Midterm Results after Open Surgical and Endovascular Management of Arterioureteral Fistula.

BACKGROUND: Arterioureteral fistula refers to the anomalous fistulous connection between the iliac artery and the ureter. It is often associated with pelvic malignancy, abdominal surgery, and radiation. As it is a potentially life-threatening condition, prompt diagnosis and management is essential. METHODS: We performed a retrospective analysis of patients treated for arterioureteral fistula in a single-vascular institution from January 2013 to March 2019. Preoperative assessment included physical and laboratory examinations and medical history, with diagnosis established through computed tomography angiography, digital subtraction angiography, or ureteroscopy. Parameters analyzed included perioperative mortality and morbidity as well as treatment durability during midterm follow-up. RESULTS: Nine patients with ten arterioureteral fistulas were included in the study. Macroscopic hematuria was the main presenting symptom, with 2 patients admitted due to hemorrhagic shock. Endovascular treatment was carried out in 6 patients. In 4 cases, single stent-graft deployment inside the common iliac artery was performed, in one case in combination with plugging of the internal iliac artery. One patient underwent implantation of an iliac-branched device, whereas in another patient coiling of the internal iliac artery sufficed for management of the fistula. Open surgical repair was carried out in three cases. Perioperative mortality was zero; one patient had prolonged hospital stay due to superficial wound infection. Recurrent hematuria and stent-graft infection were observed during follow-up in three patients after endovascular repair, all of them treated through open surgery with no further complications. One patient developed an enterocutaneous fistula after open repair during follow-up and required redo surgery. DISCUSSION: Arterioureteral fistula is a challenging clinical scenario demanding prompt diagnosis and management. Open surgery remains the treatment of choice in cases of preexisting vascular reconstruction or manifest infection. Endovascular techniques offer a viable solution in significantly comorbid patients or in patients presenting with acute, life-threatening bleeding. Rigorous follow-up is required regardless of treatment modality due to the considerable rate of reinterventions.

Endovascular and open surgical options in the treatment of uretero-arterial fistulas.

OBJECTIVE: To report and analyze the indications and results of endovascular and open surgical treatment for uretero-arterial fistula. METHODS: We retrospectively reviewed the clinical data of 25 consecutive patients with uretero-arterial fistulas admitted to our hospital from 2011 to 2020. Endpoints were technical success, freedom from open conversion, stent-graft/graft-related complications, and 30-day and one-year mortality. RESULTS: The study included 25 patients (68% female, n = 17) with 27 uretero-arterial fistulas by bilateral pathologies in two patients. The mean age was 61 ± 11 years (range 35-80). The most common predisposing factors for uretero-arterial fistula were history of pelvic operations for malignancy in 21 patients (84%), radiotherapy in 21 patients (84%), previous pelvic vascular bypass in 2 patients (8%), and iliac aneurysms in 2 patients (8%). On average, the period between the primary pelvic surgery and the diagnosis of uretero-arterial fistulas was 46 months (range 7-255). Twenty patients (80%) underwent endovascular treatment of the uretero-arterial fistulas. The primary technical success of the endovascular treatment was 95%, and the freedom from open conversion was 40% at six months and 30% at one year. Thirteen uretero-arterial fistulas (48%) underwent delayed open conversion due to recurrent bleeding in six cases (46%), stent-graft infection in three cases (23%), or pelvic abscess in four cases (31%). Primary open surgery was applied for five (20%) patients. After a mean follow-up of 34 months, early (<30 days) mortality was 8% (2/25), one-year mortality 16% (4/25), and overall mortality was 24% (6/25). CONCLUSIONS: Uretero-arterial fistula is a late complication of prior pelvic surgery, radiation, and indwelling ureteral stents. Endovascular treatment remains an effective and less invasive modality in controlling the related life-threatening arterial bleeding of the uretero-arterial fistula. Open surgical treatment is still required for patients with local sepsis, previously failed endovascular treatment or infected stent-grafts.

Endovascular Management of Ureteroarterial Fistula: Single Institution Experience and Systematic Literature Review.

