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Arterioureteral Fistulas: A Clinical, Diagnostic, and Therapeutic Dilemma

¹ Division of Diagnostic Imaging, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit 325, Houston, TX 77030.
² Department of Diagnostic Radiology, St. Luke's Episcopal Hospital, 6720 Bertner Ave., MC 2-270, Houston, TX 77030.

Received June 27, 2003; accepted after revision October 24, 2003.

 
Address correspondence to D. C. Madoff.

Introduction

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Arterioureteral fistulas are uncommon but potentially life-threatening causes of hemorrhage that usually manifest as hematuria. Approximately 90 cases of arterioureteral fistulas have been reported in the English-language literature; nearly two thirds of these were reported during the past decade [1]. Predisposing factors for arterioureteral fistulas include pelvic surgery, chronic indwelling ureteral stents, and pelvic irradiation [1–6]. Arterioureteral fistulas are being diagnosed more frequently because of increased numbers of vascular reconstructions performed, more advanced and extensive treatments of pelvic malignancy, and chronic use of ureteral stents. However, diagnosis of arterioureteral fistulas still may be elusive because of the intermittent nature of the symptoms and the difficulty in confirming the fistulous communications using radiology [1–6]. The morbidity and mortality rates for patients with arterioureteral fistulas remain high (23% mortality rate between 1980 and 1997) [4], especially when the condition goes undiagnosed despite improvements in treatment and critical care.

Radiologists play an increasingly important role in the treatment of patients with chronic use of indwelling urinary catheters and are frequently asked to consult on patients with hematuria of uncertain cause [7]. Therefore, a heightened level of awareness and watchfulness against arterioureteral fistulas is necessary for rapid diagnosis and treatment. We review the causes, risk factors, pathogenesis, signs and symptoms, diagnostic studies, and options for treatment of arterioureteral fistulas.

Causes, Risk Factors, and Pathogenesis

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Arterioureteral fistulas are abnormal communications between a major artery and the mid to distal ureter. The common or external iliac artery is usually the artery in question, but the internal iliac artery [5, 8, 9] and aorta [10] have also been involved. The name of this entity has varied and the terms "arterioureteral fistulas" and "ureteroarterial fistulas" have been used interchangeably [1–6]. This may be the result of two factors, the direction of flow and the cause of primary pathology. The direction of flow is from the artery to the ureter, which causes the primary symptom of hematuria. In addition, because of the emergent need to first treat the arterial component and prevent exsanguination, many authors refer to these communications as arterioureteral fistulas. Others prefer ureteroarterial fistulas because most fistulas between the artery and ureter result from primary ureteral pathology. That is, the ureteral vascular supply has been compromised by heavy irradiation [5] or extensive surgery for urologic or gynecologic malignancy [1]. We will refer to this entity as arterioureteral fistulas throughout this article, although both names are appropriate.

Arterioureteral fistulas can be classified in three categories according to cause: primary, secondary (iatrogenic), and pregnancy-related [1]. Primary fistulas account for less than 15% of arterioureteral fistulas and are seen mainly in combination with aortoiliac aneurysmal disease [8, 9, 11–18]. A case of primary arterioureteral fistulas in a patient with an arteriovenous malformation has also been reported [19].

Secondary fistulas account for approximately 85% of arterioureteral fistulas and have been seen after pelvic surgery for malignancy (usually urologic or gynecologic), often in association with irradiation, retroperitoneal fibrosis, and ureteral stenting, or after vascular surgery with synthetic grafting [1–6, 20, 21]. Among these patients, the median period from surgery to hematuria was 2 years (range, 2 months–30 years) in those who had a pelvic malignancy and 10 years (range, 3 months–25 years) in those who underwent vascular surgery that included reconstruction using a synthetic graft. In most (> 70%) patients, urinary outflow obstruction with hydronephrosis developed and necessitated ureteral catheter or stent placement, often with frequent stent changes or repeated operations [1]. Ureteral stenting in combination with repeated ureteral dilatation may also predispose patients to ureteral necrosis and lead to formation of arterioureteral fistulas [1–6]. A review of 23 patients [3] found that patients with ureteral intubation developed arterioureteral fistulas in a median time of 4 months (range, 15 days–12 years). In a recent literature review of 80 cases of arterioureteral fistulas, Bergqvist et al. [1] found that 42% of patients with arterioureteral fistulas had some type of urinary diversion surgery, most having required previous ureteral catheterization [22]. Finally, one patient developed hematuria related to an arterioureteral fistula between a graft artery aneurysm and the native ureter after a kidney transplantation [23].

