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Ureteral Obstruction Following Aortobifemoral Bypass: Management by Endoscopic Balloon Dilation
0022-5347/92/1471-0120$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 147, 120-122, January 1992 Printed in U.S.A.
URETERAL OBSTRUCTION FOLLOWING AORTOBIFEMORAL BYPASS: MANAGEMENT BY ENDOSCOPIC BALLOON DILATION ANTHONY S. WARD, NARIMAN D. KARANJIA AND ANDREW J. RUSSELL From the Departments of Vascular Surgery and Urology, Basingstoke District Hospital, Basingstoke, Hampshire, United Kingdom ABSTRACT
A 71-year-old man presented with left hydronephrosis 1 year after aortofemoral bypass. Hydro nephrosis was due to extrinsic compression of the ureter between the graft anteriorly and the native iliac artery. Treatment by endoscopic transluminal balloon dilation resulted in complete resolution of the hydronephrosis. KEY WORDS: aorta, hydronephrosis, balloon dilatation, kidney diseases
Ureteral obstruction after aortic reconstruction is rare. In the largest series to date 42 instances of postoperative hydro nephrosis were encountered in 3,660 aortoiliac reconstructive procedures, an incidence of just greater than 1%. 1 Ureteral obstruction poses a serious management problem. Surgical intervention may risk urinary leakage and graft contamination, while failure to act may lead to a loss of renal function. We report a recent case that was successfully managed by the simple expedient of endoscopic transluminal balloon dilation. CASE REPORT
A 71-year-old man presented with incapacitating claudica tion of the left lower limb. On examination there was a weak femoral pulse on both sides and no distal pulses. Aortography showed extensive occlusive disease in the aortoiliac segment and bilateral superficial femoral artery occlusion. At operation in March 1988 a 113 x 8 mm. polytetrafluoroethylene bypass graft was anastomosed end-to-end to the native aorta just below the left renal vein. The limbs were tunneled into the groins and anastomosed end-to-side to the common femoral-profunda femoris arteries. Convalescence was uneventful and the symp toms were fully relieved. A year later he presented to the urology department with painless hematuria. An excretory urogram (IVP) showed de layed excretion on the left side and hydronephrosis. Panendos copy and retrograde ureterography were then performed. The mucosa of the bladder and urethra appeared normal but a smooth 2 cm. stricture was identified in the lower left ureter with delayed drainage on the post-retrograde films (fig. 1). A computerized tomography (CT) scan showed the absence of a mass at the site of the stricture. However, the left ureter was seen lying between the graft limb anteriorly and behind the native iliac artery (fig. 2, A). On the right side the graft was correctly situated behind the ureter (fig. 2, B). Vascular consultation was sought and it was suggested that an attempt be made to dilate the stricture endoscopically with a balloon catheter. Therefore, the patient underwent cystoscopy and, under image intensifier control, the stricture was dilated successfully. Dilation was achieved by inflating a 6F 50 X 8 mm. Olbert balloon* to 12 atmospheres on 3 successive occa sions, each inflation lasting 1 minute. Stricturing on the bal loon, which was evident initially, was completely eliminated even at low inflation pressure. There was no extravasation after dilation nor was any expected given the probable scarring and fixation of the surrounding tissues. A 6F pigtail stent was then inserted into the ureter and left in place for 2 months. An IVP l month after removal of the stent was normal and a repeat Accepted for publication May 3, 1991. * Meadox, United Kingdom.
FIG. 1. A, retrograde ureterogram shows 2 cm. stricture in left ureter (arrow). B, post-retrograde film shows delayed drainage above stricture.
