Iliac Artery-ureteral Fistula Associated with Gibbons’ Catheter: A Case Report and Review of The Literature

0022-5347/81/1256-0878$02.00/0 THE JOURNAL OF UROLOGY Copyright© 1981 by The Williams & Wilkins Co.

Vol. 125, June

Printed in U.S.A.

ILIAC ARTERY-URETERAL FISTULA ASSOCIATED WITH GIBBONS' CATHETER: A CASE REPORT AND REVIEW OF THE LITERATURE H. N. NELSON

AND

F. A. FRIED*

From the Division of Urology, University of North Carolina School of Medicine, Chapel Hill, North Carolina

ABSTRACT

Fistulas between the iliac artery and ureter are associated with underlying ureteral and/ or arterial pathology. Factors implicated in the pathogenesis of these fistulas and a current case are presented. with hydration and restriction of activities. The site of bleeding was seen clearly at cystoscopy to be coming from the right ureter. We thought that the Gibbons catheter was responsible for the hematuria and, therefore, removed it. Immediately upon removal of the catheter massive pulsatile bleeding was encountered. An immediate arteriogram demonstrated a fistula between the right iliac artery and right ureter (fig. 2). Ligation of the proximal and distal iliac artery promptly controlled the hemorrhage and a cutaneous ureterostomy was performed. Convalescence was uneventful. At followup 10 months later the serum creatinine was 2.5 mg./dl.

FIG. 1. A, x-ray 2 hours after injection of contrast medium demonstrates hydronephrosis and ureterectasis to level of right iliac artery. B, pyelographic appearance 16 months after placement of Gibbons' catheter reveals improvement of obstruction of solitary right kidney.

Iliac artery-ureteral fistulas are uncommon. Our review of the literature, prompted by a recent experience, has yielded reports of 12 patients with this diagnosis in the last 40 years. This review identifies several contributory factors that are discussed herein. CASE REPORT

A 71-year-old woman had an aortofemoral graft approximately 20 years before the current hospitalization. The graft had been revised 10 years later. The patient was seen initially 5 years ago because of left pyonephrosis necessitating nephrectomy. The right kidney was unobstructed. She was rehospitalized 2 years ago for increasing problems with right lower extremity claudication. A femoral-to-femoral artery shunt was done. During this evaluation the solitary right kidney was discovered to be hydronephrotic (fig. 1, A). Mid ureteral obstruction was demonstrated and presumed to be related to retroperitoneal fibrosis on the basis of the vascular disease and previous surgery. A Gibbons catheter was placed without difficulty through the area of obstruction and functioned without difficulty for the next year (fig. 1, B). A small bladder stone attached to the distal end of the Gibbons catheter was removed 6 months ago. The patient continued to do well until April 1979 when she began to have episodes of hematuria that would clear Accepted for publication August 1, 1980. * Requests for reprints: Division of Urology, Department of Surgery, University of North Carolina, 427 Clinical Sciences Building, Chapel Hill, North Carolina 27514. 878

FIG. 2. Aortogram demonstrates fistula between right iliac artery and clot-filled ureter (arrows).