Three cases of arterioureteral fistulas during pregnancy were reported [24–26] in the late 1930s; all three patients had massive urinary tract infections with septic complications and massive hematuria. Two of the patients died of exsanguination; the third patient died of complications related to sepsis. In each case, the diagnosis was made postmortem. It is unclear how the patients' pregnancies contributed to the development of fistulas, but the pregnancies led to urinary obstruction, which required ureteral catheterization in two patients. Fistulas have not been reported in pregnant patients since the advent of soft flexible catheters and stents and effective antibiotic therapy.

Some conditions predisposing to development of arterioureteral fistulas include prolonged use of ureteral stents or catheters, especially rigid ones, placed at the ureteroarterial crossing; presence of a ureteral stump after nephrectomy; vascular reconstructive surgery, especially with anastomosis or pseudoaneurysms in the pelvis; radiation therapy in combination with surgery; surgery for uterine cancer or transitional cell cancer of the bladder; and ureterolithotomy complicated by urinary leak [1].

The pathophysiology leading to the development of arterioureteral fistulas is not well understood. In most patients, fistulas appear where the ureter crosses anterior to the common or external iliac artery (Fig. 1). The most prevalent theory regarding the pathogenesis of arterioureteral fistulas is that they are related to inflammatory or ischemic injury to the ureters, iliac vessels, or both [2, 6]. Surgery, radiation therapy, and urine leakage are probably responsible for the intense fibrotic inflammatory response that fixes the ureter to an artery or vascular graft [1–6, 27]. Pressure, necrosis, surgical manipulation, irradiation, chronic infection, and fibrosis may also result in ureteral ischemia. A chronic ureteral catheter may act as a firm strut and facilitate transmission of arterial pulsations to an already compromised ureter, producing pressure necrosis and fistula formation [2, 6, 27]. Abnormalities of the iliac artery, including radiation-induced changes and native aneurysmal disease, further predispose patients to arterioureteral fistulas [1]. We believe that patients undergoing vascular graft procedures who have an additional history of irradiation and chronic ureteral stenting are at higher risk of arterioureteral fistulas development than patients who do not, in view of the rarity of arterioureteral fistulas, although vascular graft procedures have also been implicated as predisposing factors [1–6].

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —Illustration shows normal ureteral and iliac arterial anatomy.

Signs and Symptoms

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Hematuria has a long differential diagnosis, including nephrolithiasis, urothelial neoplasms (i.e., renal cell carcinoma, transitional cell carcinoma, and metastases), trauma, infection, hemorrhagic cystitis, and others. Patients presenting with hematuria require full evaluations (history and physical examinations, laboratory testing, imaging) by their physicians. Many disorders that cause hematuria may be easily diagnosed by the patients' clinical presentation and diagnostic studies. Unfortunately, diagnosis is more difficult when hematuria is intermittent.

In patients with arterioureteral fistulas, the most common symptom is gross hematuria, usually intermittent in nature [4–6, 27]. Patients may initially present with bleeding ranging from microscopic hematuria to life-threatening hemorrhage (i.e., severe hypotension, shock). In one patient, hematuria occurred only after heparinization for treatment of deep venous thrombosis [9]. Infrequently, flank pain may accompany hematuria, which may be caused by clot formation in the renal pelvis and ureter. During quiescent periods, a clot occludes the communication between the ureter and iliac artery [5, 27] (Fig. 2A). After degeneration of the clot by proteolytic enzymes, the bleeding recurs [1] (Fig. 2b). A few patients with arterioureteral fistulas have also experienced symptoms of urinary tract infection or pyelonephritis. Finally, for patients with ureteral stents, bleeding may be provoked or exaggerated when the stents are exchanged [3–6, 27]. If the hemorrhage produced during a stent exchange is massive and pulsatile, the diagnosis of arterioureteral fistulas should be considered.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —Illustrations show cause for intermittent nature of hematuria. Illustration shows clot occluding communication between ureter and iliac artery. Blood is shown flowing through normal arterial pathway.

