treatment of choice. For an optimal outcome, a multidisciplinary team with imminent availability of radiology, vascular surgery, urology and anaesthesia is required.

Ureteroiliac fistula after oncological surgery: Case report and review of the literature

Fistulas arising between ureters and iliac arteries (UAF) are rare pathological events and frequently require emergency treatment, as they are associated with massive haematuria and haemorrhagic shock. The medical history plays a key role in the diagnostic and therapeutic process, as it allows to include UAF among the differential diagnoses of gross haematuria. The emergency treatments of fistulas arising between the urinary system and the vascular system include the open repairing surgery or the endovascular grafting, the latter generally better tolerated by patients suffering from multiple comorbidities or not eligible for traditional surgery. Nephrostomy or ureteral stent can be used to drain the affected upper urinary tract temporarily or permanently. Herein, we reported two cases of oncological patients affected by UAF and treated successfully by endovascular procedures. Furthermore, we performed a narrative review of the literature concerning UAF and its diagnostic and therapeutic management. Although our study did not allow us to state definitive conclusion about the diagnostic and therapeutic management of UAF due to small sample size, our findings support previous experiences in favour of the treatment of fistulas with an endovascular approach.

Ureteral- artificial iliac artery fistula: A case report

BACKGROUND

Ureteral-iliac artery fistula is a rare disease resulting from the pathological connection between the ureter and iliac artery, with artificial iliac artery-ureteral fistula being rarer. Iliac artery ureteral fistula is challenging to diagnose, and the misdiagnosis and mortality rates are high.

CASE SUMMARY

A case of artificial iliac artery ureteral fistula was reported in this paper. The patient was a 69-year-old male with paroxysmal painless hematuria. The artificial iliac artery ureteral fistula was diagnosed by angiography. The hematuria was stopped after intravascular embolization, and no bleeding occurred after 6 months of follow-up.

CONCLUSION

Ureteral arterial fistula should be considered when inconspicuous hematuria with previous iliac vessels is encountered in addition to local ureteral surgery history. A rapid endovascular approach is recommended for fistula identification.

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.

Pelvic Irradiation: A Rare Cause of Concomitant Radiation Cystitis and Uretero-Iliac Artery Fistula Causing Gross Hematuria and Hemorrhagic Shock

Uretero-iliac artery fistulas (UIAFs) are a rare cause of gross hematuria. They form as a result of poorly vascularized uretero-iliac adhesions and the resultant fibrosis and chronic inflammatory changes. Causes include previous pelvic surgery, radiotherapy, and chronic ureteral stenting. The presentation is usually intermittent massive gross hematuria with acute anemia and hemorrhagic shock. A high index of suspicion is warranted in patients with predisposing factors for prompt diagnosis and management as it may be associated with life-threatening hemorrhage. Due to the intermittent nature of symptoms, identification is not always apparent. Open surgical repair was the treatment of choice in the past. With advancements in interventional radiology techniques, endovascular stenting of the iliac artery and concomitant ureteral stenting is the current treatment of choice. We report a case of massive gross hematuria leading to hemorrhagic shock with underlying UIAF and predisposing risk factor of pelvic irradiation. Our case report describes the diagnostic challenges with associated comorbid conditions causing delays in successful management.

A Challenging Case of Ureteroiliac Artery Fistula Managed With an Endovascular Approach

Ureteroarterial fistula (UAF) is a rare but life-threatening condition because of massive hemorrhage. Risk factors include degenerative vascular diseases, previous vascular surgery, pelvic radiation, chemotherapy, pelvic surgery, and prolonged ureteral stenting. The most common presentation of UAF is massive hematuria with hemorrhagic shock. The diagnosis is always difficult even with angiography. Endovascular repair with stenting and/or coiling is effective and safe. The surgical treatment should be used in recurrent UAF cases. We reported a rare case describing rapid management of a UAF in a patient who presented with hematuria even when we had no diagnosis on the initial CT scan. The patient was in shock. Deployment of a stent graft within the common iliac artery bypassing the UAF was performed. The patient improved rapidly.

