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Uretero-Arterial Fistula
THE .JOURNAL OF UROLOGY
Vol. 73, No. 5, '\fay 1955 .Printed in U.S.k
-CRETERO-ARTERIAL FISTULA ROBERT COWEN
Uretero-arterial communication can be conceived only as the result of severe inflammatory trauma at the site of the ureteral crossing by a large vessel. Ureteral juxtaposition to the large arteries of the pelvis is receiving more attention since involvement of the ureter is being observed more frequently in extensive pelvic surgery. In nearly all cases heretofore recorded of uretero-arterial fistula, an indwelling ureteral catheter has been antecedent. Davidson and Smith reported a case in which after indwelling ureteral catheter drainage of a greatly dilated ureter in pregnancy, after a sharp, appendiceal-like pain, profound shock and hemorrhage from the bladder resulted in death. Postmortem examination showed the right ureter adherent with a communication ;-3 cm. long to the right iliac artery. In all previously reported cases, the cause has been looseness of tissue construction in gravidity and pressure fracture of a large blood vessel. In seven of the 8 knmvn cases of uretero-arterial fistula, of which only 4 cases have been recorded in detail, hemmorrhage was the cause of death. The only case with recovery was the first case reported by Moschowitz in which he performed a simultaneous bilateral iliac artery ligation. In the following case report the instigating factors were peri-ureteral inflammation over an impacted mural calculus (fig. 1, A) which had been treated unsuccessfully over a 2-year period by extractors, dilators and electrothermal transurethral ureteromeatotomy, and a low retrovesical ureterolithotomy in a dilated ureter. CASE REPORT
Florence Crittenton Hospital No. 52088-C, S. C., a 44-year old man, entered the hospital October 1:3, 195:3. Excretory urography had demonstrated a large calculus in the lower left ureter and second degree left hydronephrosis. The x-ray report indicated that the calculus and the hydronephrotic sac were increasing in size when compared with previous films. Through a Gibson incision, a left ureterolithotomy was performed under spinal anesthesia. By probing, the calculus ·was located in a densely infiltrated and edematous peri-ureteral area. The stone was removed through an incision made directly through the peri-ureteral infiltration. (In retrospect, there is the possibility that the stone had been partially extruded extra-ureterally by the previous electrothermal ureteral meatotomy.) A drain was brought out through a counter-flank puncture. The preoperatively placed left ureteral catheter ,vas taped indwelling. The postoperative period was badly complicated by abdominal distention and by a profusely draining, persistent urinary sinus through the angle of the incision. To control this, it was decided to perform cystoscopy 16 days postoperatively. Cystoscopy showed a large, granulomatous excrescence prolapsing from the left ureteral orifice and it was deemed unsafe to attempt catheterization. Accepted for publication September 29, 1954. 801
802
ROBERT COWEN
FIG. 1. A, calculus in left lower ureter after attempts at removal by instruments and meatotomy. B, excretory urogram after ureterolithotomy.
Excretory urography (fig. 1, B) showed normal function and pattern of both kidneys. Contrast medium from the left ureter did not enter the bladder, but was either retained in a large dilated ureter or in a pouch from extravasation into soft tissues. Following discharge from the hospital, the patient reported gradual diminution in the amount of urinary sinus drainage. One month postoperatively he was seen in the office. The sinus had nearly healed. Several days later I was called to his home because of sharp, tearing pain following exercises he had taken by flexing his thigh upon the abdomen, putting strain on the psoas muscle. Morphine was required for pain and the next day severe hematuria made hospital readmission urgent. Consultation (Dr. R. P. Lytle): "Late secondary hemorrhage following ureterolithotomy. Severity of bleeding suggests invasion of a major vessel such as the hypogastric. I would not recommend extraperitoneal approach save for packing, as the vessel leak may easily be enlarged. Recommend transperitoneal approach so the iliac vessel can be immediately controlled, then probably ligation can be done." Operation: Ligation of left hypogastric artery. Under general anesthe'sia a retroperitoneal approach showed no retroperitoneal blood or extravasation until retraction of the peritoneum medially resulted in arterial hemorrhage drenching the area. Digital compression of the aorta, retroperitoneally, was remarkably effective resulting in a fairly dry field. The hypogastric artery showed a long lateral tear from adhesions to the site of the ureterolithotomy incision near the
URETERO-ARTERIAL FISTULA
803
