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Diagnosis and Management of a Challenging Patient: Ureteroarterial Fistula
ARTICLE IN PRESS
Images in Clinical Urology Diagnosis and Management of a Challenging Patient: Ureteroarterial Fistula Lauren Rittenberg,1 Michael Nordsiek,1 David Cahn, Karl Zhang, Nyali Taylor, and Phillip Ginsberg While uncommon, ureteral arterial fistula (UAF) should be a differential diagnosis for persistent hematuria, as management involves coordinated treatment with a multidisciplinary team. Despite various diagnostic modalities available, accuracy in diagnosis remains a challenge. We present a patient with known UAF risk factors, including chronic ureteral stent, history of radiation, and vascular procedures. Despite multiple negative imaging studies, UAF was ultimately diagnosed and successfully managed by an endovascular approach, with resolution of her hematuria. UROLOGY ■■: ■■–■■, 2016. Published by Elsevier Inc.
A
62-year-old female was admitted for 3 months due to intermittent painless gross hematuria. Years prior, she was treated for cervical cancer with surgery and external beam radiotherapy. Recently, she underwent a colostomy for ischemic bowel, and thromboembolectomy of her right external iliac vessels secondary to complications of central line access. Additionally, a right ureteral stent was placed for ureteral obstruction. For this admission, she required multiple blood transfusions and bladder irrigation. Concern for a ureteral arterial fistula prompted a computed tomography scan and a pelvic angiogram, which were nondiagnostic (Fig. 1). During ureteral stent exchange, a massive ureteral hemorrhage was triggered. A retrograde pyelogram with provocative maneuvers removed the overlying clot and demonstrated a fistula between the external iliac and distal right ureter (Fig. 2). A Gore-Tex nonfenestrated stent graft was placed from the common iliac into the external iliac artery, and the ureteral stent was replaced (Fig. 3). Consistent with previous reports, there is modest diagnostic accuracy for computed tomography and angiography. The sensitivity of provocative retrograde pyelogram has been reported to be 63%-100%.1,2 Endovascular repair is now considered the primary treatment modality by many institutions.3-5 Multiple series demonstrate challenges in its
1
These authors contributed equally to this manuscript. Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Einstein Healthcare Network, Philadelphia, PA; the Department of Interventional Radiology, Einstein Healthcare Network, Philadelphia, PA; and the Division of Vascular Surgery, Department of Surgery, Einstein Healthcare Network, Philadelphia, PA Address correspondence to: Michael Nordsiek, D.O., 1200 Tabor Road – 3/Sley, Philadelphia, PA 19141. E-mail: [email protected]; [email protected] Submitted: March 22, 2016, accepted (with revisions): July 15, 2016
Published by Elsevier Inc.
Figure 1. Initial angiogram with pelvic runoff, without demonstrable ureteral arterial fistula.
diagnosis and treatment and, as such, a high index of suspicion is needed.1-5 References 1. Krambeck AE, DiMarco DS, Gettman MT, Segura JW. Ureteroiliac artery fistula: diagnosis and treatment algorithm. Urology. 2005;66:990994. 2. Dervanian P, Castaigne D, Travagli JP, et al. Arterioureteral fistula after extended resection of pelvic tumors: report of three cases and review of the literature. Ann Vasc Surg. 1992;6:362-369. 3. Hirsch LM, Amirian MJ, Hubosky SG, Das AK, Abai B, Lallas CD. Urologic and endovascular repair of a uretero-iliac artery fistula. Can J Urol. 2015;22:7661-7665. 4. Malgor RD, Oderich GS, Andrews JC, et al. Evolution from open surgical to endovascular treatment of ureteral-iliac artery fistula. J Vasc Surg. 2012;55:1072-1080. 5. Fox JA, Krambeck A, McPhail EF, Lightner D. Ureteroarterial fistula treatment with open surgery versus endovascular management: longterm outcomes. J Urol. 2011;185:945-950.
http://dx.doi.org/10.1016/j.urology.2016.07.017 0090-4295
1
ARTICLE IN PRESS
Figure 2. Provocative retrograde pyelogram with fistulazation into right external iliac artery as seen on digital subtraction imaging.
Figure 3. Angiogram with no flow to internal iliac artery and no extravasation to ureter.
