Massive Hemorrhage from an Arterioureteral Fistula Associated with Chronic Renal Transplant Failure

List, A; Collins, John; MacCormick, Murray

doi:10.1016/s0022-5347(17)39701-x

Cited by 8 publications

(3 citation statements)

References 4 publications

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“…Other documented causes of iatrogenic-induced fistulae include the presence of a ureteral stump post nephrectomy, vascular reconstructive surgery with the use of grafts following aortic and iliac aneurysm repair, and renal transplantation surgery. In the latter, a secondary AUF between the renal graft aneurysm and the recipient ureter was observed [ 9 ]. Urinary leak post ureterolithotomy has also been seen.…”

Section: Discussionmentioning

confidence: 99%

Arterio-Ureteral Fistula: A Rare Elusive Cause of Significant Hematuria

Waqar¹,

Mathias²,

Murali³

et al. 2023

Cureus

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Arterioureteral fistula (AUF) is a direct communication between the ureter and an artery and is a rare cause of catastrophic, life-threatening haematuria. Fistulation may occur between the ureter and the abdominal aorta, common iliac, external and internal iliac, and inferior mesenteric arteries, and is typically observed in patients with a prior history of pelvic radiotherapy, oncological pelvic surgeries, aortoiliac vascular procedures, and pelvic exenteration. There is also an increased frequency of cases amongst patients who have undergone urological diversion surgeries and in those with chronic indwelling ureteric stents requiring repeated exchange. As AUF is so rarely encountered in clinical practice, the urologist may fail to appreciate its presence until late in the patient’s presentation; such diagnostic delay is associated with high mortality and thus rapid clinical suspicion and investigative action are necessary. There are sporadic cases of this rare entity mentioned in literature. In this report, we present two cases as well as a review of the literature. A 73-year-old female presented with repeated episodic haematuria for a week in whom the cause of symptoms remained persistently elusive despite repeated imaging and operative approaches. An eventual diagnosis of a secondary right internal iliac-ureteral fistula was ascertained on a subsequent digital subtraction angiography of the renal tract. The fistula was embolised using an endovascular approach. The patient remained stable post emobilisation and was successfully discharged shortly after the procedure. In the second case, a 51-year-old female, presented with hematuria from her ileal conduit for a few days. Initially, the cause of symptoms was thought to be due to ureteric stents. During a change in her stents, brisk bleeding led to further investigation including an iliac angiogram confirming bleeding from the left common iliac artery. She had a covered common iliac artery stent, which successfully controlled her bleeding This report emphasizes the diagnostic difficulty of AUF, outlines the management principles of this rare disease, and aims to increase awareness of this rare yet potentially lethal phenomenon among practitioners of urology and interventional radiology

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Section: Discussionmentioning

confidence: 99%

Arterio-Ureteral Fistula: A Rare Elusive Cause of Significant Hematuria

Waqar¹,

Mathias²,

Murali³

et al. 2023

Cureus

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“…Anastomotic pseudoaneurysms may occur years after transplantation;26 if they rupture, a fistula in the native ureter with macrohematuria is possible. 27 Doppler spectrum analysis is suitable to detect abnormalities in flow patterns in the renal artery, making it possible to differentiate among TRAS, rejection, or cyclosporin nephrotoxicity.28 A very rare complication is the development of an arteriovenous fistula after kidney biopsy, which can be treated by percutaneous transluminal catheter embolization.29…”

Section: Discussionmentioning

confidence: 99%

Vascular Complications in Allogeneic Renal Transplantations

Storck¹,

Mickley²,

Hutschenreiter³

et al. 1995

Vascular Surgery

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Background. The incidence of vascular complications during allogeneic renal transplantations ranges from 5% to 15%. They may be donor related (additional polar arteries, multiple renal arteries, multiple renal veins, injured arteries or veins), recipient related (severe atherosclerosis, venous thrombosis, previous transplantation), or technical. In a retrospective study of 666 kidney transplantations, the incidence and treatment of vascular complications were analyzed.Patients/Results. All transplantations were performed in end-to-side technique with aortic patch if available; all kidneys were obtained from brain-dead donors. A total of 89 operations included vascular complications (13.4%). In 46 patients (6.9%), the problem arose intraoperatively, 33 complications (5%) occurred within three weeks, and another 10 (0.3%) were seen later after successful transplantation. In 17 kidneys, major additional polar arteries were encountered, 7 of which were reanastomosed, 10 were ligated. Three kidneys were lost owing to insufficient blood supply to the ureter. In 7 patients, intraoperative vascular service operations had to be carried out owing to stenosis of the iliac artery or massive kinking. Early postoperative complications included bleeding after biopsy, anastomotic leakage, and arterial or venous thrombosis (1 successful venous thrombectomy; 18 of 33 organs were removed). As for late complications, the authors (continued on next page) (Abstract continued) observed 9 transplant renal artery stenoses (TRAS); 8 were treated by percutaneous transluminal angioplasty. One patient developed an iliac aneurysm owing to chronic patch rupture.Conclusion. The majority of intraoperative complications were due to injury of the kidney during donor nephrectomy (21/46). Polar arteries should be reconstructed if possible, especially lower polar arteries, because of the danger of ureteral necrosis. In times of increasing donor organ shortage, only experienced surgeons should perform explantation and transplantation of kidneys to avoid technical faults in a considerable number of organs.

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“…9 It can be reduced to below 10% by knowing the likely diagnosis before exploration. 8,10 Current imaging studies lack sensitivity, and a negative result cannot exclude the presence of a uretero-arterial fistula. The literature has a wide variability of outcomes due to the constant evolution of imaging modality and the variety of scanners and protocols.…”

Section: Journal Of Clinical Urology 8(4)mentioning

confidence: 99%