IVP after 6 months confirmed continuing patency of the dilated segment (fig. 3). A repeat IVP 12 months after endoscopic dilation showed some recurrence of the hydronephrosis. Repeat cystoscopy and ureteral catheterization revealed the cause of the obstruction to be a stone that had previously been present in the left kidney and had descended to the dilation site. The stone was displaced back into the kidney for lithotripsy. There was no evidence of recurrent ureteral stricture at the site of the previous balloon dilation. _,
DISCUSSION
Previous reports have suggested that the incidence of ureteral obstruction after an aortic operation is approximately 1 to 2%. 1• However, early postoperative hydronephrosis probably is much more common than these figures suggest. The exact incidence depends on how actively the diagnosis is sought. Thus, in 2 series in which ultrasound scanning was done prospectively after an aortic operation hydronephrosis was recorded in 10 to 20% of the cases. 3• Most of these cases were 2
4
120
MANAGEMENT OF URETERAL OBSTRUCTION AFTER. AORTOBIFEMORAL BYPASS
121
FIG. 3. IVP 6 months after endoscopic balloon dilation shows con tinued patency of dilated segment. FIG. 2. A, CT scan at site of ureteral stricture demonstrates no mass. Left ureter lies between graft limb anteriorly and native iliac artery posteriorly. B, CT scan immediately above stricture shows dilated left ureter. On right side ureter is seen lying anterior to graft limb.
clinically silent and either resolved spontaneously or remained stable on followup. Initial reports of postoperative ureteral obstruction impli cated placement of the graft anterior to the ureter with ureteral entrapment between the graft and artery as the cause of the obstruction. 5• However subsequent have shown entrapand it seems likely that ment in less than half of the the most important cause of obstruction is the retroperitoneal fibrotic reaction that occurs around a prosthesis. 9 In a minority of instances postoperative ureteral obstruction is due to devas cularization of the ureter at placement of the aortic graft. Graft complications, such as a false aneurysm at an iliac anastomosis or graft infection, may also lead to ureteral obstruction. Indeed, ureteral dilation may be the first sign that such a graft compli cation is present. 1 Injury to a dilated, thin-walled ureter is a , real risk in these cases during subsequent graft revision or excision. Although most early postoperative cases will resolve spon taneously, intervention occasionally is required because of flank pain or renal impairment. Ureteral stenting or percutaneous nephrostomy with or without steroids may be a useful means of temporizing until spontaneous resolution occurs. 10 Late post operative ureteral obstruction poses more of a problem. Long term stenting will maintain renal function but will do nothing 6
to cure the underlying stricture. In addition there is the risk of urinary tract infection, occlusion of the lumen by debris and poor patient tolerance. Ureterolysis with or without intra peritonealization of the ureter and omental wrapping has been the most frequently used treatment when the ureter is anterior to the graft. Improvement in upper tracts has been reported in 85% of the cases. 8 However, ureterolysis may be difficult and lead to ischemia or ureteral injury with subsequent urinary leakage. When ureterolysis is not feasible uretera! resection with anastomosis may be used although there is again a poten tial risk of leakage and contamination. When the ureter and the native is entrapped between an anteriorly vessel, ureteral division with transposition and re-anastomosis to avoid the potential hazard of has been ""r,rwtPn 18 a ureteral anastomosis adjacent to the vascular graft others have suggested division and transposition of the graft itself rather than the ureter, a procedure that is also not devoid of complications:' Occasionally, nephroureterectomy has been judged the only feasible means to treat a ureteral stricture in association with a vascular graft. 1· Endoscopic transluminal dilation avoids all of these difficul ties. This approach has been used successfully to treat a variety of benign intrinsic ureteral strictures with good results at least in the short term. 11• 12 However, to the best of our knowledge this is the first time this technique has been used to treat the specific problem of ureteral obstruction after an aortic opera tion. Long-term followup will obviously be necessary in our patient. However, the technique not only is relatively simple but in the event of recurrent stenosis further dilation should be feasible. 8