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —Illustrations show cause for intermittent nature of hematuria. Illustration of same region after clot degradation shows blood flowing through both iliac artery and ureter and causing gross hematuria.

Diagnostic Studies

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Traditionally, arterioureteral fistulas have been difficult to diagnose without surgical exploration, which led to increased morbidity and mortality [3]. The hazards associated with direct exploration in these technically challenging cases include operating through previously dissected fibrotic tissue planes and the risk of injury to friable bowel, ureters, and blood vessels [3, 27]. Thus, various techniques have been used to establish the diagnosis of arterioureteral fistulas before surgery. For example, cystoscopy can localize bleeding to one of the ureteral orifices. If a ureteral catheter or stent is in place, its extraction may provoke bleeding. If the orificial bleeding is pulsatile, an arterioureteral fistula is likely to be present. Massive bleeding from the ureter detected during cystoscopy or ureteroscopy can be temporarily blocked using a balloon catheter [27–29].

Given the intermittent nature of the symptoms, the arterioureteral fistulas will probably not be visualized by imaging studies unless active hemorrhage is present. CT scans of the abdomen and pelvis are usually negative or nonspecific for arterioureteral fistulas because they show bleeding only rarely and the fistulous communications are almost never seen. CT findings may include pseudoaneurysms (Fig. 3A, 3B), signs of graft infection, and hydronephrosis with hydroureter. In addition, cross-sectional and other imaging techniques such as renal arteriography (for presumed renal injury during catheter placement or hematuria of unknown origin), superior mesenteric arteriography (for patients with ureteral–ileal conduits), or excretory urography help by excluding the more common causes of hematuria [3, 27].

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —70-year-old man who had colorectal carcinoma after pelvic exenteration presented with intermittent bleeding from ileal conduit. Axial CT image shows bilateral nephroureterostomy catheters (arrows) in close proximity to iliac arteries.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —70-year-old man who had colorectal carcinoma after pelvic exenteration presented with intermittent bleeding from ileal conduit. Sequential axial CT image obtained inferiorly to A shows irregular density (arrow) anterior to left common iliac artery that was confirmed to represent pseudoaneurysm on subsequent arteriograms (not shown).

Excretory urography and ureterography (antegrade, retrograde, or both) reveal only nonspecific findings such as intraluminal blood clot and irregularity of the mid to distal ureter. Selective iliac arteriography is considered the most sensitive technique, but its sensitivity rate is less than 50% [3]. Arteriograms and ureterograms fail to reveal the fistula during quiescent times, probably because the fistula is occluded by a thrombus. However, when angiographic findings are present they include arterial pseudoaneurysms at the point where the ureter crosses the iliac artery (Fig. 4A, 4B) or gross extravasation of contrast material into the ureter (Fig. 5A, 5B). Obtaining multiple oblique projections during arteriography helps to identify small pseudoaneurysms that may otherwise be overlooked [5]. Contrast material extravasation and fistulous communication are seen only rarely. Provocative maneuvers (Figs. 6A, 6B and 7A, 7B, 7C, 7D) such as high-pressure balloon occlusion pyeloureterography, stent removal over a guidewire, selective arterial injection using multiple oblique views, and production of friction in the ureteral lumen by the "to-and-fro" movement of ureteral catheters or ureteroscopy [3, 6] may help dislodge any occluding thrombi in the pseudoaneurysm or ureter, allowing visualization of the fistula. When these maneuvers are performed, one must be prepared to quickly inflate the balloon catheter or replace the ureteral stent to tamponade the strong hemorrhage that may result. Some authors have advocated this aggressive approach because it may be preferable to identify the bleeding site promptly and move to a definitive interventional treatment. Further surgery would be formidable because of the previous radiation and surgery [27]. In these cases of aggressive treatment, a surgical team must be ready to operate if the patient becomes unstable.