BACKGROUND: Ureteroarterial fistula (UAF) represents an uncommon complication after urological surgery; however, this is a well-documented condition in patients with predisposing risk factors. The aim of the present study is to report and analyze the endovascular management of a series of patients with UAF, treated in authors' hospital, and to report and analyze the same data concerning patients retrieved from a systematic literature review. METHODS: Authors conducted a retrospective analysis of prospectively collected data and a systematic literature review. The research was carried out through PubMed database searching the following keywords: "uretero arterial fistula" and "uretero iliac fistula." It includes only articles reporting the endovascular management. RESULTS: Forty-six articles were included in the present study for a total of 94 patients. Risk factors were as follows: chronic indwelling ureteral stents, pelvic surgery, radiotherapy, iliac artery pseudo-aneurysm, and chemotherapy. All patients had gross hematuria at presentation. Stent graft placement was performed in 89 patients, embolization in 5 patients, and iliac internal artery embolization combined with stent graft placement was performed in 24 patients. Four postprocedural complications were observed (4.2%). During a median follow-up of 8 months, 10 complications related to UAF were observed (10.6%): rebleeding (7 cases) and stent thrombosis (3 cases). Two patients died for causes related to UAF (2.1%): rebleeding (1) and retroperitoneal abscess (1). CONCLUSION: Based on the present data, endovascular treatment is feasible and safe with low postprocedural complications and mortality rate. Considering the increase in surgery and radiotherapy performed, UAF should be always debated in patients with massive hematuria.

Evolution from open surgical to endovascular treatment of ureteral-iliac artery fistula.

PURPOSE: To review the indications and results of open surgical and endovascular treatment for ureteral-iliac artery fistula (UIAF). METHODS: We reviewed the clinical data of 20 consecutive patients treated for 21 UIAFs between 1996 and 2010. Since 2004, iliac artery stent grafts were the primary treatment except for complex fistulas with enteric contamination or abscess. Endpoints were early morbidity and mortality, patient survival, vessel or graft patency, freedom from vascular or stent graft/graft infection, and freedom from recurrent bleeding. RESULTS: There were 20 patients, 15 females, and five males, with mean age of 63 ±13 years. Predisposing factors for UIAF were prior tumor resection in 18 patients, radiation in 15, ureteral stents in 15, ileal conduits in four, and ileofemoral grafts in three. All patients presented with hematuria, which was massive in 10. Treatment included iliac stent grafts in 11 patients/12 fistulas (55%), with internal iliac artery (IAA) exclusion in nine, femoral crossover graft with IAA exclusion in five, direct arterial repair in three, and ureteral exclusion with percutaneous nephrostomy and no arterial repair in one. There were no early deaths. Five of eight patients treated by open surgical repair developed complications, which included enterocutaneous fistula in three and superficial wound infection in two. Four patients (36%) treated by iliac stent grafts had complications, including pneumonia, non-ST segment elevation myocardial infarction, buttock claudication, and early stent occlusion in one each. After a median follow-up of 26 months, no one had recurrent massive hematuria, but minor bleeding was reported in three. Patient survival at 5 years was 42% compared with 93% for the general population (P < .001). Freedom from any recurrent bleeding at 3 years was 76%. In the stent graft group, primary and secondary patency rates and freedom from stent graft infection at 3 years were 81%, 92%, and 100%. CONCLUSIONS: UIAF is a rare complication associated with prior tumor resection, radiation, and indwelling ureteral stents. In select patients without enteric communication or abscess, iliac artery stent grafts are safe and effective treatment, and carry a low risk of recurrent massive hematuria or stent graft infection on early follow-up. Direct surgical repair carries a high risk of enterocutaneous fistula.

Uretro-arterial fistulas.

Ureteral arterial fistula (UAF) is an uncommon condition but one that has been increasing with over 100 cases reported. The presentation is gross hematuria in a patient with predisposing factors, such as prior pelvic surgery, past radiation therapy, and chronic ureteral stenting. When not correctly diagnosed, the associated mortality is significant. Diagnosis is best accomplished by careful angiography with frequent use of provocative maneuvers. The current best therapeutic option is sealing off the UAF by deploying a stent graft in the artery.

Endourologic implants to treat complex ureteral stenosis after kidney transplantation.

OBJECTIVE: To evaluate the safety and efficacy of nitinol stents and the Detour extra-anatomical ureteral bypass graft in treatment of ureteral stenosis after kidney transplantation. PATIENTS AND METHODS: Eighteen kidney transplant recipients with complex stenosis caused by failure of primary treatment or with high surgical risk or a poorly functioning graft (serum creatinine concentration >2.5 mg/dL) were treated using antegrade percutaneous implantation of nitinol stents (n = 16) or extra-anatomical ureteral bypass grafts (n = 3); 1 patient was treated with both techniques. RESULTS: Mean (range) follow-up of ureteral stents was 51.2 (3-118) months. Patency rate at last follow-up, resumption of dialysis therapy, or death was 75% (12 of 16 patients). In 4 patients (25%), stent occlusion developed, which was treated using a double-J catheter in 2 patients, stent removal and pyeloureterostomy using the native ureter in 1 patient, and implantation of an extra-anatomical bypass graft in 1 patient. Mean follow-up in patients with extra-anatomical ureteral bypass grafts was 32 (8-64) months. One patient developed a urinary tract infection, and another had encrustation with obstruction. CONCLUSIONS: Use of nitinol ureteral stents and extra-anatomical ureteral bypass grafts is a safe and effective alternative to surgery for treatment of post-kidney transplantation ureteral stenosis in patients with chronic graft dysfunction, those at high surgical risk, and those in whom previous surgical treatment has failed.

