Uretero-Iliac artery fistulas (UAFs) are very uncommon in urological practice. The rarity of this clinical entity may lead to a delayed or missed diagnosis which can result in life-threatening consequences. We present a case of a right ureteric and right external iliac artery fistula, its presentation, diagnosis, and management along with the review of the literature.
A 54-year-old lady underwent Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy followed by pelvic radiotherapy for carcinoma of the cervix. She presented 3 years later with a history of recurrent frank hematuria and haemodynamic instability. Her haemoglobin on admission was 6.9 g/dl. A cystoscopy demonstrated areas of radiotherapy changes only. A CT scan demonstrated blood clots within the right collecting system.
Progressive right-sided hydronephrosis was noted along with progressive deterioration in renal function. A nephrostomy and subsequent antegrade stenting were performed on the right side. Over the next few weeks, the patient went on to have periodic stent changing to improve the renal functions and massive blood transfusions performed to stabilize the dropping haemoglobin.
During a subsequent attempt to replace the right ureteric stent, the bladder filled with bright red blood clot as soon as the stent was removed. A retrograde ureteropyelogram was performed, which directly and inferolaterally demonstrated contrast flow in the line of the external iliac artery suggesting a ureteroarterial fistula. A Digital Subtraction Angiographic run confirmed a hemodynamically significant uretero-external iliac arterial fistula (Figure
Uretero-external iliac artery fistula demonstrated on angiographic run.
False aneurysm of the right common iliac artery demonstrated.
A covered stent securely placed in the right common and external iliac artery.
Uretero-iliac artery fistula (UAF) is a rare but potentially life-threatening condition [
Though the exact mechanism of the development of UAF is still uncertain, it has been postulated that as a result of previous radiation therapy and pelvic or vascular surgical procedures, the integrity of vasa vasorum could be disrupted. This results in a weakening of the adventitia and media of the large arteries and increasing their susceptibility to rupture and necrosis. The ureter can become fixed and obstructed by the surrounding inflammatory process. Chronic pulsations to the fibrosed, less compliant ureter can cause necrosis and eventually formation of a fistula [
Clinical awareness of the possibility of this condition is the most important of all diagnostic steps. Patients who underwent an exploratory laparatomy without any adequate preoperative diagnosis were reported to have a mortality rate of 64% and a retreatment rate of 25% [
Some authors have supported the diagnostic role of Magnetic Resonance Angiography [
Angiography particularly provocative angiography remains the most important diagnostic tool [
Treatment of a diagnosed or suspected UAF requires a multidisciplinary approach involving urologists, radiologists and vascular surgeons. Open surgery remains the first line treatment [
During the past few years endovascular techniques have proven not only to be effective but also very rapid in this emergency condition. A major advantage of the arterial stent is that it does not compromise the vascular supply and there is no need for additional bypass operations [
UAF remains a rare and a life-threatening emergency. A high index of suspicion should be maintained by the dealing physicians in patients with a history of intermittent hematuria who have the previously mentioned predisposing factors and in whom other common causes of hematuria have been ruled out. A multidisciplinary approach is the best in achieving successful results.