122
FLOOD, JONES AND GRAINGER REFERENCES
1. Wright, D. J., Ernst, C. B., Evans, J. R., Smith, R. F., Reddy, D. J., Shepard, A. D. and Elliott, J. P., Jr.: Ureteral complications and aortoiliac reconstruction. J. Vase Surg., 11: 29, 1990. 2. Egeblad, K., Br0chner-Mortensen, J., Kramp, T., Holstein, P. E. and Bartholdy, N. J.: Incidence of ureteral obstruction after aortic grafting: a prospective analysis. Surgery, 103: 411, 1988. 3. Schubert, P., Fortner, G., Cummings, D., Reed, D., Thiele, B. L., Bandyk, D. F. and Radke, H. M.: The significance of hydrone phrosis after aortofemoral reconstruction. Arch. Surg., 120: 377, 1985. 4. Goldenberg, S. L., Gordon, P. B., Cooperberg, P. L. and McLoughlin, M. G.: Early hydronephrosis following aortic bifur cation graft surgery: a prospective study. J. Urol., 140: 1367, 1988. 5. Ly:tton,__ B_.: Ur_eteral _o_bstruction following aortofemoral bypass grafts. Surgery, 59: 918, 1966. 6. Thomford, N. R. and Dorfman, L. F.: Ureteral obstruction caused
by an aortofemoral bypass prosthesis. Amer. J. Surg., 115: 394, 1968. 7. Antkowiak, J. G. and D'Altorio, R. A.: Ureteral obstruction sec ondary to bifurcated aortic grafts. Arch. Surg., 114: 853, 1979. 8. Sant, G. R., Heaney, J. A., Parkhurst, E. C. and Blaivas, J. G.: Obstructive uropathy-a potentially serious complication of re constructive vascular surgery. J. Urol., 129: 16, 1983. 9. Garrett, H. E., Jr., Richardson, J. W., Howard, H. S. and Garrett, H. E.: Retroperitoneal lymphocele after abdominal aortic sur gery. J. Vase. Surg., 10: 245, 1989. 10. Ruben, R. P. and Schellhammer, P. F.: Steroid therapy for ureteral obstruction after aortoiliac graft surgery. J. Urol., 125: 881, 1981. 11. Lang, E. K. and Glorioso, L. W., III: Antegrade transluminal dilatation of benign ureteral strictures: long-term results. AJR, 150: 131, 1988. 12._Kramolowsky:, E. V.,Tucker, R. n., N_elson,_C. M. K.:Management of benign ureteral strictures: open surgical repair or endoscopic dilation? J. Urol., 141: 285, 1989.
0022-5347/92/1471-0122$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 147, 122-124, January 1992 Printed in U.S.A.
URETEROCOLIC FISTULA: A UNIQUE COMPLICATION OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY H. D. FLOOD,* B. JONES AND R. GRAINGER From the Department of Urology, Meath Hospital, Dublin, Ireland
ABSTRACT A unique case of ureterocolic fistula at the site of stone fragment impaction after piezoelectric shock wave lithotripsy is described. Pathological examination of the nephroureterectomy specimen indicated xanthogranulomatous pyelonephritis with the process extending into the ureter and fistulous tract. KEY WORDS: extracorporeal shockwave lithotripsy; kidney calculi; pyelonephritis, xanthogranulomatous; urinary fistula
Ureterocolic fistula is rare and has been reported as occurring spontaneously, 1• and in association with diverticular disease, 1• colonic carcinoma4 and Hodgkin's disease. 5 To our knowledge only 3 cases have been reported in which fistula was associated with stone obstruction of the ureter at the fistula site. 6-8 Al though renocolic and other forms of fistula are well de·scribed with xanthogranulomatous pyelonephritis,9 there is only 1 re ported case of ureterocolic fistula in association with xantho granulomatous ureteritis. 10 Obstruction is a well recognized complication of extracorpo real shock wave lithotripsy (ESWLt) and has prompted the use of ureteral stents for prophylaxis, particularly in patients with stone diameters of greater than 2 cm. However, to our knowledge there are no reported cases of ureterocolic fistula complicating ureteral stone obstruction after ESWL. We de scribe such a case following renal stone fragmentation by extracorporeal piezoelectric lithotripsy. 3
2
CASE REPORT
A 61-year-old woman presented with a 5-day history of left loin pain and fever. Plain abdominal film and renal ultrasound revealed left hydronephrosis secondary to a 3 cm. calculus at the ureteropelvic junction. The patient was started on intra venous antibiotics. Early pyonephrosis was drained by pushing the stone to the kidney and passing a double pigtail stent (fig. Accepted for publication Mayl 7, 1991. * Current address: Section of Urology, University of Michigan, 2916D Taubman Center, Box 0330, Ann Arbor, Michigan 48109. t Dornier Medical Systems, Inc., Marietta, Georgia. :j: Medical Engineering Corp., New York, New York.
