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Ureteral Obstruction Secondary to Inflammatory Isolated External Iliac Artery Aneurysm
EJVES Extra 1, 1–2 (2001) doi:10.1053/ejvx.2000.0001, available online at http://www.idealibrary.com on
CASE REPORT
Ureteral Obstruction Secondary to Inflammatory Isolated External Iliac Artery Aneurysm L. Iso˜kay1, B. Kocak∗1 and M. Bayazit2 Departments of 1Urology and 2Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey Key Words: Iliac artery aneurysm; Ureteral obstruction; Inflammatory aneurysm.
Introduction Extrinsic obstruction of the ureter is a common urological problem in which the diagnosis may be difficult to establish. Isolated iliac aneurysm is uncommon and often gives rise to urinary tract obstruction.1–3 It should be considered when performing differential diagnosis of extrinsic ureteral obstruction. We report one patient with right hydroureteronephrosis secondary to extrinsic ureteral trapping due to inflammatory isolated external iliac aneurysm.
Case Report A 49-year-old man was admitted because of right inguinal pain. Physical examination was unremarkable. Laboratory investigations revealed an ESR value of 54 mm/h. Excretory urography demonstrated a right hydroureteronephrosis. Retrograde pyeloureterography revealed a right hydroureteronephrosis with lower ureteral stenosis. Computerised tomography (CT) of the abdomen confirmed a right iliac artery aneurysm of 4 cm in length and 2 cm in diameter and an encased right ureter. At exploration, an isolated aneurysm of the right external iliac artery, 4 cm in length, and entrapment of the right ureter in perianeurysmal fibrosis was observed. Resection of the aneurysm with Dacron graft ∗ Corresponding author: Burak Kocak, Guleryuz Sok. No: 4/3 Y. Ayranci 06550 Ankara, Turkey. Tel: +90-532-3451272, Fax: +90-3123116351, E-mail: [email protected] 1533–3167/01/000000+02 $35.00/0 2001 Harcourt Publishers Ltd.
replacement of the external iliac artery and ureterolysis was performed. Microscopic examination of the fibrotic tissue revealed a ‘‘Perianeurysmal retroperitoneal fibrosis’’. Convalescence was uneventful.
Discussion Inflammatory iliac aneurysms are uncommon. The incidence of isolated iliac artery aneurysm is 1.9% and that of isolated internal iliac aneurysm is only 0.5% of abdominal aortic aneurysm.1 Patients with iliac artery aneurysms are most likely to present with urological manifestations.2,3 Isolated iliac aneurysm often gives rise to urinary tract obstruction. Rarely external iliac artery aneurysms may cause ureteral obstruction.4 The ureters may be obstructed either by direct compression of the aneurysm or by entrapment of the ureter in fibrotic process, which may be perianeurysmal immediately or more extensive in the retroperitoneum, resembling idiopathic retroperitoneal fibrosis.3,4 The pathology of this fibrotic process is characterised by proliferation of fibrous tissues with inflammatory cell infiltration.2,3 There are two basic explanations for the development of perianeurysmic fibrosis and retroperitoneal scarring. One is that small leaks develop at the weakest points of the aneurysm. After these seal, a retroperitoneal inflammatory reaction ensues and results in scarring that may extend laterally to encase and subsequently obstruct the ureter. The second explanation relates to
2
L. Iso˜kay et al.
the generalised atherosclerotic process involved in the formation of the aneurysm. Atherosclerosis often has an associated desmoplastic inflammatory component that extends to involve the adventitia of the scarring in the retroperitoneum.2,5 Patients who present with this type of retroperitoneal fibrosis may be difficult to differentiate from those with idiopathic retroperitoneal fibrosis.3 Treatment of choice is resection of the aneurysm and replacement by a vascular graft. Ureterolysis should be performed if the ureters are enveloped by perianeurysmal fibrosis. We present a rare case of ureteral obstruction secondary to isolated external iliac artery aneurysm which is described only in childhood cases in the literature.
EJVES Extra, 2001
References 1 Silver D, Anderson EE, Porter JM. Isolated hypogastric artery aneurysm. Review and report of three cases. Arch Surg 1967; 95: 308–312. 2 Minato N et al. Surgical treatment of isolated iliac artery aneurysm with ureteral obstruction and/or renal failure. J Cardiovasc Surg 1990; 31: 189–193. 3 Marino R et al. Urological manifestations of isolated iliac artery aneurysms. J Urol 1987; 137: 232–234. 4 Villani U, Leoni S, Mora A. Unilateral hydroureteronephrosis secondary to iliac aneurysm. Urology 1985; 26: 62–63. 5 Resnick MI, Kursh ED. Extrinsic obstruction of the ureter. In: Campbell’s Urology, 7th edition. Philadelphia: W.B. Saunders Company, 1998: 387–422.
