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

Omran, Safwan; Schäfer, Hasso; Kapahnke, Sebastian; Müller, Verena; Bürger, Matthias; Konietschke, Frank; Frese, J.; Neymeyer, J.; Greiner, Andreas

doi:10.1177/1708538120970823

Cited by 8 publications

(9 citation statements)

References 27 publications

(31 reference statements)

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“…Krambeck et al [ 4 ] only describe seven AUF patients between 1975 and 2004, while Omran et al [ 5 ] and Simon et al [ 6 ] describe 25 AUF patients between 2011 and 2020 and 16 AUF patients between 2005 and 2020, respectively. This suggests that the reported incidence is increasing.…”

Section: Discussionmentioning

confidence: 99%

“…In the last decade, combination of therapies are more frequently performed. In the acute phase vascular and urologic surgeons work together in open surgery or the interventional radiologist starts with placing an endovascular stent graft and the vascular surgeon follows with a delayed open reconstruction (extra-anatomic bypass) or treating of graft infection and stent thrombosis [ 5 , 13 ]. One of the measures to prevent future fistula formation may include considering nephrostomy instead of chronic indwelling stent in patients with multiple risk factors.…”

Section: Discussionmentioning

confidence: 99%

“…Noteworthy, in our cohort four new secondary AUFs were seen within 1 year and one ACF, all successfully treated by an endovascular stent. Simon et al [ 6 ] and Omran et al [ 5 ] describe recurrent AUFs, but no literature was found on new secondary AUFs. A possible explanation could be that these patients were > 70 years and all had radiation therapy in the past.…”

Section: Discussionmentioning

confidence: 99%

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Arterio-ureteral fistula: a nationwide cross-sectional questionnaire analysis

et al. 2022

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Purpose Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but potentially lethal. Although the number of reports has increased over the past two decades, the true incidence and contemporary urologists’ experience and approach in clinical practice remains unknown. This research is conducted to provide insight in the incidence of AUF in The Netherlands, and the applied diagnostic tests and therapeutic approaches in modern practice. Methods A nationwide cross-sectional questionnaire analysis was performed by sending a survey to all registered Dutch urologists. Data collection included information on experience with patients with AUF; and their medical history, diagnostics, treatment, and follow-up, and were captured in a standardized template by two independent reviewers. Descriptive statistics were used. Results Response rate was 62% and 56 AUFs in 53 patients were reported between 2003 and 2018. The estimated incidence of AUF in The Netherlands in this time period is 3.5 AUFs per year. Hematuria was observed in all patients; 9% intermittent microhematuria, and 91% presenting with, or building up to massive hematuria. For the final diagnosis, angiography was the most efficient modality, confirming diagnosis in 58%. Treatment comprised predominantly endovascular intervention. Conclusion The diagnosis AUF should be considered in patients with persistent intermittent or massive hematuria.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Arterio-ureteral fistula: a nationwide cross-sectional questionnaire analysis

et al. 2022

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“…These numbers are likely underestimated. For instance, Rafael et al and Safwan et al each reported their separate single center experience with UAF to be 21 cases and 27 cases, between 1996–2010, and 2011–2020, respectively [ 6 , 8 ].…”

Section: Discussionmentioning

confidence: 99%

Endovascular coil embolization of inferior mesenteric artery to ileal-conduit fistula: a case report