View larger version (164K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A. —77-year-old man with transitional cell carcinoma of bladder after radical cystectomy and ileal loop diversion who presented with massive hematuria during routine catheter exchange. Excretory urogram shows left nephroureterostomy catheter exiting stoma in right lower quadrant.

View larger version (172K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B. —77-year-old man with transitional cell carcinoma of bladder after radical cystectomy and ileal loop diversion who presented with massive hematuria during routine catheter exchange. Pelvic arteriogram reveals pseudoaneurysm (arrow) of inferior aspect of right common iliac artery.

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A. —61-year-old woman with cervical carcinoma who developed hydronephrosis after radiation therapy. She subsequently underwent ureteroileoneocystostomy and descending loop colostomy. She presented with massive hematuria 10 months after surgery. Selective right iliac arteriogram shows communication to distal right ureter (arrow). Air and blood are noted in ileal conduit.

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B. —61-year-old woman with cervical carcinoma who developed hydronephrosis after radiation therapy. She subsequently underwent ureteroileoneocystostomy and descending loop colostomy. She presented with massive hematuria 10 months after surgery. Slightly delayed phase of arteriogram shows contrast material pooling in urinary bladder (arrow). Patient was initially treated with balloon occlusion (in proximal right external iliac artery just distal to common iliac artery bifurcation) for 72 hr. After balloon was deflated, no additional hemorrhage was seen. She underwent right external iliac artery ligation 2 days later. During same hospital admission 5 weeks later, revision of ileal conduit was planned but left ureter was necrotic from anastomosis to renal pelvis and required left nephroureterectomy. Patient died 1 week later during same hospital admission from gram-negative endotoxic shock and acute cardiac arrhythmia.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A. —44-year-old man with rectal carcinoma after anterior perineal resection who had bilateral hydronephrosis requiring bilateral ureteral stents. He developed hematuria that initially appeared to be caused by radiation cystitis, which required blood transfusions. Pelvic arteriogram shows two separate distinct pseudoaneurysms (black arrows) where ureteral stent (white arrow) crosses anterior to right common iliac artery.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B. —44-year-old man with rectal carcinoma after anterior perineal resection who had bilateral hydronephrosis requiring bilateral ureteral stents. He developed hematuria that initially appeared to be caused by radiation cystitis, which required blood transfusions. Contrast study via arterial catheter shows inadvertent cannulation of fistula with reverse-curved catheter placed in right common iliac artery during attempted right internal iliac artery catheterization. Contrast material is seen filling right ureter and urinary bladder. Note clot (arrowheads) in right ureter and urinary bladder (arrows). (Also note that selective catheterization into pseudoaneurysms should not be attempted. It can be extremely hazardous and may be associated with severe hemorrhage.)

