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Endovascular Treatment of a Right-Sided Ureteroiliac Fistula in a Patient with a Simultaneous Left-Sided Ureteroileal Fistula

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Case Reports in Urology
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We describe an 80-year-old female with a left ureteroileal fistula and simultaneously a right ureteroiliac fistula. Her history highlights the predisposing factors of radiation, major surgery in the region, and presence of bilateral double-J-stents. She was successfully treated with an endovascular approach after being initially misdiagnosed. There seems to be an increase in reporting ureteral fistulas, however this entity remains a rare clinical condition that can lead to life-threatening situations. A fast and accurate diagnosis of an ureteroarterial fistula remains a challenge.
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Hindawi Publishing Corporation
Case Reports in Urology
Volume 2011, Article ID 284505, 5pages
doi:10.1155/2011/284505
Case Report
Endovascular Treatment of a Right-Sided Ureteroiliac Fistula in
a Patient with a Simultaneous Left-Sided Ureteroileal Fistula
G. M. Veenstra,1, 2 L. M. C. L. Fossion,2G. Debonnaire,1, 3 and K. de Laet2
1Faculty of Health, Medicine and Life Sciences, Maastricht University, 6200 MD Maastricht, The Netherlands
2Department of Urology, Maxima Medical Centre, De Run 4600 5504 DB, Veldhoven, The Netherlands
3Department of Vascular Surgery, Maxima Medical Centre, Veldhoven, The Netherlands
Correspondence should be addressed to G. M. Veenstra, geert.veenstra@gmail.com
Received 25 May 2011; Accepted 21 June 2011
Academic Editors: K. Madbouly, J. Park, and F. M. Solivetti
Copyright © 2011 G. M. Veenstra et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
We describe an 80-year-old female with a left ureteroileal fistula and simultaneously a right ureteroiliac fistula. Her history
highlights the predisposing factors of radiation, major surgery in the region, and presence of bilateral double-J-stents. She was
successfully treated with an endovascular approach after being initially misdiagnosed. There seems to be an increase in reporting
ureteral fistulas, however this entity remains a rare clinical condition that can lead to life-threatening situations. A fast and accurate
diagnosis of an ureteroarterial fistula remains a challenge.
1. Introduction
There seems to be an increased incidence of ureteroarterial
fistulae (UAF), which are presumably related to improved
cancer survival and aggressive multimodality treatment
for abdominopelvic cancers [1]. Chronic ureteral stenting,
pelvic (external beam) radiotherapy, pelvic surgery, and
peripheral vascular disease are known risk factors for devel-
oping UAF [1]. A fistula between the iliac artery and ureter
is considered rare; it can cause severe hematuria with need
for blood transfusions and is considered a life-threatening
condition. In the past UAF have mostly been treated by
either surgery or a combination of surgery and arterial
embolisation. Particularly in the last 10 years endovascular
stenting is increasingly used instead of open techniques due
to the high perioperative risk and comorbidities in patients
with ureteroarterial fistulas. We present a case of such an
endovascular stenting for treatment of a UAF.
2. Case Report
An 80-year-old female underwent a Hartmann’s procedure
with intraoperative radiation therapy in 2008. A metastasec-
tomy for liver metastasis was done before the Hartmann’s
procedure in a separate operation. Neoadjuvant therapy
included radiation therapy with a dose of 5 ×5Gy and
chemotherapy with 6 cycles of capecitabine, oxaliplatin,
and bevacizumab. Since December 2009 JJ-stents were
placed for ureteral stricture and functional obstruction with
regularly bilateral replacement afterwards. In November
2010, extensive abscess drainage from the Douglas Cavity
was needed after occluded ureteral stents with Candida
glabrata infection. Furthermore she was diagnosed with
Type 2 (noninsulin-dependent) diabetes mellitus and angina
pectoris.