et al. 2022

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Background Uretero-arterial fistulas (UAFs) are uncommon and pose a diagnostic dilemma, making them life threatening if not recognized and treated expediently. UAFs to small arteries such as a branch of the inferior mesenteric artery (IMA) are very uncommon and present a further diagnostic and treatment challenge. There should be a high index of suspicion for UAFs when intervening on patients with history of treated pelvic cancers and long-standing ureteric stents experiencing hematuria not attributable to another cause. Case presentation We present a case of a fistula formed between a distal branch of the IMA—superior rectal artery—and an ileal-conduit in a patient with a long-standing reverse nephroureterostomy (Hobbs) catheter presenting with abdominal pain and hematuria through the conduit. During a tube exchange, contrast injection demonstrated a fistula with the superior rectal artery, multiple ileal intraluminal blood clots, and active extravasation. The patient became tachycardic and hypotensive, actively bleeding through the ileal-conduit, prompting a massive transfusion protocol. Successful endovascular coiling of the superior rectal artery was performed with resolution of active extravasation and stabilization of the patient. The patient recovered and was discharged in stable condition 10 days later. Conclusions Although UAFs are uncommon, our case demonstrated key predisposing risk factors to fistula development; pelvic cancer surgery, pelvic radiation, and a prolonged ureteric stent through the ileal-conduit. Typically, UAFs arise from communication with the iliac arterial system, however in this instance we have demonstrated that fistulization to other arterial vessels is also possible. Endovascular management has become the preferred method of therapy, typically involving the placement of covered stents when involving the iliac arterial system. In this instance stent grafting was not possible due to the small caliber vessel and therefore had to be embolized.

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“…Uretero–arterial fistula (UAF) represents a rare condition that manifests as massive or intermittent hematuria and requires collaboration between a urologist, vascular surgeon and interventional radiologist [ 1 , 2 , 3 ]. Specific-cause mortality varies between 7–90%, depending on type of treatment (open vs endovascular), hemodynamic status of the patient and hospital infrastructure [ 1 , 4 , 5 , 6 ]. UAF incidence is increasing due to improved survival after aggressive management of pelvic tumors that involves large surgical resections, urinary diversions and radiotherapy [ 5 , 7 , 8 ].…”

Section: Introductionmentioning

confidence: 99%

Challenges in Diagnosis of Uretero–Arterial Fistulas after Complex Pelvic Oncological Procedures—Single Center Experience and Review of the Literature

et al. 2022

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Uretero–arterial fistula (UAF) represents a rare condition that manifests as massive or intermittent hematuria and requires collaboration between a urologist, vascular surgeon and interventional radiologist. In this article, we present our experience with UAF diagnosis, treatment pathways and the results of a nonsystematic review of the literature published in the last decade regarding modern diagnostic procedures. Material and method: We analyzed the clinical data of nine consecutive patients from our institution diagnosed with UAF in the interval of 2012–2022 who underwent open or endovascular surgical treatment. We reviewed patient characteristics, diagnoses and treatment pathways. The literature search resulted in 14 case series, published from 2012 to 2022, describing a total of 670 cases of UAF. Results: The mean age of patients in our cohort was 65.3 years (IQR: 51–79). UAFs were more common in women (77.7%). All patients presented a history of surgical intervention and ir-radiation for pelvic malignancy with permanent ureteric stenting. Overall, 88.8% of patients had urinary diversion, either via ileal conduit or cutaneous ureterostomy. The most common clinical manifestation of UAF was gross hematuria with or without clots accompanied by flank pain due to stent obstruction, while three patients presented with hypovolemic shock. Angiography represents the best option for diagnosis, followed by angioCT, with a sensitivity of 59.83% and 47.01%, respectively. There is no definitive imaging modality associated with high accuracy in detecting UAF and negative findings do not exclude the disease. In emergency cases with massive bleeding, surgical exploration remains the most appropriate management option for both diagnosis and treatment. Endovascular stent graft placement is preferred over open surgery in stable hemodynamic patients. Conclusions: Uretero–arterial fistulas represent a life-threatening complication and must be treated with great awareness. Angiography represents the best modality for diagnosis, followed by computed tomography. However, there is no definitive imaging modality and, in some cases, open approach remains the only option for diagnosis and treatment.

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

Cited by 8 publications

References 27 publications

Arterio-ureteral fistula: a nationwide cross-sectional questionnaire analysis

Arterio-ureteral fistula: a nationwide cross-sectional questionnaire analysis

Endovascular coil embolization of inferior mesenteric artery to ileal-conduit fistula: a case report

Challenges in Diagnosis of Uretero–Arterial Fistulas after Complex Pelvic Oncological Procedures—Single Center Experience and Review of the Literature

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