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A. —61-year-old man with colon carcinoma who underwent partial colectomy with colostomy and creation of rectal pouch, chemotherapy, and irradiation 6 years earlier and presented with hematuria, hypotension, and rectal bleeding. Three years before this hospital admission, he developed bilateral renal obstruction requiring bilateral nephroureteral stents but soon lost complete function of his left kidney. Despite cystectomy and anterior rectal resection, bleeding continued so patient underwent right renal arteriography. Initially, no bleeding site was seen and embolization was not performed. However, hematuria persisted and total right renal artery was embolized, necessitating dialysis. Despite this, hematuria persisted and further angiographic investigation was required. Anteroposterior pelvic arteriogram obtained for recurrent hematuria shows universal stent (arrow) crossing right external iliac artery without evidence of hemorrhage.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B. —61-year-old man with colon carcinoma who underwent partial colectomy with colostomy and creation of rectal pouch, chemotherapy, and irradiation 6 years earlier and presented with hematuria, hypotension, and rectal bleeding. Three years before this hospital admission, he developed bilateral renal obstruction requiring bilateral nephroureteral stents but soon lost complete function of his left kidney. Despite cystectomy and anterior rectal resection, bleeding continued so patient underwent right renal arteriography. Initially, no bleeding site was seen and embolization was not performed. However, hematuria persisted and total right renal artery was embolized, necessitating dialysis. Despite this, hematuria persisted and further angiographic investigation was required. Pelvic arteriogram obtained after removal of universal stent shows irregularity of right external iliac artery (arrow) consistent with pseudoaneurysm.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C. —61-year-old man with colon carcinoma who underwent partial colectomy with colostomy and creation of rectal pouch, chemotherapy, and irradiation 6 years earlier presented with hematuria, hypotension, and rectal bleeding. Three years before this hospital admission, he developed bilateral renal obstruction requiring bilateral nephroureteral stents but soon lost complete function of his left kidney. Despite cystectomy and anterior rectal resection, bleeding continued so patient underwent right renal arteriography. Initially, no bleeding site was seen and embolization was not performed. However, hematuria persisted and total right renal artery was embolized, necessitating dialysis. Despite this, hematuria persisted and further angiographic investigation was required. Pelvic arteriogram obtained during antegrade right ureterography shows close proximity of distal ureteral stump and iliac artery (short arrows), which is suggestive of arterioureteral fistula. Note filling defect in distal ureter (long arrow) consistent with clot.

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7D. —61-year-old man with colon carcinoma who underwent partial colectomy with colostomy and creation of rectal pouch, chemotherapy, and irradiation 6 years earlier presented with hematuria, hypotension, and rectal bleeding. Three years before this hospital admission, he developed bilateral renal obstruction requiring bilateral nephroureteral stents but soon lost complete function of his left kidney. Despite cystectomy and anterior rectal resection, bleeding continued so patient underwent right renal arteriography. Initially, no bleeding site was seen and embolization was not performed. However, hematuria persisted and total right renal artery was embolized, necessitating dialysis. Despite this, hematuria persisted and further angiographic investigation was required. Pelvic arteriogram shows complete exclusion of pseudoaneurysm after deployment of 9 x 20 mm Wallgraft endoprosthesis (Boston Scientific) in right external iliac artery. Ureteral component was not treated because patient was no longer making urine. After endovascular repair of arterioureteral fistula, patient underwent dialysis for 1 year, but died from azotemia after refusing further dialysis treatments.

Therapeutic Approaches to Arterioureteral Fistulas

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Since the pathologic process of arterioureteral fistulas was first described in 1899 [30], numerous vascular and urologic interventions have been performed with varying degrees of success. Although the arterial and ureteral components must both be considered in the treatment plan, an accurate preoperative diagnosis is essential to decrease morbidity and mortality rates. In patients who were explored surgically without a preoperative diagnosis, the mortality rate has been reported to be as high as 64% [22, 31]. However, when the correct diagnosis is made before surgery, the mortality rate decreased to 8% [23].

At present, no consensus has been reached about the best treatment option. In situations of massive life-threatening hemorrhage with no correct diagnosis of arterioureteral fistulas, most patients undergo a nephrectomy or nephroureterectomy [4]. Sometimes ureteral reconstruction, ureterostomy (surgical or percutaneous) or pyelonephrostomy, ligation of the ureter, embolization of the renal artery, renal irradiation, and autotransplantation have been performed and led to increased morbidity rates without substantial effects on controlling the hematuria [3, 21, 27, 32].

An alternative treatment method for the ureteral component of arterioureteral fistulas was recently reported [10]. A sonographically guided percutaneous nephrostomy was performed so that multiple metallic coils were inserted in an antegrade fashion into the ureteral lumen just proximal to the fistula (Fig. 8). Pyelonephritis developed 12 days after the procedure and was adequately treated using antibiotics, but no further episodes of hematuria occurred during 53 months of follow-up. Although the use of transrenal ureteral occlusion with metallic coils and gelatin sponges had been reported in the treatment of intractable lower urinary tract fistulas [33, 34], this technique had not been used previously to treat arterioureteral fistulas. Additional percutaneous ureteral occlusion techniques for the treatment of ureteral fistulas (not including arterioureteral fistulas) include balloon occlusion, isobutyl-2-cyanoacrylate embolization, liquid nylon plug occlusion, and ureteral fulguration [35].

