Uncommon Complication of Ureteral Stenting for Obstructive Uropathy: Case Report of a Ureteroarterial Fistula

Purpose: Ureteroarterial fistula (UAF) is an uncommon condition. Only 162 cases have been reported since initially described in 1908. Low clinical suspicion and misdiagnosis have led to unnecessary nephrectomies and renal embolization. Associated mortality ranges 7% to 23% but can be as high as 58% in those not diagnosed preoperatively. Familiarity with UAFs is central to improved detection and management of this atypical cause of hematuria.

Materials and Methods: We describe the presentation, diagnosis, and endovascular management of a case of a ureteroiliac fistula.

Results: A 61-year-old man with recurrent rectal cancer after abdominal perineal resection and external-beam radiation 3 years prior was admitted with hematuria and urosepsis. He had a history of obstructive uropathy secondary to tumor burden for which bilateral metallic ureteral stents were placed 11 months prior with subsequent failure requiring bilateral percutaneous nephrostomy (PCN) tubes. He underwent bilateral PCN tube exchanges and cystoscopic removal of the nonfunctional and colonized ureteral stents. Immediately after surgery, he became hypotensive, required pressor support, and was found to have large-volume hematuria from his right PCN bag. Labs showed a drop in hemoglobin (8.6 to 6.2 g/dL). Computed tomography angiogram showed a fistulous connection between the right proximal external iliac artery and ureter. Emergent angiogram, coil embolization of the hypogastric artery, and subsequent deployment of a 9- ´ 38-mm, balloon-expandable, covered iCast stent (Atrium Medical, Wayne, NJ) resulted in hemoglobin stabilization and lactate normalization before discharge 7 days later. The patient ultimately was rehospitalized 2 months later with perforated cholecystitis and opted for comfort measures only. Despite the limited follow-up period, he had no further episodes of hematuria or urosepsis with imaging showing stent patency.

Conclusions: Although uncommon, greater incidence of UAFs can be expected in the future because of increasing life expectancy, expanding multimodal pelvic cancer treatments, and increased use of chronic indwelling ureteral stents for obstructive uropathy. Recognizing risk factors and knowing appropriate diagnosis and treatment options are critical to early detection and management of patients with this potentially fatal condition.