A multidisciplinary case of ureteroiliac fistula after radical cystectomy

Ureteroiliac fistula is a rare complication associated with ureteral stenting and iliac artery reconstruction and can lead to life-threatening hemorrhage. We report a case of acute bleeding from a ureteroiliac fistula in an 89-year-old man with bladder cancer who had undergone pelvic radiation, radical cystectomy, and ileal conduit complicated by ureteral strictures requiring routine stent exchanges. Multidisciplinary diagnostic therapies revealed the fistula, which was treated with hypogastric artery coiling and covered stent placement. No further bleeding issues had resulted from the fistula at 11 months of follow-up. The presence of a ureteroiliac fistula should be considered in any patient with a similar history.

[A CASE OF URETEROARTERIAL FISTULA REQUIRING SURGICAL TREATMENT AFTER ENDOVASCULAR STENT PLACEMENT]

A 36-year-old woman was operated on at the age of 29 years for cervical cancer, and bilateral ureteral stents were inserted during radical hysterectomy. Subsequently, total pelvic irradiation and para-aortic lymph node irradiation were administered as postoperative radiation therapy. Four years following the surgery, the patient visited previous hospital for ureteral stent replacement; however, following this visit, there was no further contact with her. Seven years after the surgery, the patient presented with gross hematuria. Removal of right ureteral stent led to the observation of severe bleeding. The patient was, thus, transferred to our hospital because of suspected right ureteroarterial fistula. Angiography and intravascular ultrasonography showed a pseudoaneurysm at the distal end of the right common iliac artery. Thus, an endovascular stent graft was placed in the right common iliac artery, which led to resolution of the gross hematuria. One month after discharge, the patient developed right pyelonephritis and hydronephrosis; thus, she underwent right nephrostomy. Six months after undergoing right nephrostomy, the patient developed a fever of 39°C and started bleeding from the site of the right nephrostomy. A computerized tomography scan revealed a pseudoaneurysm in the right common iliac artery, and the endovascular stent graft was seen sliding into the artery. Thus, endovascular stent graft removal, pseudoaneurysm resection, and femoral-femoral artery bypass surgeries were performed. Thereafter, the patient showed no recurrence of infection or hematuria and no evidence of blood flow disorder to the lower extremities. In recent years, endovascular treatment for ureteroarterial fistulas is considered as the first-line treatment modality. However, in cases with infection, there is a possibility of vascular wall weakening, resulting in the formation of pseudoaneurysms, and sliding of the endovascular stent graft.

Successful transcatheter arterial embolization for uretero-inferior epigastric arterial fistula: A rare complication of cutaneous ureterostomy

A 70-year-old man presented with pulsatile bleeding upon changing his catheter for cutaneous ureterostomy. He was suspected to have a uretero-arterial fistula. Computed tomography showed an abnormally dilated right inferior epigastric artery, the suspected bleeding source. Angiography revealed a tortuous dilated branch from the inferior epigastric artery. Transcatheter arterial embolization was performed with a gelatin sponge and coil. He was discharged 15 days after the procedure. Uretero-arterial fistula is a rare but fatal complication among patients with long-term indwelling ureter catheters. An abnormal inferior epigastric artery surrounding the cutaneous ureterostomy should be considered a rare cause of uretero-arterial fistula.

Management and endovascular therapy of ureteroarterial fistulas: experience from a single center and review of the literature

Background

Ureteroarterial fistula (UAF) is a rare but potentially life threatening disease. The aim of this study was to evaluate the outcome of endovascular therapy for UAF treatment.

Methods

This retrospective case series evaluates a single center experience of percutaneous stent graft (SG) angioplasty and/or coil embolization for UAF. Patient follow-up included technical and early clinical success, complications and revisional procedures. We also conducted a systematic review of the literature reporting on endovascular UAF management.

