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Arteriovesical Fistula After Pancreatic Transplantation
0022-5347/95/1545-1861$03.00/0
TIE JOURNAL OF UROLGCY
Vol. 151.1861-1862. November 1996 printed in U . S A
Copyright 0 1995 by AMER~CAN UROLGCICM, A s s o c w ~ ohc. ~,
ARTERIOVESICAL FISTULA AFTER PANCREATIC TRANSPLANTATION PETER A. NASH AND J. SAMUEL LITTLE. JR.* From the Department of Umhgy. Indiana University Medical Center. Indianapolis. Indiana
KEYW o r n : pancreas, bladder, fistula, transplantation
Fistula formation between the urinary tract and pelvic vasculature is rare. We report a case of life threatening hematuria resulting from a fistula between an iliac artery pseudoaneurysm and the bladder 7 years after pancreatic transplantation with bladder drainage. CASE REPORT
A 40-year-old man with insulin-dependent diabetes underwent living related renal transplantation in July 1984for end stage renal disease secondary to diabetic nephropathy. In September 1987 he underwent whole pancreas transplantation. A Carrel1 patch, including the celiac and superior mesenteric arteries, was anastomosed to the left, iliac artery and exocrine drainage was achieved to the bladder via duodenocystostomy. A combination of venom gr& t,hrombsis and rejection led to pancreatic graft failure soon after transplantation. Subsequently the patient remained well with a functioning recurred, nmessitatrenal d o g & . urinary tract ing continuous low dose antibiotic prophylaxis that was tolerated without incident. Therefore, continued conservative management was elected rather than graft removal. Two weeks before hospitalization in September 1994 an episode of self-limiting painless gross hematuria occurred. On the day before transfer to our institution he was admitted to the local hospital in hemdynamically unstable condition with severe gross painless hematuria. Cystoscopy revealed a blood clot at the duodenal orifice and p r o h e hemorrhage ensued when it was removed, prompting the subsequent transfer. At presentation to our facility the patient was in hemodynamically stable condition with clear bladder irrigation. Noncontrast abdominal computerized tomography revealed a pseudoaneurysm of the left external iliac d r y (me figure). Hemorrhage soon recurred, resulting in clot retention and
hemodynamic instability. Cystoscopy revealed massive hemorrhage from the dome of the bladder, which prompted BUTgical exploration. A left iliac artery pseudoaneurysm associatedwith an autoinfarcted pancreas transplant was identitied with fistulization into the bladder. The pseudoaneurysm was resected, the bladder was repaired and omentum was interpomd. Urine was sterile and culture of the pseudoaneuryemwas negative. Convalescence was uneventful. DISCUSSION
CWentlY bladder drainage h the most common technique ex-e drainage after Pm-tiC -PlantationconSWuently lower &- tract complications develop in up to 50% Of Patients after S ~ u l t a m o WPanand kidney transplantation with the majority (90%)related to the panrreas transplant*' Fbmment tract infections and gross hematuria represent the most fresuent complications. Fistula formation between lower and Pelvic Vasdature is rare. The mod COmmOdY reported fistulas form between the distal ureter and iliac h*% and are m U d y iatrogenic in origin. However, spontaneous fistulas have been reported.2Arteriovesical fistulas are more rare with O d Y 3 cases PreviOmlY reported-' The condition occurred 1week after exploration of a lower abdominal gunehot wound, weeks after ureteroLthOtomY and loYears after renal hwPlantatiOn, respectively. While disruptions of the iliac h r y have been reported with pancreatic transplantation, to OUT knowledge OUT report represents the first case of an &*OVeakd fietula d g after whole P m m a tramPlantation with dudenOCYsh~mY* It is Speculated that a combination Of rejection and eX0mine resulted in P a m a t i c autolysis and PseudOaneurysm formation at the iliac artery. The patent duodenal segment served as a conduit for recurrent infections and $xepted for publication M a y 5, 1995. into the bladder. Hematuria after pancreatic fistulization Resuestsfor re rints:hpment of uH-1725, univemie MedicJCenkr, 550 NO& university Blvd., Indianapo- transplantation with bladder drainage in the acute setting lis, Indiana 46202. is usually related to the anastomosis with chronic bleeding Of
Noncontrast abdominopelvic computerized tomograph .A, pseudoaneurysm (Ps) of left external iliac artery (arrow).B, more caudal view shows communication among autolyzed pancreas, pseu&aneurysm (closed arrow)and bladder dome (b)via duodenal stump (open arrow). 1861
1862
FISTULA AFTER PANCREAS TRANSPLANTATION
resulting from duodenal ulceration. However, persistent unexplained bleeding or life threatening hemorrhage should lead one to consider the diagnosis of arteriovesical fistula. REFERENCES
1. Ploeg, R. J., Eckhoff. D. E., DAlessandro, A. M., Stegall, M. D., Knechtle, S. J., Pirsch, J. D., Sollinger, H. W. and Belzer, F. 0.:
Urologic complications and enteric conversion after pancreas transplantation with bladder drainage. Transplant. Proc., 26:
458, 1994.
2. Rennick, J. M., Link, D. P. and Palmer, J. M.: Spontaneous rupture of an iliac artery aneurysm into a ureter: a case report and review of the literature. J. Urol., 116: 111, 1976. 3. Bernath, A. S., Addonizio, J. C. and Arciola, A,: Iliac arterybladder fistulization ten years post-renal transplantation. Urology, 22: 635,1983.