[Early and late complications following 388 nephrectomies in different diseases of the kidney and the ureter]. / Ranni i kusni uslozhneniia sled 388 nefrectomii pri razlichni zaboliavaniia na bubrek i ureter.

Early and late complications of nephrectomy include: chronic renal failure (CRF), haemorrhagic events, lumbar fistulas and other complications of different origin. This study covers 388 nephrectomies due to different diseases of the kidneys and the urethra. Clinical diagnosis and treatment of the patients are held at the Chair of Urology of the Alexandrovska Hospital for the period 1990-1995. There are established the following early and late complications: renal failure--in 37 patients (9.53%), haemorrhagic events--in 2 patients (0.51%), lumbar fistulas--in 4 patients (1.03%). Other complications are calculous anuria in 1 patient (0.25%), nephrectomy following plastic surgery of a kidney calyx--in 1 patient (0.25%), nephrectomy in a case with one functionally preserved kidney--1 patient (0.25%), nephrectomy in a case following kidney transplantation--1 patient (0.25%), and fatal outcome through the early postoperative period--in 2 patients (0.51%). Authors conclude that: 1) nephrectomy is followed by complications through the early and the late postoperative period; 2) complications following nephrectomy are rare but they are one of the most serious and important sequella in urologic surgery.

Mortality from grossly encrusted bilateral pyelitis, ureteritis, and cystitis by Corynebacterium group D2.

This is the first report of death due to gross encrustations of the entire upper urinary tract and bladder by Corynebacterium group D2 in a man with no history of renal transplantation or prolonged catheterizations. This case demonstrates that debilitated patients with a prior endoscopic procedure are at risk for this disease process. Prolonged treatment with appropriate antibiotics, acidification of the urine, and removal of crusts is essential for proper management.

Percutaneous nephrostomy and ureteral stenting in gynecologic malignancies.

OBJECTIVE: To identify the indications, complications, and efficacy of percutaneous nephrostomies and ureteral stents in women with gynecologic cancer. METHODS: In a retrospective study, 40 women underwent urinary diversion with percutaneous nephrostomy and ureteral stents. Nine had ureteral stenosis on initial presentation, 18 had persistent or recurrent cancer, nine had no evidence of disease, and four had operative ureteral damage. Of the nine who were without disease, seven had a urinary conduit. RESULTS: Thirty-five patients had ureteral stenosis, which was bilateral in 24, and five had a ureteral fistula. Sixteen had a unilateral and 22 had bilateral percutaneous nephrostomies, with two cases having stents only. The most common complication was hematuria. Thirteen women were later hospitalized for pyelonephritis. Twenty-nine (72.5%) had ureteral stents, which were bilateral in 12. Renal function was abnormal in 26, but improved in 14 and returned to normal in six. Five fistulas were managed with ureteral stents alone and four were closed. The median time to death (N = 22) was 5.5 months, 12 months in primary cases versus 5.5 months in recurrent cases. Twelve of the remaining 18 were alive without evidence of disease at a median of 38 months, five were alive with disease at a median of 16 months, and one was lost to follow-up. CONCLUSIONS: These techniques are safe and often improve renal function. The procedures have different roles in women with primary and recurrent gynecologic cancer, in those without evidence of recurrent disease, and in those with urinary conduits.

[Gunshot wounds of the ureter]. / Les plaies par balle de l'uretère.

Lesions of the ureter caused by penetrating wounds of the abdomen rare a are complication of abdominal gunshot wounds, of which the reported incidence is 2 to 17%. The preoperative diagnosis is difficult and unrecognized initially in every third case. There are no early clinical signs of ureteral lesions. There is often no hematuria. Only IVP can male the preoperative diagnosis possible. As a matter of fact, the diagnosis will often be established by the surgical exploration made during the laparotomy required by the extent of the associated lesions. The ureteral blast contusion is an important cause of secondary necrosis with fistula. The treatment is mainly based on ureteroureterostomy after debridement. The transanasmotic drainage of urine is controversial. Mortality results from associated abdominal lesions and morbidity consists in a risk of secondary nephrectomy.