Critical Role of Clinical Suspicion in the Diagnosis of Arterio-Ureteral Fistula.

We read the case report of an arterio-ureteral fistula (AUF) by Lee and Lee (1). with great interest, prompting us to share a similar experience. A 65-year-old female presented with sudden onset left flank pain, hematuria, and hematochezia. She had undergone total proctocolectomy 32 years ago due to familial adenomatous polyposis-associated colon cancer and abdominoperineal resection with concurrent chemoradiation therapy (CCRT) for cancer recurrence 3 years ago. Initial systolic blood pressure was 89 mm Hg and pulse rates were 105 beats/min. Hemoglobin level was decreased to 7.0 g/dL despite transfusion. Gastroduodenoscopy failed to reveal bleeding focus of hematochezia. CT demonstrated high attenuated hematoma in urinary bladder and renal pelvis and small nipple-like aneurysmal projection in common iliac artery adjacent double-J (DJ) ureteral catheter without a sign of contrast-medium extravasation (Fig. 1A). Ongoing evaluation of bleeding focus, her physician consulted to interventional radiologist for renal artery embolization due to continuous hematuria. There was no evidence of active bleeding in kidney on CT review. History of surgery and CCRT and CT findings of nipple-like projection near DJ catheter suggested iliac AUF. Instead of renal artery embolization, we placed balloon expandable polytetrafluoroethylene-covered stent (Lifestream; BD Bard, Tempe, AZ) at external iliac artery with internal iliac artery coils embolization (Fig. 1B, C). After treatment, her symptoms of flank pain, hematuria and hematochezia improved and discharged from hospital with prophylactic antibiotics. Follow-up cystography and CT review revealed a fistula between the bladder and the ileum. The overflowed blood in urinary bladder was the probable cause of hematochezia. She underwent elective surgery to repair vesico-ileal fistula one month later and recovered from the fistula-associated symptoms.

Fig. 1

Endovascular treatment of arterio-ureteral fistula using a stent-graft.

A. The axial CT image of a 65-year-old female shows small pseudoaneurysm (arrow) in the left common iliac artery adjacent to the double-J ureteral catheter (arrowhead).

B. Iliac arteriogram shows a small contour-bulging pseudoaneurysm (arrow) without ureteral contrast media leakage.

C. After microcoil embolization of the internal iliac artery (arrowhead) for endoleak prevention, a stent-graft (arrows) was placed in the iliac artery to cover the pseudoaneurysm. Iliac arteriogram shows neither pseudoaneurysm nor endoleaks.

As stated by Lee and Lee (1), the AUF is a rare condition and misdiagnosis can cause dire consequences. Intermittent bleeding natures and subtle abnormal image findings make it difficult to diagnose and to treat earlier (2). Endovascular treatment would be most feasible approach because it is less invasive and most patients had undergone surgery and radiation therapy (3). This presenting case can be a typical secondary AUF due to previous cancer surgery, CCRT, and placement of DJ ureteral stent. Combined vesico-ileal fistula caused hematochezia and obscured the bleeding focus. CT was known to have limited role for diagnosis because it showed positive finding in only 38–42% of patients (34). However, preprocedural CT evaluation with clinical suspicion would be most important for early diagnosis and safe treatment (5). When patients with cancer surgery, CCRT, and ureteral stent present with massive hematuria, radiologists should be aware of possibility of AUF and inspect closely around ureteral stent. We thank to Lee and Lee (1) for presenting interesting case and thorough literature review.