In January 2011, she presented at the emergency room
with intermittent macroscopic hematuria. An irrigation
catheter was placed and manual irrigation was continued
to remove all clots out of the bladder. Laboratory findings
at admission included a hemoglobin level of 7,2 mmol/L
and a creatinine level of 370 µmol/L. Ultrasound of the
kidney showed bilateral hydronephrosis. One day after
admission a cystoscopy and ureteral stent exchange was
performed in the operation room because of persistent
hematuria and suspected occlusion of the ureteral stents.
Removal of the right double-J catheter revealed a pulsatile
arterial bleeding from the right ureteral orifice. The ureteral
stent was quickly changed and the bleeding subsided. An
emergency peroperative hemoglobin was 3,4 mmol/L (norm
>7,5 mmol/L). The patient was stabilized and 4 Packed
2Case Reports in Urology
A21
L
1
5
6
R
1
8
5
Figure 1: Computed tomography angiography (CTA) axial image;
suspected active hemorrhage with clots in the right pyelocaliceal
system.
Cells were given at the OR. Open surgery was primarily
not considered an option because of the patients extensive
abdominal surgical history. At the radiologist intervention
department, computed tomography angiography (CTA) was
performed for further diagnosis (see Figure 1).
An active hemorrhage was suspected at the level of the
right pyelum and clots were seen in the pyelocaliceal system.
Since the patient was hemodynamically stable, it was decided
to wait and an expectant policy was agreed. However, in the
following night, the patient had gross hematuria again and
embolisation of the right kidney was performed with two
coils in the right renal artery (see Figure 2).
After embolisation, the left ureteral catheter still had
to be repositioned in the operating room. A retrograde
ureterography showed a ureteroileal fistula (see Figure 3). A
new ureteral catheter was placed and a abdominal surgeon
was consulted regarding the fistula. A conservative approach
was advised. Within 24 hour massive hematuria recurred.
Hemoglobin level dropped despite Packed Cells transfusion.
After questioning our primary diagnosis of bleeding of the
right pyelum, a fistula between the (common) iliac artery and
the ureter was suspected. An ureterogram failed to visualize
the fistula, so did a new CT angiography. However, on clinical
grounds ureteral arterial fistula was now highly suspected. An
endovascular approach was chosen since open surgical repair
would be very dicult in this patient.
Before the stent was placed an angiography of the
right iliac artery failed to locate the exact position of the
UAF. Under general anesthesia, a stent graft (Endurant
stent type ENEW1010C80EE) was inserted via the right
femoral artery and deployed at the iliac-ureteral conduct. A
ureteral stent was in place to help positioning the stent graft.
After placement postdilatation was done using a Reliant
moulding-balloon.Intraoperative arteriography revealed no
endoleakage (see Figure 4). Also in the late phase, no leakage
of contrast was seen. Hematuria decreased almost instantly
after the endovascular stent was placed.
After endovascular stent placement life-long antiplatelet
therapy with acetylsalicylic acid was started. Antibiotic treat-
ment was given for a period of 9 days. No prophylactic antibi-
otic therapy was given. Three months after the endovascular
stent procedure a nephrostomy tube was placed in the left
kidney because of recurrent ureteral stent occlusion. Four
months after embolisation and stent placement the patient
is alive with a creatinine blood level of 180 µmol/L.
3. Discussion
Ureteroarterial fistulas usually present with gross hematuria
along with flank pain in about half the cases due to obstruc-
tion of the ureter. Bleeding can be massive and dramatic, but
can also be intermittent. Replacement of ureteral stents can
be a precipitating event provoking hematuria [112]. The
exact mechanism of the development of UAF is still unclear.
Pressure necrosis of the catheterized ureter is believed to
contribute to the formation of a fistula [3]. The pulsations of
the iliac artery transmitted through an already compromised
ureter to a stiintraluminal catheter can readily produce
necrosis. Previous radiation therapy and pelvic or vascular
surgical procedures, may induce weakening of the ureteral
and the arterial wall. When ureteral stenting is necessary for
a longer period, it is therefore advisable to use small and soft
silicone stents [1,2].
The diagnosis of ureteroarterial fistulae can be dicult.