879 DISCUS8I0bT

In our review of the literature on iliac artery-ureteral fistulas we noted 3 basic categories of disease processes that are contributory to the pathogenesis of these fistulas: iliac artery aneurysms, mycotic and atherosclerotic, primary ureteral disease, and surgical trauma. In most instances of iliac arteryureteral fistulas there also has been a period ofureteral catheter drainage (see table). One is led to conclude that the combination of a diseased iliac artery and an indwelling ureteral catheter greatly increases the risk of this complication. Iliac artery aneurysms. The earliest reports of iliac arteryureteral fistulas occurred during pregnancy complicated sepsis with obstruction and right pyelonephritis. Three such cases have been reported. 1- 3 In each instance the patient was treated with an indwelling ureteral catheter for periods ranging from 3 weeks to 3 months. Postmortem examinations in these 3 patients revealed a mycotic aneurysm of the iliac artery. Iliac artery aneurysms secondary to atherosclerosis also may produce ureteral obstruction. These aneurysms usually are asymptomatic but may present with rupture into the retroperitoneum, small bowel or ureter. 4 Iliac artery-ureteral fistulas in ureteral remnants have been reported. 5•6 In these cases the aneurysm had produced hydronephrosis and the patients had had a nephrectomy. Rennick and associates reported a case of rupture of an iliac artery aneurysm into the ipsilateral ureter. 7 Their patient is unique in that there was no antecedent instrumentation of the ureter to fistulization and the aneurysm ·01as diagnosed as being the point of ureteral obstruction. r,-u,·u1.rv ureteral disease, The evei,op,merrt of iliac arteryurete:ral following te:rolltho,tc,m has been reported. 8- 10 The cases reported by Cowen.,9 and Nicita and associates 10 also involved ureteral catheter drainage. In the

References

Age-Sex

Han1er2

34-F (pregnant)

Taylor and Reinhart"

20- F(pregnant)

Davidson and Smith 1

18-F (pregnant)

Whitmore 12

43-F

Cowen9

44-M

Hodges'

64-M

A.rap and associates8

53-F

Beaugie 13

58-M

Shultz and associates6

71-M

Reiner and associates II

57-F

latter case catheter neous fistula that had ureteral fistula

treat a ureterocutanc•TQ1<:te>rl

1 n1onth, The iliac artery-

following closure of the

Iliac artery-ureteral fistulas of radical pelvic surgery. In 1 report extravasation follovving disruption of a ureteroileal anastomosis was treated by a proximal T-tube ureterostomy. 11 The iliac artery-ureteral fistula caused exsanguination 3 weeks later. Another patient reported on by Whitmore had bilateral ureteral obstruction and urinary fistulas following a hysterectomy for carcinoma of the cervix. 12 She was treated by left ureteral catheterization and right ureteroneocystostomy and, subsequently, an iliac artery-ureteral fistula developed. Beaugie reported a fistula between the iliac artery and the proximal end of an ileal conduit in a patient with carcinoma of the bladder treated by cystectomy and ileal conduit. 13 All 3 of the patients in this group died of the iliac artery fistula. The published reports dealing with iliac artery-ureteral fistulas clearly implicate ureteral catheterization in the pathogenesis of this problem. Our case is unique in that the provoking factor was a 2-year period of drainage with a Gibbons catheter. In this case arteriography was helpful in confirming our clinical diagnosis and did not delay the surgical intervention. The increasing use of long-term internal ureteral catheters for the treatment of ureteral obstruction has significantly imthe quality of life in this group of patients. When chronic ureteral intubation is considered one should assess the condition of the ipsilateral iliac artery with radiographs to demonstrate arterial calcification. Ultrasound examination also is useful to confirm dilatation of this vessel. The presence of an iliac artery aneurysm should be considered a relative contraindication to ipsilateral ureteral catheterization, particularly .~u.,;,nv,

vv1a 1,u•L.a,c.vrn,

Etiology /Presenting Signs and Symptoms

Treatment

Rt. pyelonephritis treated with indwelling ureteral catheter for 3 mos., hemorrhage from rt. iliac artery-ureteral fistula demonstrated at postmortem examination Rt, pyelonephritis treated with indwelling ureteral catheter for 3 wks,, hemorrhage from rt iliac artery-ureteral fistula demonstrated at postmortem examination Bilat, pyelonephritis ti-eated with indwelling ureteral catheter for 4 wks, hemonhage from rt. iliac artery-ureteral

Outcome

None

Died

None

Died

None

Died

fistula demonstrated at postmortem examination Postop, hysterectomy complicated by a It. ureterocutaneous fistula and pyelonephritis, treated with uretecal catheter for 3 wks., iliac artery-ureteral fistula found at Postop. lt. ureterolithotomy with pn,w,1~c,u treated by ureteral ca1:hete1,iza,ticm }Aid ureteral obstruction secondary to rt. rysrn treated urete:ral catheter artery-ureteral fistula cte,,el,)n,,ct

Ligation of iliac artery and priSurvived mary closure of ureteral defect Ligation of artery

Died

Ligation of iliac a.rteTy

Survived

Surgical exploration

Died.

