International Journal of Urology

(2002)

9,

120–121

Case Report

Blackwell Science, LtdOxford, UKIJU

International Journal of Urology0919-81722002 Blackwell Science Asia Pty Ltd

92February 2002433

Ureteroarterial fistula controlled by intraluminal ureteral occlusionT Inoue

et al.10.1046/j.0919-8172.2001.00433.x

Case ReportBEES SGML

Correspondence: Takahiro Inoue, Department of Urol-ogy, Faculty of Medicine, Kyoto University, 54Kawahara-cho, Sakyoku, Kyoto 606-8507, Japan. Email:takahi@.kuhp.kyoto-u.ac.jp

Received 7 May 2001; revision 16 July 2001; accepted 27 August 2001.

Ureteroarterial fistula controlled by intraluminal ureteral occlusion

TAKAHIRO INOUE,

1

TAKUICHI HIOKI,

1

YASUAKI ARAI,

2

YOSHITAKA INABA

2

AND YOSHIKI SUGIMURA

1

Departments of

1

Urology and

2

Interventional Radiology Aichi Cancer Center Hospital, Nagoya, Japan

Abstract

A 73-year-old woman underwent a pelvic exenteration for transitional cell carcinoma of the bladderand radiation-induced rectovaginal fistula. The patient had undergone radical hysterectomy andradiotherapy for cervical cancer 30 years earlier. Fifteen months after the operation, she suffered fromureteroaortic fistula, which was controlled by intraluminal ureteral occlusion using Gianturco coils.During 53 months of follow up, she has been free of hemorrhagic episodes.

Key words

Gianturco coil, intraluminal ureteral occlusion, ureteroarterial fistula.

Introduction

Ureteroarterial fistula is extremely uncommon.

1–3

How-ever, prompt diagnosis and treatment are crucial in thislife-threatening disorder. Before 1980, the mortality ratewas 70% but it has decreased to 14% due to advancesin critical care management.

1

The usual managementapproach includes: (i) vascular procedures (i.e. ligationor embolization of the involved artery with or withoutbypass); or (ii) primary closure.

2,3

This is the first reportof ureteroarterial fistula controlled for a long time usingan endourological approach

Case report

A 73-year-old woman was referred to our hospital witha diagnosis of invasive transitional cell carcinoma of thebladder and a non-functioning right kidney. Her medical

history was significant for cervical cancer, which wasdiagnosed 30 years earlier. She had been treated withradical hysterectomy and radiotherapy. She had alsoexperienced radiation-induced rectovaginal fistula for1 year. A pelvic exenteration and right nephrectomywith left cutaneous ureterostomy and end colostomywere carried out. Convalescence was uneventful exceptfor pyelonephritis secondary to obstruction by a 12-Frindwelling ureterostomy catheter (an open-tippedCouncil catheter) that had been placed postoperativelyfor mild hydronephrosis and peristoma skin troublesdue to improper appliance.

Fifteen months after the exenteration, the patient wasreadmitted for control of pulsating massive hemorrhagefrom her cutaneous ureterostomy. The results of emer-gent aortography were unremarkable (Fig. 1a). How-ever, a left retrograde ureterogram obtained afterremoval of the indwelling catheter showed contrastmaterial extravasating from the left ureter into theabdominal aorta just cranial to the bifurcation (Fig. 1b).Selective arteriography of the aorta just proximal tothe fistula showed apparent extravasation of the con-trast material. After informed consent was obtained,ultrasound-guided percutaneous nephrostomy of the leftkidney was undertaken and multiple metallic coils wereinserted in a retrograde fashion into the left ureterallumen just above the fistula. This successfully controlled

Ureteroarterial fistula 121

the hemorrhage (Fig. 2). A digital subtraction arterio-gram obtained after the embolization revealed noextravasation of contrast material. Gross hematuria sub-sided 3 days after the therapy. Twelve days postopera-tively, the patient developed pyelonephritis. She wastreated by extensive antibiotic therapy. She respondedwell and her hematuria resolved. During 53 months offollow up, she has been free of further hemorrhagicepisodes with left nephrostomy.

Discussion

Ureteroarterial fistula are being seen more frequentlybecause of the use of indwelling ureteral catheters andthe growing number of vascular operations.

1–3

Weapplied a 6-Fr ureteral catheter for an indwelling cuta-neous ureterostomy tube intraoperatively. However, themid-ureteral stenosis and peristoma skin troubles thatoccurred after the removal of the 6-Fr ureteral cathetermeant we had to use a drainage catheter. This 12-Fr ure-teral catheter might have played an important role in theformation of the fistula. Open surgical approaches (i.e.ligation of involved artery with or without bypass revas-cularization procedures or direct suture using patchgraft) with concomitant urinary diversion or nephros-tomy are commonly used to treat this problem.

1–3

Vaso-occlusive coils can also be used to embolize theinvolved artery.

2

Its disadvantage is that distal arterialperfusion may be sacrificed and additional revascular-ization procedures may be required to regain perfusionto the lower extremity.

This patient had a fistula between the aorta and theleft ureter and had previous irradiation. Both surgicalrepair and arterial embolization were considered diffi-cult, because of compromised tissues associated withpelvic irradiation, multi-operation and the comorbidconditions of this patient. The retrograde insertion ofGianturco coils via cutaneostomy proximal to the fistulasuccessfully controlled the bleeding. Admittedly, therisk of rebleeding still remains. Strict management ofnephrostomy catheter and urinary tract infections isrequired for the long-term prevention of recurrence.

Transrenal ureteral occlusion with Gianturco coilsfor intractable lower urinary fistula has been reportedpreviously.

4

However, the exact mechanism by whichthe coils cause ureteral occlusion is not known. Theuroepithelial hyperplasia together with thrombus causedby the coils might play some role in our case. To ourknowledge, this is the first case of an intraluminal ure-teral occlusion technique used to manage an uretero-arterial fistula with long-term control.

References

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et al.

Arterio-ureteral fistula after extended resection of pelvic tumors:Report of three cases and review of the literature.

Ann.Vasc. Surg.

1992;

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: 362–9.2 Quillin SP, Darcy MD, Picus D. Angiographic evalu-

ation and therapy of ureteroarterial fistulas.

Am. J.Roentgenol.

1994;

162

: 873–8.3 Cass AS, Odland M. Ureteroarterial fistula: A case

report and review of literature.

J. Urol.

1990;

143

: 582–3.4 Gregg MG, Irwin SJ. Transrenal ureteral occlusion

with Gianturco coils and gelatin sponge.

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: 1047–8.

Fig. 1

(a) Aortogram shows no extravasation of the con-trast material. (b) Retrograde ureterogram obtained afterremoval of the ureteral stent shows contrast materialextravasating from left ureter (arrow) into crossing aorta(arrowhead).

Fig. 2

Gianturco coils inserted into the ureter intralumi-nally are indicated by the arrow.