CASE REPORT
Ureteral Obstruction Secondary to Inflammatory Isolated External Iliac Artery Aneurysm L. Iso˜kay1, B. Kocak∗1 and M. Bayazit2 Departments of 1Urology and 2Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey Key Words: Iliac artery aneurysm; Ureteral obstruction; Inflammatory aneurysm.
Introduction Extrinsic obstruction of the ureter is a common urological problem in which the diagnosis may be difficult to establish. Isolated iliac aneurysm is uncommon and often gives rise to urinary tract obstruction.1–3 It should be considered when performing differential diagnosis of extrinsic ureteral obstruction. We report one patient with right hydroureteronephrosis secondary to extrinsic ureteral trapping due to inflammatory isolated external iliac aneurysm.
Case Report A 49-year-old man was admitted because of right inguinal pain. Physical examination was unremarkable. Laboratory investigations revealed an ESR value of 54 mm/h. Excretory urography demonstrated a right hydroureteronephrosis. Retrograde pyeloureterography revealed a right hydroureteronephrosis with lower ureteral stenosis. Computerised tomography (CT) of the abdomen confirmed a right iliac artery aneurysm of 4 cm in length and 2 cm in diameter and an encased right ureter. At exploration, an isolated aneurysm of the right external iliac artery, 4 cm in length, and entrapment of the right ureter in perianeurysmal fibrosis was observed. Resection of the aneurysm with Dacron graft ∗ Corresponding author: Burak Kocak, Guleryuz Sok. No: 4/3 Y. Ayranci 06550 Ankara, Turkey. Tel: +90-532-3451272, Fax: +90-3123116351, E-mail: [email protected] 1533–3167/01/000000+02 $35.00/0 2001 Harcourt Publishers Ltd.
replacement of the external iliac artery and ureterolysis was performed. Microscopic examination of the fibrotic tissue revealed a ‘‘Perianeurysmal retroperitoneal fibrosis’’. Convalescence was uneventful.
Discussion Inflammatory iliac aneurysms are uncommon. The incidence of isolated iliac artery aneurysm is 1.9% and that of isolated internal iliac aneurysm is only 0.5% of abdominal aortic aneurysm.1 Patients with iliac artery aneurysms are most likely to present with urological manifestations.2,3 Isolated iliac aneurysm often gives rise to urinary tract obstruction. Rarely external iliac artery aneurysms may cause ureteral obstruction.4 The ureters may be obstructed either by direct compression of the aneurysm or by entrapment of the ureter in fibrotic process, which may be perianeurysmal immediately or more extensive in the retroperitoneum, resembling idiopathic retroperitoneal fibrosis.3,4 The pathology of this fibrotic process is characterised by proliferation of fibrous tissues with inflammatory cell infiltration.2,3 There are two basic explanations for the development of perianeurysmic fibrosis and retroperitoneal scarring. One is that small leaks develop at the weakest points of the aneurysm. After these seal, a retroperitoneal inflammatory reaction ensues and results in scarring that may extend laterally to encase and subsequently obstruct the ureter. The second explanation relates to
2
L. Iso˜kay et al.
the generalised atherosclerotic process involved in the formation of the aneurysm. Atherosclerosis often has an associated desmoplastic inflammatory component that extends to involve the adventitia of the scarring in the retroperitoneum.2,5 Patients who present with this type of retroperitoneal fibrosis may be difficult to differentiate from those with idiopathic retroperitoneal fibrosis.3 Treatment of choice is resection of the aneurysm and replacement by a vascular graft. Ureterolysis should be performed if the ureters are enveloped by perianeurysmal fibrosis. We present a rare case of ureteral obstruction secondary to isolated external iliac artery aneurysm which is described only in childhood cases in the literature.
EJVES Extra, 2001
References 1 Silver D, Anderson EE, Porter JM. Isolated hypogastric artery aneurysm. Review and report of three cases. Arch Surg 1967; 95: 308–312. 2 Minato N et al. Surgical treatment of isolated iliac artery aneurysm with ureteral obstruction and/or renal failure. J Cardiovasc Surg 1990; 31: 189–193. 3 Marino R et al. Urological manifestations of isolated iliac artery aneurysms. J Urol 1987; 137: 232–234. 4 Villani U, Leoni S, Mora A. Unilateral hydroureteronephrosis secondary to iliac aneurysm. Urology 1985; 26: 62–63. 5 Resnick MI, Kursh ED. Extrinsic obstruction of the ureter. In: Campbell’s Urology, 7th edition. Philadelphia: W.B. Saunders Company, 1998: 387–422.