View larger version (59K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8. —Illustration shows percutaneous antegrade transrenal approach used for placement of metallic coils and gelatin sponge (Gelfoam, UpJohn) into distal ureter. Iliac arterial component remains patent.

Management of the arterial component of arterioureteral fistulas varies and is influenced by associated local infections, the presence of associated aneurysmal or occlusive disease, the available collateral circulation to the ipsilateral leg, and the presence of an arterial graft. Vascular surgical procedures include local reconstruction (i.e., arteriorrhaphy, patch closure, interposition graft, bypass), ligation with or without extraanatomic bypass (if arterioureteral fistulas arise from either common or external iliac artery), and ligation of the internal iliac artery [1]. In 1908, Moschowitz [36] reported the first successful treatment of bilateral arterioureteral fistulas in which the external iliac arteries were ligated bilaterally. The patient did well after the procedure, experiencing only transient lower extremity ischemia with no additional hematuria. The treatment options for arterioureteral fistulas remained unchanged until 1965, when Arap et al. [37] reported the use of a prosthetic graft for primary reconstruction of a diseased iliac artery. Nine years later, Shultz et al. [17] reported a similar case in which the patient underwent nephrectomy for an arterioureteral fistula without experiencing recurrent bleeding. In the 1980s and early 1990s, several reports of successful treatment of these lesions using surgical ligation, intraoperative balloon occlusion, or radiologic embolization of the iliac artery followed immediately by extraanatomic bypass were published [15, 20, 22, 38–41]. Some authors have described limb ischemia requiring delayed arterial bypass or limb amputation after common iliac artery ligation, and others have reported death during open vascular repair [3, 27]. Two clinical examples of patients treated with embolization and subsequent extraanatomic bypass for arterioureteral fistulas are shown in Figures 9A, 9B, 9C and 10A, 10B, 10C, 10D.

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A. —50-year-old man with rectal carcinoma who underwent abdominoperineal resection and who presented with bleeding from right nephrostomy and colostomy requiring emergent blood transfusion. Six months before this admission, patient had surgery for tumor recurrence. His distal right ureter was transected and right ureteral stent was placed. During routine stent exchange in cystoscopy, access to ureter was lost, and right ureteral orifice could not be recannulated. Two months later, patient presented with right hydronephrosis caused by distal right ureteral stricture, necessitating percutaneous nephrostomy catheter placement. Seven months later, patient returned with massive hematuria from right nephrostomy. Anteroposterior pelvic arteriogram shows fistulous communication between right common iliac artery and right ureter (arrow). Internal iliac arteries (not shown) were ligated bilaterally before arteriography (at different times) because of extensive additional pelvic surgery, which involved removal of massive pelvic abscess.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B. —50-year-old man with rectal carcinoma who underwent abdominoperineal resection and who presented with bleeding from right nephrostomy and colostomy requiring emergent blood transfusion. Six months before this admission, patient had surgery for tumor recurrence. His distal right ureter was transected and right ureteral stent was placed. During routine stent exchange in cystoscopy, access to ureter was lost, and right ureteral orifice could not be recannulated. Two months later, patient presented with right hydronephrosis caused by distal right ureteral stricture, necessitating percutaneous nephrostomy catheter placement. Seven months later, patient returned with massive hematuria from right nephrostomy. Right iliac arteriogram shows successful coil embolization of right common iliac artery.

