1Husameddin El Khudari, 1Brennan J. Barrett, 1Rakesh Varma
1University of Alabama at Birmingham, Birmingham, United States
A 54-year-old male with rectal cancer status post pelvic exenteration, bilateral ureterosigmoidostomies, and perineal reconstruction. The postoperative course was complicated by a urine leak requiring antegrade ureteral stents. 4 months after surgery he presented with intermittent bleeding from his ostomy. Endoscopy could not locate the source of bleeding. CTA also failed to identify the source of bleeding. The patient accidentally removed his ureteral stents and subsequently had another episode of life-threatening bleeding requiring multiple units of blood transfusion. Interventional radiology was consulted for possible embolization. The inferior mesenteric angiogram showed no active extravasation or pseudoaneurysm formation, however, some contrast refluxed into the distal abdominal aorta, and contrast noted to opacify a tubular structure and pool in the left lower quadrant. A right common iliac angiogram was then performed and showed a fistulous communication to the right ureter. The right internal iliac artery was then embolized using coils to prevent retrograde flow. Next, a balloon-expandable stent was deployed extending from the proximal right common iliac artery across the bifurcation into the proximal right external iliac artery. A distal aortogram demonstrated no further opacification of the arterio-ureteral fistula, no endoleak, and free flow in the external iliac artery.
Arterio-ureteral fistula is a rare condition that occurs in patients with a prior history of abdominal surgery, radiation, or chronic ureteral stents. It usually presents with hematuria, however, the diagnosis is usually delayed due to the intermittent nature of the bleed and the lack of awareness of this entity as a cause of hematuria. Endovascular interventions are the mainstay of management. A careful review of the patient’s history and imaging as well as a high index of suspicion for this diagnosis is essential when evaluating a patient with bleeding urinary ostomy.