2
UROLOGY ■■ (■■), 2016
Images in Clinical Urology Diagnosis and Management of a Challenging Patient: Ureteroarterial Fistula Lauren Rittenberg,1 Michael Nordsiek,1 David Cahn, Karl Zhang, Nyali Taylor, and Phillip Ginsberg While uncommon, ureteral arterial fistula (UAF) should be a differential diagnosis for persistent hematuria, as management involves coordinated treatment with a multidisciplinary team. Despite various diagnostic modalities available, accuracy in diagnosis remains a challenge. We present a patient with known UAF risk factors, including chronic ureteral stent, history of radiation, and vascular procedures. Despite multiple negative imaging studies, UAF was ultimately diagnosed and successfully managed by an endovascular approach, with resolution of her hematuria. UROLOGY ■■: ■■–■■, 2016. Published by Elsevier Inc.
A
62-year-old female was admitted for 3 months due to intermittent painless gross hematuria. Years prior, she was treated for cervical cancer with surgery and external beam radiotherapy. Recently, she underwent a colostomy for ischemic bowel, and thromboembolectomy of her right external iliac vessels secondary to complications of central line access. Additionally, a right ureteral stent was placed for ureteral obstruction. For this admission, she required multiple blood transfusions and bladder irrigation. Concern for a ureteral arterial fistula prompted a computed tomography scan and a pelvic angiogram, which were nondiagnostic (Fig. 1). During ureteral stent exchange, a massive ureteral hemorrhage was triggered. A retrograde pyelogram with provocative maneuvers removed the overlying clot and demonstrated a fistula between the external iliac and distal right ureter (Fig. 2). A Gore-Tex nonfenestrated stent graft was placed from the common iliac into the external iliac artery, and the ureteral stent was replaced (Fig. 3). Consistent with previous reports, there is modest diagnostic accuracy for computed tomography and angiography. The sensitivity of provocative retrograde pyelogram has been reported to be 63%-100%.1,2 Endovascular repair is now considered the primary treatment modality by many institutions.3-5 Multiple series demonstrate challenges in its
1
These authors contributed equally to this manuscript. Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Einstein Healthcare Network, Philadelphia, PA; the Department of Interventional Radiology, Einstein Healthcare Network, Philadelphia, PA; and the Division of Vascular Surgery, Department of Surgery, Einstein Healthcare Network, Philadelphia, PA Address correspondence to: Michael Nordsiek, D.O., 1200 Tabor Road – 3/Sley, Philadelphia, PA 19141. E-mail: [email protected]; [email protected] Submitted: March 22, 2016, accepted (with revisions): July 15, 2016
Published by Elsevier Inc.
Figure 1. Initial angiogram with pelvic runoff, without demonstrable ureteral arterial fistula.
diagnosis and treatment and, as such, a high index of suspicion is needed.1-5 References 1. Krambeck AE, DiMarco DS, Gettman MT, Segura JW. Ureteroiliac artery fistula: diagnosis and treatment algorithm. Urology. 2005;66:990994. 2. Dervanian P, Castaigne D, Travagli JP, et al. Arterioureteral fistula after extended resection of pelvic tumors: report of three cases and review of the literature. Ann Vasc Surg. 1992;6:362-369. 3. Hirsch LM, Amirian MJ, Hubosky SG, Das AK, Abai B, Lallas CD. Urologic and endovascular repair of a uretero-iliac artery fistula. Can J Urol. 2015;22:7661-7665. 4. Malgor RD, Oderich GS, Andrews JC, et al. Evolution from open surgical to endovascular treatment of ureteral-iliac artery fistula. J Vasc Surg. 2012;55:1072-1080. 5. Fox JA, Krambeck A, McPhail EF, Lightner D. Ureteroarterial fistula treatment with open surgery versus endovascular management: longterm outcomes. J Urol. 2011;185:945-950.
http://dx.doi.org/10.1016/j.urology.2016.07.017 0090-4295
1
ARTICLE IN PRESS
Figure 2. Provocative retrograde pyelogram with fistulazation into right external iliac artery as seen on digital subtraction imaging.
Figure 3. Angiogram with no flow to internal iliac artery and no extravasation to ureter.
2
UROLOGY ■■ (■■), 2016