Results

We identified 17 UAF in 16 patients (12 male, 4 female, mean age 69.8 ± 11.3 years) who underwent endovascular UAF therapy at our tertiary hospital. All patients presented with hematuria. 5/17 (29.4%) presented with flank pain, in 7 (41.2%) cases patients were in hypovolemic shock. Risk factors of UAF included chronic indwelling ureteral stents in all fistulas, major pelvic surgery in 13 cases (76.5%). In 6 cases (35.3%) SG were placed from the common iliac artery (CIA) to the external iliac artery (EIA) following coil embolization of the proximal internal iliac artery (IIA). SG placement without previous coil embolization was performed in 10 fistulas (58.8%). In one case only coil embolization of the IIA was performed. Mean follow-up was 654 (range: 1–3269) days. All procedures were technically successful and no procedure related deaths occurred during follow-up. During the initial hospital stay hematuria disappeared in 14/17 cases (82.4%). Overall, four patients suffered recurrent hematuria, which in three cases resolved after a secondary intervention. One recurrent UAF related death occurred during follow-up 229 days after initial treatment.

A total of 152 UAF cases were additionally analyzed from our systematic literature review: SG placement with or without embolization was performed in 140 cases (92.1%) while embolization alone was done in 12 cases (7.9%). Complications included UAF recurrence (18/152, 11.8%), SG thrombosis (7/140, 5%), and SG infections (5/140, 3.6%) with an overall complications rate of 13.8%. Five patients died due to UAF (3.3%).

Conclusion

Endovascular therapy offers high technical success rates and rapid bleeding control of UAF. Severe complications like SG occlusions or SG infections are rare but significant. Antibiotic treatment and single anti-platelet therapy improve SG durability as well as close and long follow-up to timely perform repeated endovascular or surgical treatment if necessary.

Evidence-based medicine

Level 4, case series.

Ureteroarterial fistula embolization by transradial approach: A case report

Ureteroarterial fistula is a rare condition wherein a communication develops between a ureter and the common, internal, or external iliac artery. Localizing the fistula can be difficult, as cystoscopy, CT angiography, and conventional angiography have low sensitivity in identifying the fistula. Provocative maneuvers within the ureter, however, can aid in the visualization of fistulae on angiography. Prior reports of endovascular repair have utilized transfemoral access, which makes performing concurrent provocative maneuvers in the ureter challenging. We present a case of successful endovascular ureteroarterial fistula localization and embolization in an 80-year-old woman with recurrent gross hematuria by the transradial approach, aided by concurrent provocative maneuvers performed via cystoscopy. The transradial endovascular approach facilitated a multi-disciplinary joint procedure that resulted in effective treatment of the patient.

Advanced cervical cancer in young women: imaging study of late and very late radiation-related side effects after successful treatment by combined radiotherapy

Background

Radical combined radiotherapy (RT) is a standard treatment for advanced cervical cancer. The aim of our study was to identify morphological late (≥6 months) and very late (≥5 years) radiation-related comorbidities on computed tomography (CT), positron emission tomography/computerized tomography (PET/CT) or magnetic resonance imaging (MRI) scans in young females who survived ≥5 years since RT and were considered as successfully treated. Secondly, we studied a rate of clinically silent radiation-related toxicities apparent on imaging scans that might influenced on future well-being of survived females. Thirdly, we analyzed reasons why patients underwent imaging scans.

Methods

We included 41 subjects aged under 50 years (mean 41.8±7.2 years, median 41 years), who survived ≥5 years since RT, with at least one available imaging scan ≥3 years since RT. The mean time between RT and the last available scan was 12.3±7.9 years (median 9 years); the mean time of clinical follow-up was 15.4±7.1 years (median 14 years).

