Ureterocutaneous fistulas secondary to urinary calculous disease

URETEROCUTANEOUS FISTULAS SECONDARY TO URINARY CALCULOUS DISEASE B . GOLDWASSER, M .D .

M . HUSZAR, M .D .

M . HERTZ, M .D .

P. JONAS, M .D .

O . NATIV, M .D .

M . MANY, M .D ., PH .D .

From the Departments of Urology, Diagnostic Radiology, and Pathology, The Chaim Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel

ABSTRACT-Fistulas of the ureter are uncommon and are usually secondary to trauma or iatrogenic in nature . Spontaneous rupture of the ureter is rare, usually ending in a periureteral abscess . Two cases of spontaneous rupture of the ureter secondary to calculous disease resulting in ureterocutaneous fistulas are described .

Fistulas involving the ureter are uncommon . When they do occur, they are usually secondary to trauma or to surgical procedures involving the ureter, rectum, or the female reproductive organs . Fistulas of the ureter to the colon,

duodenum, appendix, uterus, salpinx, vagina, peritoneum, artery, bronchus, and urinary bladder have been described . A single case of a congenital ureteral fistula to the seminal vesicle has been reported .'

Case 1 . (A) Plain film of abdomen showing calcified shadows in region of left kidney and ureter ; note large calcified shadow at level of fifth lumbar vertebra . (B) Fistulography revealing passage of dye into left kidney and lower ureter. (C) Fistulography revealing filling defects in left kidney and ureter ; note large rounded filling defect to left of fifth lumbar vertebra, corresponding well with calcified shadow seen in (A) . FIGURE 1 .

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fistulography was performed which revealed passage of dye into the left ureter, kidney, and bladder (Fig . 1) . Suspected calculi could be visualized below and above the fistulous opening as well as in the left kidney (Fig . 1) . Excretory urography proved the left kidney to be nonfunctioning ; this was supported by a renogram and renoscan . Renal function tests were within normal limits . Urine cultures for mycobacterium tuberculosis were negative as was the purified protein derivative (PPD) skin test . Examination of the discharge for fungi was negative . The patient was operated on, and a left nephroureterectomy was performed . Ex situ examination of the pathologic specimen revealed an impacted calculus right below the fistulous orifice (Fig . 2) . Above this the ureter was dilated and the kidney was impacted with calculi and pus . Case 2

Case 1 . Left kidney and ureter with marker pointing out site of fistulous orifice . FIGURE 2 .

Spontaneous rupture of the ureter is uncommon and the formation of a fistula communicating to the skin is rare . We present 2 such cases . Case Reports Case 1

A seventy-year-old man was admitted to the urologic service because of a draining fistula in the left flank . Three years prior to the present hospitalization a left upper-third ureterolithotomy was performed at another hospital. A preoperative excretory urography revealed two additional calculi within the left kidney. The postoperative course was reported as uneventful, the patient was free of complaints, and postoperative excretory urography was not performed . A month prior to his present admission, the patient underwent excision and drainage of what appeared to be a superficial stitch abscess near the operative scar in the left flank . Because of a continuous discharge from the left flank,

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An eighty-year-old man was admitted to general surgery with a discharging fistula in the region of the left groin . Ten years prior to this admission he had undergone a suprapubic prostatectomy and cystolithotomy. Excretory urography at the time revealed a small calculus in the lower pole of the left kidney. A few months before his present hospitalization he had a transurethral litholapaxy for bladder calculi . A few days prior to his present admission he complained of left lower abdominal pain with distention, and on the day of his admission a discharge appeared in the left groin . Physical examination was normal except for the opening of a fistula in the left groin and a prostatectomy scar in the lower abdomen . Laboratory tests including renal function tests were within normal range . Fistulography revealed communication with the left ureter and passage of dye into the left kidney (Fig . 3A,B) . Plain films of the abdomen revealed renal calculi (Fig . 3C) while excretory urography showed a nonfunctioning left kidney . The patient refused surgery . He was discharged from the hospital and lost to follow-up . Comment Spontaneous rupture of the ureter is uncommon. It has been observed consequent to ureteral calculi, ureteral infections, ureteral tumors, and colonic and duodenal diseases . That such a rupture should cause a fistula communicating with the skin is rare . In 1939

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3 . Case 2 . (A) Fistulography revealing passage of dye into what appears to be left ureter . (B) Now it can be clearly seen that dye passes up left ureter into kidney. (C) Plain film of abdomen showing calcified shadows in region of left kidney and bladder . FIGURE

Smith' reviewed all 11 cases of spontaneous rupture of the ureter reported in the literature . All had been caused by calculi, but none had communicated with the skin . In all of these there was extravasation of urine and periureteral abscess formation . Similar cases were reported in later years, all ending the same way. Ureterocutaneous fistulas were described following resection of the rectum' and percutaneous renal biopsy,° and are mentioned by Peters and Bright 5 as possible complications of blunt trauma to the kidney. In our Case 1 we studied the length of the ureter for a scar of the previous ureterolithotomy, but found none . We therefore conclude that since the patient had no extravasation or evidence of a fistula after the ureterolithotomy the calculus impacted below the present fistulous opening in the ureter, caused proximal dilation with rupture at the weakest site-that of a previous ureterolithotomy .

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In Case 2 since the patient was known to suffer from renal calculi on the left side and presented with a spontaneous ureterocutaneous fistula we surmise that the underlying cause must have been an impacted calculus . Duke University Medical Center Division of Urology

Box 3707 Durham, North Carolina 27710 (DR . GOLDWASSER) References 1 . Mulholland SC, Edson M, and O'Connell KJ : Congenital Uretero-seminal vesicle fistula, J Urol 106 : 649 (1971) . 2 . Smith 5 : Spontaneous ureteral rupture with periureteral abscess formation, Am J Surg 45 : 139 (1939) . 3 . Aubert J, Roland D, and Casamayou J : Uretero-cutaneous fistula following resection of the rectum, J Urol Nephrol 82 : 100 (1976) . 4 . Fraser RA, and Leary FJ : Uretero-cutaneous fistula following percutaneous renal biopsy, J Urol 109 : 931 (1973) . 5 . Peters PC, and Bright TC : Blunt renal injuries in genitourinary trauma, Urol Clin North Am 4 : 17 (1977) .

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