TIE JOURNAL OF UROLGCY
Vol. 151.1861-1862. November 1996 printed in U . S A
Copyright 0 1995 by AMER~CAN UROLGCICM, A s s o c w ~ ohc. ~,
ARTERIOVESICAL FISTULA AFTER PANCREATIC TRANSPLANTATION PETER A. NASH AND J. SAMUEL LITTLE. JR.* From the Department of Umhgy. Indiana University Medical Center. Indianapolis. Indiana
KEYW o r n : pancreas, bladder, fistula, transplantation
Fistula formation between the urinary tract and pelvic vasculature is rare. We report a case of life threatening hematuria resulting from a fistula between an iliac artery pseudoaneurysm and the bladder 7 years after pancreatic transplantation with bladder drainage. CASE REPORT
A 40-year-old man with insulin-dependent diabetes underwent living related renal transplantation in July 1984for end stage renal disease secondary to diabetic nephropathy. In September 1987 he underwent whole pancreas transplantation. A Carrel1 patch, including the celiac and superior mesenteric arteries, was anastomosed to the left, iliac artery and exocrine drainage was achieved to the bladder via duodenocystostomy. A combination of venom gr& t,hrombsis and rejection led to pancreatic graft failure soon after transplantation. Subsequently the patient remained well with a functioning recurred, nmessitatrenal d o g & . urinary tract ing continuous low dose antibiotic prophylaxis that was tolerated without incident. Therefore, continued conservative management was elected rather than graft removal. Two weeks before hospitalization in September 1994 an episode of self-limiting painless gross hematuria occurred. On the day before transfer to our institution he was admitted to the local hospital in hemdynamically unstable condition with severe gross painless hematuria. Cystoscopy revealed a blood clot at the duodenal orifice and p r o h e hemorrhage ensued when it was removed, prompting the subsequent transfer. At presentation to our facility the patient was in hemodynamically stable condition with clear bladder irrigation. Noncontrast abdominal computerized tomography revealed a pseudoaneurysm of the left external iliac d r y (me figure). Hemorrhage soon recurred, resulting in clot retention and
hemodynamic instability. Cystoscopy revealed massive hemorrhage from the dome of the bladder, which prompted BUTgical exploration. A left iliac artery pseudoaneurysm associatedwith an autoinfarcted pancreas transplant was identitied with fistulization into the bladder. The pseudoaneurysm was resected, the bladder was repaired and omentum was interpomd. Urine was sterile and culture of the pseudoaneuryemwas negative. Convalescence was uneventful. DISCUSSION
CWentlY bladder drainage h the most common technique ex-e drainage after Pm-tiC -PlantationconSWuently lower &- tract complications develop in up to 50% Of Patients after S ~ u l t a m o WPanand kidney transplantation with the majority (90%)related to the panrreas transplant*' Fbmment tract infections and gross hematuria represent the most fresuent complications. Fistula formation between lower and Pelvic Vasdature is rare. The mod COmmOdY reported fistulas form between the distal ureter and iliac h*% and are m U d y iatrogenic in origin. However, spontaneous fistulas have been reported.2Arteriovesical fistulas are more rare with O d Y 3 cases PreviOmlY reported-' The condition occurred 1week after exploration of a lower abdominal gunehot wound, weeks after ureteroLthOtomY and loYears after renal hwPlantatiOn, respectively. While disruptions of the iliac h r y have been reported with pancreatic transplantation, to OUT knowledge OUT report represents the first case of an &*OVeakd fietula d g after whole P m m a tramPlantation with dudenOCYsh~mY* It is Speculated that a combination Of rejection and eX0mine resulted in P a m a t i c autolysis and PseudOaneurysm formation at the iliac artery. The patent duodenal segment served as a conduit for recurrent infections and $xepted for publication M a y 5, 1995. into the bladder. Hematuria after pancreatic fistulization Resuestsfor re rints:hpment of uH-1725, univemie MedicJCenkr, 550 NO& university Blvd., Indianapo- transplantation with bladder drainage in the acute setting lis, Indiana 46202. is usually related to the anastomosis with chronic bleeding Of
Noncontrast abdominopelvic computerized tomograph .A, pseudoaneurysm (Ps) of left external iliac artery (arrow).B, more caudal view shows communication among autolyzed pancreas, pseu&aneurysm (closed arrow)and bladder dome (b)via duodenal stump (open arrow). 1861
1862
FISTULA AFTER PANCREAS TRANSPLANTATION
resulting from duodenal ulceration. However, persistent unexplained bleeding or life threatening hemorrhage should lead one to consider the diagnosis of arteriovesical fistula. REFERENCES
1. Ploeg, R. J., Eckhoff. D. E., DAlessandro, A. M., Stegall, M. D., Knechtle, S. J., Pirsch, J. D., Sollinger, H. W. and Belzer, F. 0.:
Urologic complications and enteric conversion after pancreas transplantation with bladder drainage. Transplant. Proc., 26:
458, 1994.
2. Rennick, J. M., Link, D. P. and Palmer, J. M.: Spontaneous rupture of an iliac artery aneurysm into a ureter: a case report and review of the literature. J. Urol., 116: 111, 1976. 3. Bernath, A. S., Addonizio, J. C. and Arciola, A,: Iliac arterybladder fistulization ten years post-renal transplantation. Urology, 22: 635,1983.