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C. —50-year-old man with rectal carcinoma who underwent abdominoperineal resection and who presented with bleeding from right nephrostomy and colostomy requiring emergent blood transfusion. Six months before this admission, patient had surgery for tumor recurrence. His distal right ureter was transected and right ureteral stent was placed. During routine stent exchange in cystoscopy, access to ureter was lost, and right ureteral orifice could not be recannulated. Two months later, patient presented with right hydronephrosis caused by distal right ureteral stricture, necessitating percutaneous nephrostomy catheter placement. Seven months later, patient returned with massive hematuria from right nephrostomy. Spot image after embolization shows coils placed across fistulous communication with ureter (arrow). Patient immediately underwent left-to-right femoral–femoral bypass and was discharged 7 days after surgery with no additional hematuria or lower extremity ischemia.

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A. —70-year-old man who had rectal carcinoma after pelvic exenteration who presented with intermittent bleeding from ileal conduit. Left posterior oblique pelvic arteriogram shows bilateral retrograde nephroureterostomy catheters overlying bilateral common iliac arteries. No bleeding site is seen.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B. —70-year-old man who had rectal carcinoma after pelvic exenteration who presented with intermittent bleeding from ileal conduit. Arteriogram via right external iliac artery catheter during right common iliac artery embolization procedure reveals fistulous communication (arrow).

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C. —70-year-old man who had rectal carcinoma after pelvic exenteration who presented with intermittent bleeding from ileal conduit. Pelvic arteriogram shows that despite treatment with left-to-right femoral–femoral bypass graft (white arrow), hematuria again developed 5 days later. Contrast material in ileal conduit (black arrows) shows that arterioureteral fistula exists between left common iliac artery and left ureter.

View larger version (175K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10D. —70-year-old man who had rectal carcinoma after pelvic exenteration who presented with intermittent bleeding from ileal conduit. Abdominal aortogram shows treatment with coil embolization of distal aorta and left common iliac artery. Left axillobifemoral bypass (not shown) was performed immediately after embolization. Patient was discharged 19 days after surgery without further episodes of hematuria.

The recent addition of endovascular stentgrafts as a therapeutic alternative holds great promise in providing patients with a less invasive but effective method of treating arterioureteral fistulas and provides many of the essential features of an ideal therapy. These features include complete closure of the fistula, maintenance of antegrade blood flow through the iliac artery, no need for direct arterial or ureteral surgery, and avoidance of subsequent procedures for revascularization of the lower extremity [22]. In addition, surgical approaches to correcting fistulous communications are frequently compromised by postoperative and postirradiation changes in patients who may be hemodynamically unstable.

Multiple cases of covered stenting for arterioureteral fistulas have recently been reported. The first, reported in 1996 by Kerns et al. [22], used an autologous vein graft placed over a balloon-expandable stent. Later reports described the use of personally constructed, polytetrafluoroethylene-covered balloon-expandable stents [2, 29, 31, 42–44]. In 2002, two reports described successful management of arterioureteral fistulas using newly released commercially available polyethylene terephthalate– and polytetrafluoroethylene-covered self-expanding stents [6, 29]. Cases of successful endovascular exclusion of arterioureteral fistulas are shown in Figures 7D and 11A, 11B.

View larger version (180K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A. —35-year-old woman with cervical carcinoma who developed left-sided hematuria and hypotension. Left anterior oblique pelvic arteriogram shows irregular contrast-medium filling (arrow) suggestive of pseudoaneurysm at proximal portion of left external iliac artery. Note left ureter filled with contrast medium from previous antegrade nephrostogram (arrowheads).

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B. —35-year-old woman with cervical carcinoma who developed left-sided hematuria and hypotension. Left external iliac arteriogram shows successful exclusion of pseudoaneurysm after deployment of 8 x 60 mm Wallgraft endoprosthesis (arrows) (Boston Scientific). Note ileostomy (arrowheads). Urine cleared on next day and patient was discharged on seventh day after surgery. No additional bleeding episodes had occurred by 2-year follow-up.