mural portion. Clamping and ligation of the pulsating stump of the hypogastric artery above, and two distal stumps were easily effected. The patient tolerated the procedure well and the operative blood loss was less than 500 cc. Although the left femoral and popliteal arteries could not be palpated the interference ,vas attributed to the packing, which was removed in 24 hours -with fair arterial pulsations. Daily blood studies showed a red blood cell count of 4.3 million that fell to 2.2 million/cu.mm. Hemoglobin and hematocrit levels were commensurate. Marked leukocytosis, with marked shift to the left, was present at all times. The white blood cell count varied from 47,400 to 20,300 per cu.mm. This was classified as a leukemoid reaction. Platelets were adequate, numbering 246,000 on one occasion. There was no depression of prothrombin. The blood nonprotein nitrogen rose from 49 on admission to 69 mg./100 ml. on the day of operation. The uncorrected sedimentation rate on the day of operation was elevated to 58 mm. in 1 hour. Blood cultures on two occasions were negative. (Dr. Edw. Zawadski.) SUMMARY
A case of uretero-arterial fistula, due to perforation of the ureter into the hypogastric artery, is reported. The communication was at the site of a retrovesical incision into a peri-ureteral infiltrated area and resulted from many ureteral dilatations, extraction attempts, and an electrothermal transurethral ureterotomy. The perforation occurred 45 days postoperatively following exercises flexing the thigh and stress on the psoas muscle. Acute tearing pain with severe hemorrhage from the bladder was accompanied by a leukemoid blood reaction. Blood cultures were negative. Progressive paralytic ilcus that caused death 5 days after a successful hypogastric arterial ligation must be attributed to leukemoid reaction; because of complete insertion of the long intestinal tube and failure of electrolyte and fluid balance.
28 W. Adams Ave., Detroit 26, 1vlieh. REFERENCES DAVIDSON, 0. -w. AND SMITH, R. P.: Uretero-arterial fistula. J. Urol., 42: 257, 1939. MoscHOWITZ, A. V.: Simultaneous ligation of both iliac arteries for hemorrhage after bilateral ureterolithotomy. Recovery. Ann. Surg., 48: 872, 1908. TURNER, A. F. JR., ORR, L. M. AND HAYWARD, J.C.: Crepitant cellulitis following ureteral instrumentation. J. Urol., 61: 432, 1949. TAYLOR, W. N. AND REINHART, H. L.: JVIycotic aneurysm of common iliac artery, with rupture into right ureter. J. Urol., 42: 21, 1939.
Vol. 73, No. 5, '\fay 1955 .Printed in U.S.k
-CRETERO-ARTERIAL FISTULA ROBERT COWEN
Uretero-arterial communication can be conceived only as the result of severe inflammatory trauma at the site of the ureteral crossing by a large vessel. Ureteral juxtaposition to the large arteries of the pelvis is receiving more attention since involvement of the ureter is being observed more frequently in extensive pelvic surgery. In nearly all cases heretofore recorded of uretero-arterial fistula, an indwelling ureteral catheter has been antecedent. Davidson and Smith reported a case in which after indwelling ureteral catheter drainage of a greatly dilated ureter in pregnancy, after a sharp, appendiceal-like pain, profound shock and hemorrhage from the bladder resulted in death. Postmortem examination showed the right ureter adherent with a communication ;-3 cm. long to the right iliac artery. In all previously reported cases, the cause has been looseness of tissue construction in gravidity and pressure fracture of a large blood vessel. In seven of the 8 knmvn cases of uretero-arterial fistula, of which only 4 cases have been recorded in detail, hemmorrhage was the cause of death. The only case with recovery was the first case reported by Moschowitz in which he performed a simultaneous bilateral iliac artery ligation. In the following case report the instigating factors were peri-ureteral inflammation over an impacted mural calculus (fig. 1, A) which had been treated unsuccessfully over a 2-year period by extractors, dilators and electrothermal transurethral ureteromeatotomy, and a low retrovesical ureterolithotomy in a dilated ureter. CASE REPORT
Florence Crittenton Hospital No. 52088-C, S. C., a 44-year old man, entered the hospital October 1:3, 195:3. Excretory urography had demonstrated a large calculus in the lower left ureter and second degree left hydronephrosis. The x-ray report indicated that the calculus and the hydronephrotic sac were increasing in size when compared with previous films. Through a Gibson incision, a left ureterolithotomy was performed under spinal anesthesia. By probing, the calculus ·was located in a densely infiltrated and edematous peri-ureteral area. The stone was removed through an incision made directly through the peri-ureteral infiltration. (In retrospect, there is the possibility that the stone had been partially extruded extra-ureterally by the previous electrothermal ureteral meatotomy.) A drain was brought out through a counter-flank puncture. The preoperatively placed left ureteral catheter ,vas taped indwelling. The postoperative period was badly complicated by abdominal distention and by a profusely draining, persistent urinary sinus through the angle of the incision. To control this, it was decided to perform cystoscopy 16 days postoperatively. Cystoscopy showed a large, granulomatous excrescence prolapsing from the left ureteral orifice and it was deemed unsafe to attempt catheterization. Accepted for publication September 29, 1954. 801
802
ROBERT COWEN
FIG. 1. A, calculus in left lower ureter after attempts at removal by instruments and meatotomy. B, excretory urogram after ureterolithotomy.