l, A). Proteus mirabilis was cultured from the urine. An excre tory urogram 1 week after stent placement showed a hypertro phied right kidney and a small, poorly functioning although draining left kidney with calculi. There was no evidence of ureteral abnormality at this stage. A renogram 2 weeks later demonstrated a glomerular filtration rate of 54 ml. per minute on the right side and 12 ml. per minute on the left side. The patient was discharged from the hospital and had 3 sessions of piezoelectric lithotripsy as an outpatient using the EDAP LT 01 device during a 6-week interval. As usual the patient expe rienced transient hematuria after each session and reported passing gravel after treatment. The kidney was stone-free after 3 sessions and the double pigtail stent was removed. The patient was rehospitalized elsewhere 6 weeks later for investigation of fatigue and night sweats. Ultrasound at this hospitalization indicated gross left hydronephrosis. A plain abdominal film at this time showed a large stone fragment in the upper pelvic ureter (fig. 1, B). On retrospective review of the plain x-ray before stent removal this stone fragment was visible at the same level. By this time the patient was septicemic and a urological opinion was sought. Intravenous antibiotics were commenced and 2 days later atraumatic ureteroscopy (9.5F Wolf ureteroscope) was performed. The ureter 10 cm. from the left ureteral orifice could not be passed due to edema and inflammation. A stone could not be visualized. However, a guide wire was passed successfully to the kidney and a Double J :j: stent was positioned followed by drainage of thick pus. Percutaneous nephrostomy was performed 2 days later for persistent hydronephrosis. The tube also drained viscid pus, which yielded fecal organisms. A nephrostogram 3 days later
Vol. 147, 120-122, January 1992 Printed in U.S.A.
URETERAL OBSTRUCTION FOLLOWING AORTOBIFEMORAL BYPASS: MANAGEMENT BY ENDOSCOPIC BALLOON DILATION ANTHONY S. WARD, NARIMAN D. KARANJIA AND ANDREW J. RUSSELL From the Departments of Vascular Surgery and Urology, Basingstoke District Hospital, Basingstoke, Hampshire, United Kingdom ABSTRACT
A 71-year-old man presented with left hydronephrosis 1 year after aortofemoral bypass. Hydro nephrosis was due to extrinsic compression of the ureter between the graft anteriorly and the native iliac artery. Treatment by endoscopic transluminal balloon dilation resulted in complete resolution of the hydronephrosis. KEY WORDS: aorta, hydronephrosis, balloon dilatation, kidney diseases
Ureteral obstruction after aortic reconstruction is rare. In the largest series to date 42 instances of postoperative hydro nephrosis were encountered in 3,660 aortoiliac reconstructive procedures, an incidence of just greater than 1%. 1 Ureteral obstruction poses a serious management problem. Surgical intervention may risk urinary leakage and graft contamination, while failure to act may lead to a loss of renal function. We report a recent case that was successfully managed by the simple expedient of endoscopic transluminal balloon dilation. CASE REPORT