Results

Fourteen (34.1%) females underwent the first imaging scan in emergency situation and 27 (65.9%) patients due to variable chronic complaints. Grade III-V radiation-related comorbidities occurred in 19 (46.3%) females including one case of death due to radiation-induced osteosarcoma. In 14 of 19 patients, comorbidities were multiple. Four (9.8%) females suffered from life-threatening complications (grade IV): one from an uretero-arterial fistula with massive hematuria and 3 from bowel perforations. Eleven (26.8%) subjects suffered from bowel strictures with ileus development, they underwent mean 1.7±0.8 surgery (median 1.5). The mean time since RT to the first surgery for intestinal complications was 5.4±6.0 years (median 3 years), to the second 12.0±9.6 years (median 11.5 years) and to the third surgery 9.0±4.2 years (median 9 years). Late fistulas formations (vesico-recto-vaginal) were seen in 6 (14.6%) patients. Bone complications were diagnosed in 9 (22.0%) of treated females, one case of osteosarcoma included, 4 of 9 bone complications were clinically silent. In 5 (12.2%) subjects, toxicities grade III-IV first time manifested >5 years since RT, majority of them were multiple. The bowel perforation and fistulas formations were the earliest manifested grade III-IV toxicities, with median time 3 years since RT, the bone complications were the latest manifested with median time 16 years since RT.

Conclusions

Our study is not able to bring information about the incidence of late and very late radiation related comorbidities, according to International Federation of Gynecology and Obstetrics (FIGO) recommendations patients are clinically followed only for 5 years and imaging cross-sectional scans are not recommended. However, our study shows that if females successfully treated for advanced cervical cancer report abdominal/pelvic clinical problems, it is highly probable their imaging scans will reveal late radiation related side-effects that may affect the rest of their life. It puts forward question whether females after radical RT should been regularly followed by cross-sectional imaging methods.

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.

Complications of Ileal Conduits after Radical Cystectomy: Interventional Radiologic Management

Since their introduction into clinical practice in the 1950s, ileal conduits have been the most common type of urinary diversion used after radical cystectomy worldwide. Although ileal conduits are technically simpler to construct than other forms of urinary diversion, a variety of complications can occur in the early and late postoperative periods. Early complications include urine leakage, urinary obstruction, postoperative fluid collection (eg, urinoma, hematoma, lymphocele, or abscess), and fistula formation. Late complications include ureteroileal anastomotic stricture, stomal stenosis, conduit stenosis, and urolithiasis. Although not directly related to ileal conduits, ureteroarterial fistula can occur in patients with an ileal conduit. Interventional radiologists can play a pivotal role in diagnosis and management of these complications by performing image-guided minimally invasive procedures. In this article, the authors review the surgical anatomy of an ileal conduit and the underlying pathophysiology of and diagnostic workup for complications related to ileal conduits. The authors also discuss and illustrate current approaches to interventional radiologic management of these complications, with emphasis on a collaborative approach with urologists or endourologists to best preserve patients' renal function and maintain their quality of life. ^©RSNA, 2020.

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.

Uretero-arterial fistula treated with endovascular stent graft following multiple interventions

INTRODUCTION

Uretero-arterial fistula is a rare life-threatening condition. Its diagnosis and management remains a challenge for urologists.

CASE PRESENTATION

A 64-year-old man presented to our hospital with gross hematuria. He had history of rectal cancer treated with neoadjuvant chemoradiotherapy followed by low anterior resection and chronic ureteral stenting for bilateral ureteral strictures. He developed recurrent hemorrhagic shocks due to sudden massive gross hematuria. Repeated computed tomography and angiography could not identify the source of bleeding. After prophylactic embolization of the right renal artery and right nephrectomy, angiography finally revealed a uretero-arterial fistula from the right external iliac artery. Percutaneous balloon-expandable covered stent graft was used to successfully treat the fistula.

CONCLUSIONS

Urologists should consider possible uretero-arterial fistula in patients with recurrent hematuria along with several risk factors and convincing medical history.

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.