The long-term success of covered-stent treatment of arterioureteral fistulas is not yet known. Of note is its potential for stent occlusions and graft infections. More important, the 12-month primary patency for stent-grafts in occlusive aortoiliac disease is 70% [45]. Surgical revision in this already compromised setting would be difficult, so antiplatelet agents (to maintain stent-graft patency) and prophylactic antibiotics may be of use, but this is currently unknown [6]. If an infection later develops or if the stent-graft fails and causes persistent hemorrhage, occlusion, or refistulization, extraanatomic vascular reconstruction may be required [46] (Fig 12A, 12B). One patient experienced stent-graft occlusion at 8 months after deployment necessitating a femoral–femoral bypass. However, nearly 10 similar cases have been reported in the literature, and no mortality using covered-stents in the treatment of arterioureteral fistulas has been reported.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A. —74-year-old man with prostate carcinoma who underwent cystectomy for hemorrhagic cystitis after irradiation and presented in hemorrhagic shock with continuous bleeding through ileal conduit. Anteroposterior pelvic arteriogram shows contrast material in left ureter and ileal conduit (arrow). Actual fistulous communication cannot be visualized. Left internal iliac artery was embolized using metallic coils and stent-graft was placed across left common iliac artery.

View larger version (165K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B. —74-year-old man with prostate carcinoma who underwent cystectomy for hemorrhagic cystitis after irradiation and presented in hemorrhagic shock with continuous bleeding through ileal conduit. Three months later, pelvic aortogram was obtained; it shows hemorrhage through stent-graft (white arrowheads) that required operative vascular reconstruction. Contrast material fills ureter (black arrowheads). White arrows mark pseudoaneurysm or ureter proximal to ureteral stenosis. Coils in left internal iliac artery (large black arrow) and ileostomy (small black arrows) are also seen. Hematuria resolved during same admission after vascular reconstruction and did not recur. (Courtesy of Rilling WS, Milwaukee, WI)

As mentioned before, both the ureteral and vascular components of arterioureteral fistulas must be addressed to have a successful outcome, and the treatment should be based on the patient's clinical situation. The arterial component must be treated expeditiously because failure to do so can lead to exsanguination. Currently, the use of stent-graft technology seems to be a promising alternative to surgical options and shows less morbidity and mortality, especially if the surgical bed has already been contaminated and has substantial adhesions from previous surgery and radiation. Although stent-grafts do not treat the ureteral component per se, the fistulous communication between the artery and ureter is essentially excluded. Long-term follow-up after stent-graft deployment for arterioureteral fistulas has not been reported; however, our anecdotal experience has shown that urine leakage with this type of therapy has not been a problem. Two patients treated with stent-grafts in 2001 at our institution continue to have urinary diversion [6] without clinical or radiologic signs of urine leak at the fistula site. This may be because continued urinary diversion through percutaneously placed catheters may provide adequate drainage [47–49] or the severely fibrotic tissues around the fistula prevent the leakage of urine in the pelvis. In addition, the ureteral component should be treated with permanent removal of the ureteral stent because failure to do so could potentially lead to refistulization or infection. After the ureteral stent is removed, treatment is then focused on continued relief of the preexisting obstructive uropathy. Patients with adequate renal function should be treated with percutaneous drainage, and those with suboptimal function of the ipsilateral renal unit may require dialysis.

Conclusion

Top Introduction Causes, Risk Factors, and... Signs and Symptoms Diagnostic Studies Therapeutic Approaches to... Conclusion References

 
Arterioureteral fistulas are being reported more frequently and continue to present clinical, diagnostic, and therapeutic challenges. Heightened awareness and a high index of suspicion for arterioureteral fistulas are required for prompt diagnosis and treatment. Provocative maneuvers performed during pelvic arteriography are often necessary for the depiction of the fistulous communication if standard arteriography or urography fails to do so. Open surgical repair can potentially address both the ureteral and vascular components of arterioureteral fistulas, but simple ureteral and arterial repairs are usually not possible because most patients are considered poor candidates for surgery. Minimally invasive techniques such as stent-grafts are currently being used and may represent the best therapeutic options. Further studies of endografts with evaluation for long-term follow-up are necessary before definitive conclusions can be drawn, but so far those techniques look promising.

References

Top Introduction Causes, Risk Factors, and... Signs and Symptoms Diagnostic Studies Therapeutic Approaches to... Conclusion References

 

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