A 71-year-old man presented with incapacitating claudica tion of the left lower limb. On examination there was a weak femoral pulse on both sides and no distal pulses. Aortography showed extensive occlusive disease in the aortoiliac segment and bilateral superficial femoral artery occlusion. At operation in March 1988 a 113 x 8 mm. polytetrafluoroethylene bypass graft was anastomosed end-to-end to the native aorta just below the left renal vein. The limbs were tunneled into the groins and anastomosed end-to-side to the common femoral-profunda femoris arteries. Convalescence was uneventful and the symp toms were fully relieved. A year later he presented to the urology department with painless hematuria. An excretory urogram (IVP) showed de layed excretion on the left side and hydronephrosis. Panendos copy and retrograde ureterography were then performed. The mucosa of the bladder and urethra appeared normal but a smooth 2 cm. stricture was identified in the lower left ureter with delayed drainage on the post-retrograde films (fig. 1). A computerized tomography (CT) scan showed the absence of a mass at the site of the stricture. However, the left ureter was seen lying between the graft limb anteriorly and behind the native iliac artery (fig. 2, A). On the right side the graft was correctly situated behind the ureter (fig. 2, B). Vascular consultation was sought and it was suggested that an attempt be made to dilate the stricture endoscopically with a balloon catheter. Therefore, the patient underwent cystoscopy and, under image intensifier control, the stricture was dilated successfully. Dilation was achieved by inflating a 6F 50 X 8 mm. Olbert balloon* to 12 atmospheres on 3 successive occa sions, each inflation lasting 1 minute. Stricturing on the bal loon, which was evident initially, was completely eliminated even at low inflation pressure. There was no extravasation after dilation nor was any expected given the probable scarring and fixation of the surrounding tissues. A 6F pigtail stent was then inserted into the ureter and left in place for 2 months. An IVP l month after removal of the stent was normal and a repeat Accepted for publication May 3, 1991. * Meadox, United Kingdom.
FIG. 1. A, retrograde ureterogram shows 2 cm. stricture in left ureter (arrow). B, post-retrograde film shows delayed drainage above stricture.
IVP after 6 months confirmed continuing patency of the dilated segment (fig. 3). A repeat IVP 12 months after endoscopic dilation showed some recurrence of the hydronephrosis. Repeat cystoscopy and ureteral catheterization revealed the cause of the obstruction to be a stone that had previously been present in the left kidney and had descended to the dilation site. The stone was displaced back into the kidney for lithotripsy. There was no evidence of recurrent ureteral stricture at the site of the previous balloon dilation. _,
DISCUSSION
Previous reports have suggested that the incidence of ureteral obstruction after an aortic operation is approximately 1 to 2%. 1• However, early postoperative hydronephrosis probably is much more common than these figures suggest. The exact incidence depends on how actively the diagnosis is sought. Thus, in 2 series in which ultrasound scanning was done prospectively after an aortic operation hydronephrosis was recorded in 10 to 20% of the cases. 3• Most of these cases were 2
4
120
MANAGEMENT OF URETERAL OBSTRUCTION AFTER. AORTOBIFEMORAL BYPASS
121
FIG. 3. IVP 6 months after endoscopic balloon dilation shows con tinued patency of dilated segment. FIG. 2. A, CT scan at site of ureteral stricture demonstrates no mass. Left ureter lies between graft limb anteriorly and native iliac artery posteriorly. B, CT scan immediately above stricture shows dilated left ureter. On right side ureter is seen lying anterior to graft limb.
