Systematic Review of the Management of Ureteroarterial Fistula After Ileal Conduit Diversion

Purpose: Ureteroarterial fistula (UAF) is a rare yet clinically significant entity whose incidence has been rising because of the increased use of chronic ureteral stenting in patients with a history of pelvic malignancy, irradiation, and surgery. Modern management has focused on endovascular approaches because of the prohibitive nature of performing open surgical intervention in a hostile anatomic environment. However, no studies currently exist to guide management of UAF in the setting of ileal conduit diversion when the theoretic risks of endograft infection from enteric flora must be weighed with those of open surgical repair.

Materials and Methods: PubMed was used to perform a search of the English language literature for case reports, series, and clinical studies describing UAFs. A total of 177 publications were originally identified after which 16 publications containing 21 cases involving ileal conduit diversion were selected for analysis. Patient demographics, past medical history, treatment modality, procedural data, and clinical outcome were reviewed.

Results: Twenty-one patients (14 women) with a mean age of 63.4 years were treated. Risk factors for the development of UAF included prior surgical intervention for pelvic malignancy (21 of 21), chronic ureteral stenting (19 of 21), pelvic irradiation (15 of 21), and female gender (14 of 21). Mean ureteral stenting duration was 23 months (2–120 months). Fistulization was almost exclusively unilateral (19 of 21) and involved a common iliac artery (20 of 21). Definitive surgical repair (4 of 21) had a 25% procedure-related mortality rate. Endovascular bridging for definitive surgical repair (6 of 22) had a 100% survival rate with 83% freedom from reintervention. Definitive endovascular treatment with covered stents (8 of 22) had a 100% survival rate with a 63% freedom from reintervention rate. Two cases required a future ureteronephrectomy. No endograft infection or urosepsis was identified. Follow-up duration ranged from 5 to 62 months.

Conclusions: Definitive endovascular treatment offers the best clinical outcomes for UAF in the setting of ileal conduit diversion but requires close follow-up. Surgical intervention should be reserved for failure of endovascular therapy.