Arterioureteral fistula: overview of clinical characteristics, endovascular management, and outcomes

BACKGROUND

Arterioureteral fistula (AUF) is a condition resulting from the pathologic connection between the ureter and the artery. Despite the low incidence, it can lead to devastating clinical consequences due to massive hematuria with a considerable mortality rate.

MATERIAL AND METHODS

From January 2009 to December 2018, eight patients with AUF from two tertiary referral centers were included. Clinical data including presenting symptoms, previous pelvic surgery or radiotherapy, indwelling ureteral stents, primary vascular pathology, angiographic findings, type of treatment, survival, and recurrence were analyzed.

RESULTS

All eight patients (six women, mean age 62.4 ± 14.5 years) presented with macroscopic hematuria and were successfully treated by endovascular management. One patient developed AUF due to an underlying iliac artery aneurysm, and the rest were due to secondary causes. Six patients had a history of an indwelling ureteral stent for a median of 5.5 months (1-84 months). All of the patients were successfully treated by endovascular management. For the median follow up of 987 days, three patients had recurrence of hematuria in a mean of 6.3 months, two patients were treated by surgery, while one was treated by endovascular treatment.

CONCLUSION

AUF should be confirmed through a purposeful iliac angiogram or ureterography when suspected based on a relevant history or CT findings. AUF can be successfully treated by endovascular management. The surgical option should be considered in cases of recurrence.

ABBREVIATIONS

AUF: arterioureteral fistula; CIA: common iliac artery; DJ: double J; EIA: external iliac artery; IIA: internal iliac artery; NBCA: N-butyl cyanoacrylate; PCN: percutaneous nephrostomy.

Endovascular Treatment for Arterioureteral Fistula of the Abdominal Aorta: A Case Report and Literature Review

We present a rare case demonstrating successful endovascular management of an arterioureteral fistula involving the abdominal aorta. Arterioureteral fistulas are rare but life-threatening, with mortality rates ranging from 7% to 23%. Early recognition and prompt management are essential for preventing catastrophic consequences, including hypovolemic shock. However, recognition of an arterioureteral fistula requires a high index of clinical suspicion due to its rarity and the lack of a sensitive diagnostic method. Arterioureteral fistulas could be induced by traumatic events in patients who have a history of pelvic surgery, radiation, and prolonged placement of a ureteral stent. Endovascular stent graft placement could be a valid treatment option for arterioureteral fistulas involving the abdominal aorta.

Massive hematuria due to an autogenous saphenous vein graft and urinary bladder fistula in an extra-anatomic iliofemoral bypass: a case report

INTRODUCTION

Gross hematuria caused by rupture of an artery in the urinary tract is a rare but potentially fatal condition. Iliac artery aneurysms, pelvic surgery with radiation, vascular reconstructive surgery, surgery for stenosis of the ureteropelvic junction, and transplantation are reported to be associated with this condition. In the vascular reconstructive surgery group, the most common etiology is rupture of the degenerated artery or synthetic graft in the ureter.

CASE PRESENTATION

We present a case of rupture of the small anastomotic pseudoaneurysm at the proximal anastomosis of a right iliofemoral autogenous vein extra-anatomic graft in the urinary bladder. To our knowledge, this is the first report of a rupture of an autogenous vein graft in the urinary bladder. Our patient, a 24-year-old Albanian farmer, was admitted to the emergency department in severe hemorrhagic shock induced by exsanguinating hematuria. He underwent immediate surgery, during which direct sutures to the bladder were placed and the saphenous graft was replaced with a synthetic one. The patient recovered completely, was free of hematuria, and showed no signs of pathological communication between the urinary and arterial tracts on postoperative cystoscopy and computed tomographic angiography during 2 years of follow-up.