clinically silent and either resolved spontaneously or remained stable on followup. Initial reports of postoperative ureteral obstruction impli cated placement of the graft anterior to the ureter with ureteral entrapment between the graft and artery as the cause of the obstruction. 5• However subsequent have shown entrapand it seems likely that ment in less than half of the the most important cause of obstruction is the retroperitoneal fibrotic reaction that occurs around a prosthesis. 9 In a minority of instances postoperative ureteral obstruction is due to devas cularization of the ureter at placement of the aortic graft. Graft complications, such as a false aneurysm at an iliac anastomosis or graft infection, may also lead to ureteral obstruction. Indeed, ureteral dilation may be the first sign that such a graft compli cation is present. 1 Injury to a dilated, thin-walled ureter is a , real risk in these cases during subsequent graft revision or excision. Although most early postoperative cases will resolve spon taneously, intervention occasionally is required because of flank pain or renal impairment. Ureteral stenting or percutaneous nephrostomy with or without steroids may be a useful means of temporizing until spontaneous resolution occurs. 10 Late post operative ureteral obstruction poses more of a problem. Long term stenting will maintain renal function but will do nothing 6
to cure the underlying stricture. In addition there is the risk of urinary tract infection, occlusion of the lumen by debris and poor patient tolerance. Ureterolysis with or without intra peritonealization of the ureter and omental wrapping has been the most frequently used treatment when the ureter is anterior to the graft. Improvement in upper tracts has been reported in 85% of the cases. 8 However, ureterolysis may be difficult and lead to ischemia or ureteral injury with subsequent urinary leakage. When ureterolysis is not feasible uretera! resection with anastomosis may be used although there is again a poten tial risk of leakage and contamination. When the ureter and the native is entrapped between an anteriorly vessel, ureteral division with transposition and re-anastomosis to avoid the potential hazard of has been ""r,rwtPn 18 a ureteral anastomosis adjacent to the vascular graft others have suggested division and transposition of the graft itself rather than the ureter, a procedure that is also not devoid of complications:' Occasionally, nephroureterectomy has been judged the only feasible means to treat a ureteral stricture in association with a vascular graft. 1· Endoscopic transluminal dilation avoids all of these difficul ties. This approach has been used successfully to treat a variety of benign intrinsic ureteral strictures with good results at least in the short term. 11• 12 However, to the best of our knowledge this is the first time this technique has been used to treat the specific problem of ureteral obstruction after an aortic opera tion. Long-term followup will obviously be necessary in our patient. However, the technique not only is relatively simple but in the event of recurrent stenosis further dilation should be feasible. 8
122
FLOOD, JONES AND GRAINGER REFERENCES
1. Wright, D. J., Ernst, C. B., Evans, J. R., Smith, R. F., Reddy, D. J., Shepard, A. D. and Elliott, J. P., Jr.: Ureteral complications and aortoiliac reconstruction. J. Vase Surg., 11: 29, 1990. 2. Egeblad, K., Br0chner-Mortensen, J., Kramp, T., Holstein, P. E. and Bartholdy, N. J.: Incidence of ureteral obstruction after aortic grafting: a prospective analysis. Surgery, 103: 411, 1988. 3. Schubert, P., Fortner, G., Cummings, D., Reed, D., Thiele, B. L., Bandyk, D. F. and Radke, H. M.: The significance of hydrone phrosis after aortofemoral reconstruction. Arch. Surg., 120: 377, 1985. 4. Goldenberg, S. L., Gordon, P. B., Cooperberg, P. L. and McLoughlin, M. G.: Early hydronephrosis following aortic bifur cation graft surgery: a prospective study. J. Urol., 140: 1367, 1988. 5. Ly:tton,__ B_.: Ur_eteral _o_bstruction following aortofemoral bypass grafts. Surgery, 59: 918, 1966. 6. Thomford, N. R. and Dorfman, L. F.: Ureteral obstruction caused
by an aortofemoral bypass prosthesis. Amer. J. Surg., 115: 394, 1968. 7. Antkowiak, J. G. and D'Altorio, R. A.: Ureteral obstruction sec ondary to bifurcated aortic grafts. Arch. Surg., 114: 853, 1979. 8. Sant, G. R., Heaney, J. A., Parkhurst, E. C. and Blaivas, J. G.: Obstructive uropathy-a potentially serious complication of re constructive vascular surgery. J. Urol., 129: 16, 1983. 9. Garrett, H. E., Jr., Richardson, J. W., Howard, H. S. and Garrett, H. E.: Retroperitoneal lymphocele after abdominal aortic sur gery. J. Vase. Surg., 10: 245, 1989. 10. Ruben, R. P. and Schellhammer, P. F.: Steroid therapy for ureteral obstruction after aortoiliac graft surgery. J. Urol., 125: 881, 1981. 11. Lang, E. K. and Glorioso, L. W., III: Antegrade transluminal dilatation of benign ureteral strictures: long-term results. AJR, 150: 131, 1988. 12._Kramolowsky:, E. V.,Tucker, R. n., N_elson,_C. M. K.:Management of benign ureteral strictures: open surgical repair or endoscopic dilation? J. Urol., 141: 285, 1989.