Resection of rt. iliac replacement with graft revision of conduit Ligation of iliac artery with graft, resection of distal ureteral stump Oversewing :rt. iliac artery tear

Died

1 mo.,

Rennick and associates 7

66-M

Nicita and associates10 Present case

52-M

75-F

art:erv-ure1:er,al fistula Postop. cystectomy ,;vith ileal and :radiation therapy, iliac artery-conduit fistula devdoped 7 wks. later patch g"faft of rt. iliac artery) rt. nephrectomy secto obstruction, fistula of rt. iliac artery aneurysm to rt ureteral stump Postop, pelvic exenteration with ilea! conduit, bilat, ureteral obstruction treated with T-tube ureterostomies, iliac artery-ureteral fistula developed following removal oflt. Ttube Ureteral obstruction secondary to It. iliac artery aneurysm with concomitant stone disease and rt. ureteral reflux, history of flank pain and intermittent gross hematuria Postop, distal rt. ureterolithotomy complicated by sepsis, iliac artery-ureteral fistula developed Postop. repair of abdominal aortic aneurysm with It, pyonephrosis secondary to obstruction requiring lt nephrectomy, rt. ureteral obstruction secondary to fibrosis treated with Gibbons' catheter, iliac artery-ureteral fistula developed

and proximal cutaneous ure-

Survived

Survived (4 wks.)

terostomy Ligation of aneurysm with rt. nephrectomy

Died

Rt. nephrectomy, ligation of rt. iliac artery Ligation of rt. iliac artery, cutaneous ureterostomy

Survived

880

NELSON AND FRIED

for a prolonged period. REFERENCES 1. Davidson, 0. W. and Smith, R. P.: Uretero-arterial fistula. Report of a case. J. Urol., 42: 257, 1939.

2. Hamer, H. G.: Fatal ureteral hemorrhage due to erosion into iliac artery; report of a case occurring during indwelling catheter drainage for pyelitis of pregnancy. Trans. Amer. Ass. GenitoUrin. Surg., 32: 177, 1939. 3. Taylor, W. N. and Reinhart, H. L.: Mycotic aneurysm of common iliac artery with rupture into right ureter. Report of a case. J. Urol., 42: 21, 1939. 4. Marowitz, A. M. and Norman, J.C.: Aneurysms of the iliac artery. Ann. Surg., 154: 777, 1961. 5. Hodges, C. V.: Iliac artery-ureteral fistula. Urologists' Correspondence Club Newsletter, July 27, 1959. 6. Shultz, M. L., Ewing, D. D. and Lovett, V. F.: Fistula between iliac

aneurysm and distal stump of ureter with hematuria: a case report. J. Urol., 112: 585, 1974. 7. 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. 8. Arap, S., Nardy, 0. W., Goes, G. M., Azevedo, J. R. and de Campos Freire, J. G.: Fistula ureteroarterial. Rev. Paulista Med., 67: 352, 1965. 9. Cowen, R.: Uretero-arterial fistula. J. Urol., 73: 801, 1955. 10. Nicita, G., Lunghi, F., Diligenti, L. M., Ferrarese, D., Fiorelli, C.

and Turini, D.: Arteriovesical fistula after ureterolithotomy: a case report and review of the literature. J. Urol., 120: 370, 1978. 11. Reiner, R. J., Conway, G. F. and Threlkeld, R.: Ureteroarterial fistula. J. Urol., 113: 24, 1975. 12. Whitmore, W. F., Jr.: Uretero-arterial fistula and uretero-vaginal fistula: report of a case. Urologia, 21: 184, 1954. 13. Beaugie, J. M.: Fistula between external iliac artery and ileal conduit. Brit. J. Urol., 43: 450, 1971.