In this case we primarily suspected the hematuria to originate
from the kidney. A review from van den Bergh et al. found
similar cases where an incorrect diagnosis resulted in a
nephrectomy in 11 cases and embolisation of a renal artery
in 4 cases [3]. Retrograde ureterography will not be of
much help in a patient whose fistulous tract is temporarily
closed by clots in the ureter or in the fistulous opening.
Literature reports a sensitivity of a retrograde pyelogram
of 45–60% [4]. Arteriography may demonstrate the site of
the fistula only when it is performed during an episode of
active bleeding. Overall it has a sensitivity of 23 to 41%
[1,4]. Provocative angiography, a technique to demonstrate
ureteroarterial fistulae by deliberately moving the patient’s
indwelling stents to “unclot” the fistula while simultaneously
performing angiography was not performed in our patient.
In some cases it might drastically improve sensitivity [1].
However, it is not advised in unstable patients. In our patient
the diagnosis was made after excluding other diagnoses
because hemorrhage recurred after embolisation of the
kidney and no others abnormalities were found on the CT
scan or during cystoscopy.
Endovascular stent graft repair is commonly performed
for UAF. However not all reports about endovascular stenting
are successful. Ando et al. described a case in Japanese with
bilateral UAF where left-sided endovascular treatment failed
and thromboembolism occurred in the covered stent on the
right side. [5]. Occlusion of the lumen of the endovascular
stent graft eight months after treatment for an UAF has been
described earlier by Rodriguez et al. [6]. Krambeck et al.
described marginal results with endovascular stenting in two
of three patients who required secondary treatment owing
to graft occlusion and continued hemorrhage [1]. Though
several case reports confirmed successful use of endovascular
stenting of UAF by stent grafts and demonstrated successful
short-term results despite the theoretical risk of infection,
Case Reports in Urology 3
(a) (b)
Figure 2: Arteriography; (a) shows the right arteria renalis. Notice the double J stent and numerous clips after the liver metastasectomy. (b)
shows the coils after the embolisation of the right arteria renalis.
Figure 3: Retrograde ureterography left showing leakage of contrast in the intestines.
4Case Reports in Urology
(a) (b)
(c) (d)
Figure 4: Angiography; (a) prestent placement, no extravasation of contrast into the ureter is seen. (b) endovascular stent placement over a
guiding wire. (c) endovascular stent placement after removing of the guide wire. (d) Control after stent placement; no endoleakage.
occlusion, and stent-fracture after deployment of stent grafts
[1,3,712]. It was therefore desirable that the long-
term results of endovascular treatment by stent-grafts for
uretero-arterial fistulas are reviewed [7]. Fox et al. compared
endovascular treatment with open surgery with a median
followup of 15.5 months (range 1 to 99). They did not
identify a clear advantage for endovascular or open vascu-
lar surgical management and concluded that endovascular
stenting is preferred in most cases. Particularly in inoperative
patients and in acute emergency conditions an endovascular
approach seems ideal [8]. If open surgical repair should
follow in patients after a primary stent placement who are
suitable for operation is still unclear.
4. Conclusion
An ureteroarterial fistula is still a rare and dangerous
condition. With the liberal use of chronic, indwelling
ureteral stents, extensive pelvic surgery, radiotherapy, and
vascular pathology an increase of the incidence has been
noted. Diagnosis remains a challenge because conventional
radiographic tests are often unsuccessful in identifying the
fistula. Hematuria might not be associated directly with an
UAF, however it should be on the dierential diagnosis list in
patients with predisposing risk factors. Endoluminal repair
using a stent graft represents a minimally invasive treatment
that can be performed safely even in a hostile abdomen. A
longer followup will be necessary for definitive long-term
results.
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Case Reports in Urology 5
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... It is important to bear in mind that the source of a urinary tract bleeding through the ureteral orifice is not always the kidney. If the urologist and interventional radiologist do not keep that in mind, this could lead to unnecessary renal embolization or even nephrectomy due to misdiagnosis [6,12,15]. A high degree of suspicion in patients with known risk factors for UVF is the key to a correct diagnosis. ...
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