0022-5347/92/1471-0122$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 147, 122-124, January 1992 Printed in U.S.A.
URETEROCOLIC FISTULA: A UNIQUE COMPLICATION OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY H. D. FLOOD,* B. JONES AND R. GRAINGER From the Department of Urology, Meath Hospital, Dublin, Ireland
ABSTRACT A unique case of ureterocolic fistula at the site of stone fragment impaction after piezoelectric shock wave lithotripsy is described. Pathological examination of the nephroureterectomy specimen indicated xanthogranulomatous pyelonephritis with the process extending into the ureter and fistulous tract. KEY WORDS: extracorporeal shockwave lithotripsy; kidney calculi; pyelonephritis, xanthogranulomatous; urinary fistula
Ureterocolic fistula is rare and has been reported as occurring spontaneously, 1• and in association with diverticular disease, 1• colonic carcinoma4 and Hodgkin's disease. 5 To our knowledge only 3 cases have been reported in which fistula was associated with stone obstruction of the ureter at the fistula site. 6-8 Al though renocolic and other forms of fistula are well de·scribed with xanthogranulomatous pyelonephritis,9 there is only 1 re ported case of ureterocolic fistula in association with xantho granulomatous ureteritis. 10 Obstruction is a well recognized complication of extracorpo real shock wave lithotripsy (ESWLt) and has prompted the use of ureteral stents for prophylaxis, particularly in patients with stone diameters of greater than 2 cm. However, to our knowledge there are no reported cases of ureterocolic fistula complicating ureteral stone obstruction after ESWL. We de scribe such a case following renal stone fragmentation by extracorporeal piezoelectric lithotripsy. 3
2
CASE REPORT
A 61-year-old woman presented with a 5-day history of left loin pain and fever. Plain abdominal film and renal ultrasound revealed left hydronephrosis secondary to a 3 cm. calculus at the ureteropelvic junction. The patient was started on intra venous antibiotics. Early pyonephrosis was drained by pushing the stone to the kidney and passing a double pigtail stent (fig. Accepted for publication Mayl 7, 1991. * Current address: Section of Urology, University of Michigan, 2916D Taubman Center, Box 0330, Ann Arbor, Michigan 48109. t Dornier Medical Systems, Inc., Marietta, Georgia. :j: Medical Engineering Corp., New York, New York.
l, A). Proteus mirabilis was cultured from the urine. An excre tory urogram 1 week after stent placement showed a hypertro phied right kidney and a small, poorly functioning although draining left kidney with calculi. There was no evidence of ureteral abnormality at this stage. A renogram 2 weeks later demonstrated a glomerular filtration rate of 54 ml. per minute on the right side and 12 ml. per minute on the left side. The patient was discharged from the hospital and had 3 sessions of piezoelectric lithotripsy as an outpatient using the EDAP LT 01 device during a 6-week interval. As usual the patient expe rienced transient hematuria after each session and reported passing gravel after treatment. The kidney was stone-free after 3 sessions and the double pigtail stent was removed. The patient was rehospitalized elsewhere 6 weeks later for investigation of fatigue and night sweats. Ultrasound at this hospitalization indicated gross left hydronephrosis. A plain abdominal film at this time showed a large stone fragment in the upper pelvic ureter (fig. 1, B). On retrospective review of the plain x-ray before stent removal this stone fragment was visible at the same level. By this time the patient was septicemic and a urological opinion was sought. Intravenous antibiotics were commenced and 2 days later atraumatic ureteroscopy (9.5F Wolf ureteroscope) was performed. The ureter 10 cm. from the left ureteral orifice could not be passed due to edema and inflammation. A stone could not be visualized. However, a guide wire was passed successfully to the kidney and a Double J :j: stent was positioned followed by drainage of thick pus. Percutaneous nephrostomy was performed 2 days later for persistent hydronephrosis. The tube also drained viscid pus, which yielded fecal organisms. A nephrostogram 3 days later