Excretory urography (fig. 1, B) showed normal function and pattern of both kidneys. Contrast medium from the left ureter did not enter the bladder, but was either retained in a large dilated ureter or in a pouch from extravasation into soft tissues. Following discharge from the hospital, the patient reported gradual diminution in the amount of urinary sinus drainage. One month postoperatively he was seen in the office. The sinus had nearly healed. Several days later I was called to his home because of sharp, tearing pain following exercises he had taken by flexing his thigh upon the abdomen, putting strain on the psoas muscle. Morphine was required for pain and the next day severe hematuria made hospital readmission urgent. Consultation (Dr. R. P. Lytle): "Late secondary hemorrhage following ureterolithotomy. Severity of bleeding suggests invasion of a major vessel such as the hypogastric. I would not recommend extraperitoneal approach save for packing, as the vessel leak may easily be enlarged. Recommend transperitoneal approach so the iliac vessel can be immediately controlled, then probably ligation can be done." Operation: Ligation of left hypogastric artery. Under general anesthe'sia a retroperitoneal approach showed no retroperitoneal blood or extravasation until retraction of the peritoneum medially resulted in arterial hemorrhage drenching the area. Digital compression of the aorta, retroperitoneally, was remarkably effective resulting in a fairly dry field. The hypogastric artery showed a long lateral tear from adhesions to the site of the ureterolithotomy incision near the
URETERO-ARTERIAL FISTULA
803
mural portion. Clamping and ligation of the pulsating stump of the hypogastric artery above, and two distal stumps were easily effected. The patient tolerated the procedure well and the operative blood loss was less than 500 cc. Although the left femoral and popliteal arteries could not be palpated the interference ,vas attributed to the packing, which was removed in 24 hours -with fair arterial pulsations. Daily blood studies showed a red blood cell count of 4.3 million that fell to 2.2 million/cu.mm. Hemoglobin and hematocrit levels were commensurate. Marked leukocytosis, with marked shift to the left, was present at all times. The white blood cell count varied from 47,400 to 20,300 per cu.mm. This was classified as a leukemoid reaction. Platelets were adequate, numbering 246,000 on one occasion. There was no depression of prothrombin. The blood nonprotein nitrogen rose from 49 on admission to 69 mg./100 ml. on the day of operation. The uncorrected sedimentation rate on the day of operation was elevated to 58 mm. in 1 hour. Blood cultures on two occasions were negative. (Dr. Edw. Zawadski.) SUMMARY
A case of uretero-arterial fistula, due to perforation of the ureter into the hypogastric artery, is reported. The communication was at the site of a retrovesical incision into a peri-ureteral infiltrated area and resulted from many ureteral dilatations, extraction attempts, and an electrothermal transurethral ureterotomy. The perforation occurred 45 days postoperatively following exercises flexing the thigh and stress on the psoas muscle. Acute tearing pain with severe hemorrhage from the bladder was accompanied by a leukemoid blood reaction. Blood cultures were negative. Progressive paralytic ilcus that caused death 5 days after a successful hypogastric arterial ligation must be attributed to leukemoid reaction; because of complete insertion of the long intestinal tube and failure of electrolyte and fluid balance.
28 W. Adams Ave., Detroit 26, 1vlieh. REFERENCES DAVIDSON, 0. -w. AND SMITH, R. P.: Uretero-arterial fistula. J. Urol., 42: 257, 1939. MoscHOWITZ, A. V.: Simultaneous ligation of both iliac arteries for hemorrhage after bilateral ureterolithotomy. Recovery. Ann. Surg., 48: 872, 1908. TURNER, A. F. JR., ORR, L. M. AND HAYWARD, J.C.: Crepitant cellulitis following ureteral instrumentation. J. Urol., 61: 432, 1949. TAYLOR, W. N. AND REINHART, H. L.: JVIycotic aneurysm of common iliac artery, with rupture into right ureter. J. Urol., 42: 21, 1939.