CONCLUSION

The incidence of artery-to-urinary tract fistulas is growing due to the increasing use of urologic and vascular surgery, pelvic oncologic surgery, and radiation therapy. In addition to fistulas involving a degenerated artery and ureter or synthetic grafts and ureter, they can also involve an autogenous vein graft and the urinary bladder. In our patient, the fistula was a result of erosion of the bladder from a pseudoaneurysm at the proximal anastomosis of an autogenous vein iliofemoral bypass in an extra-anatomic position. Open surgery remains the best treatment option, although there is increasing evidence of successful endovascular treatment.

Endovascular management and the risk of late failure in the treatment of ureteroarterial fistulas

Ureteroarterial fistula (UAF) is a rare and life-threatening source of hematuria. A high index of suspicion is warranted for early diagnosis and timely intervention. Because of high perioperative risk and comorbidities in UAF patients, the endovascular approach has become preferred for repair. Infection can complicate this mode of therapy, and treatment with antibiotics is important. Herein we present five cases of secondary UAFs treated with stent graft alone or stent graft and embolization.

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 treatment of ureteroarterial fistula using a covered stent, evaluated by intravascular ultrasound: a case report

Background

Ureteroarterial fistula is a rare life-threatening complication of indwelling ureteral stents. The mechanism has not yet been fully evaluated using intravascular imaging.

Case presentation

An-84-year-old female was referred to our unit because of large volume pulsatile bleeding from the left ureter during routine stent exchange in the urology department. The hematuria was initially managed by rapidly exchanging for a new stent; however, the patient went into hypovolemic shock due to acute blood loss. The patient underwent implantation of the bilateral ureteral stents due to urinary retention caused by retroperitoneal fibrosis 2 years ago. To prevent ureteral infection, occlusion of the stents and stone formation, the stents were exchanged every 6 months. Computed tomography revealed contact between the left ureter and the common iliac artery. Therefore, ureteroarterial fistula was suspected and endovascular therapy was performed. Although angiography did not show definite blood flow into the ureter, a soft guidewire was advanced from the subintima of the external iliac artery to the left ureter. The diagnosis of ureteroarterial fistula was confirmed. Intravascular ultrasound identified the stent in the ureter and its connection to the subintima of the external iliac artery. The ureter did not contact directly to the inner lumen of the iliac arteries according to the ultrasound findings; therefore, we considered that the risk of stent-graft infection might not be high. After coil embolization of the ipsilateral internal iliac artery, a covered stent was implanted in the external iliac artery to seal the subintimal entry. The patient had no further episodes of any gross hematuria on dual anti-platelet therapy, when the ureteral stent was exchanged three time during 1 year after the endovascular therapy.

Conclusions

We demonstrated a case of ureteroarterial fistula, in which intravascular ultrasound allowed to visualize the communication between the ureter and the subintimal lumen in the external iliac artery.

Electronic supplementary material

The online version of this article (10.1186/s42155-019-0060-6) contains supplementary material, which is available to authorized users.

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.

Endovascular Repair of an Iliac Ureteroarterial Fistula with Late Stent Thrombosis and Migration into the Bladder

BACKGROUND

Ureteroarterial fistulas are rare. We describe a case of ureteral-arterial fistulas (UAF) repaired with an endovascular stent graft and examine late complications associated with the procedure.

CASE REPORT

A 37-year-old woman with a history of complicated locally invasive cervical cancer treated with chemoradiation presented initially with right leg rest pain and chronic intermittent gross hematuria. She was found to have an ureteroarterial fistula and underwent successful endovascular exclusion with a covered stent with resolution of her symptoms. She returned 1 year later with stent-graft thrombosis manifesting as lower extremity rest pain, requiring a femoral-femoral bypass. She then returned 6 months later with imaging evidence of extravascular migration of the stent graft into the bladder. Because of a poor prognosis of recurrent gynecologic cancer, extraction was not attempted, and she underwent complete urinary diversion.

CONCLUSIONS

UAFs are a rare occurrence but may be treated successfully with endovascular stent grafting. Despite technical success, late complications such as stent thrombosis may occur even with anticoagulation. Extravascular stent migration may occur in the presence of a chronically dilated ureter.