Early diagnosis and management of arterio-ureteral fistulas: A literature review.

OBJECTIVES: Arterio-ureteralfistula (AUF) is an infrequent but potentially life-threatening condition. The aim of this study was reviewing the literature to build a flow-chart useful for an early and effective diagnosis and treatment of this pathology. MATERIALS AND METHODS: A literature search in PubMed was conducted. In addition, retrieved articles were cross-referenced. Data parameters included oncologic, vascular and urological history, diagnostics, treatment, and follow up were collected using a standard template by 2 independent reviewers. RESULTS: A total of 140 cases of AUF out of 172 available in the literature at the time of the review, were considered. All patients presented gross hematuria. Chronic indwelling ureteral catheter (CIUC); history of pelvic surgery (HPS) and history of pelvic radiotherapy (HRT) were present respectively in 81%, 62.1%and 58.6% of the sample. The most predominant location of AUF was at the common iliac artery ureteral crossing. Angiography with provocative measures had the highest diagnostic sensitivity (50%) and endovascular treatment with stent-graft placement across the fistula is the current state of the art treatment choice. CONCLUSIONS: Failure to diagnose can postpone a potentially life-saving targeted therapy and lead to complications. The identifi-cation of the Trifecta hematuria, history of pelvic surgery (HPS) and history of pelvic radiotherapy (HPR) would allow the identity-fication of patients at high risk of AUF, who may benefit from more sensitive early diagnostic investigations such as CT angiography and provocative angiography. The treatment of choice in case of AUF to date consist in endovascular prosthesis placement.

Arterioureteral fistula: overview of clinical characteristics, endovascular management, and outcomes.

BACKGROUND: Arterioureteral fistula (AUF) is a condition resulting from the pathologic connection between the ureter and the artery. Despite the low incidence, it can lead to devastating clinical consequences due to massive hematuria with a considerable mortality rate. MATERIAL AND METHODS: From January 2009 to December 2018, eight patients with AUF from two tertiary referral centers were included. Clinical data including presenting symptoms, previous pelvic surgery or radiotherapy, indwelling ureteral stents, primary vascular pathology, angiographic findings, type of treatment, survival, and recurrence were analyzed. RESULTS: All eight patients (six women, mean age 62.4 ± 14.5 years) presented with macroscopic hematuria and were successfully treated by endovascular management. One patient developed AUF due to an underlying iliac artery aneurysm, and the rest were due to secondary causes. Six patients had a history of an indwelling ureteral stent for a median of 5.5 months (1-84 months). All of the patients were successfully treated by endovascular management. For the median follow up of 987 days, three patients had recurrence of hematuria in a mean of 6.3 months, two patients were treated by surgery, while one was treated by endovascular treatment. CONCLUSION: AUF should be confirmed through a purposeful iliac angiogram or ureterography when suspected based on a relevant history or CT findings. AUF can be successfully treated by endovascular management. The surgical option should be considered in cases of recurrence. ABBREVIATIONS: AUF: arterioureteral fistula; CIA: common iliac artery; DJ: double J; EIA: external iliac artery; IIA: internal iliac artery; NBCA: N-butyl cyanoacrylate; PCN: percutaneous nephrostomy.

Arterio-Ureteral Fistula: Systematic Review of 445 Patients.

PURPOSE: Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but increasingly reported and potentially lethal. This systematic review comprehensively presents risk factors, pathophysiology, location and clinical presentation of AUF aiming to increase clinical awareness of this rare but life-threatening condition, and to put this entity into a contemporary perspective with modern diagnostic tools and treatment strategies. MATERIALS AND METHODS: This review was performed according to the PRISMA (Preferred Reporting Items for a Systematic Review and Meta-Analysis of Individual Participant Data) guidelines. A literature search in PubMed® and EMBASE™ was conducted. In addition, retrieved articles were cross-referenced. Data parameters included oncologic, vascular and urological history, diagnostics, treatment, and followup, and were collected using a standard template by 2 independent reviewers. RESULTS: A total of 245 articles with 445 patients and 470 AUFs were included. Most patients had chronic indwelling ureteral stents (80%) and history of pelvic oncology (70%). Hematuria was observed in 99% of the patients, of whom 76% presented with massive hematuria with or without previous episodes of (micro)hematuria. For diagnosis, angiography had a sensitivity of 62%. The most predominant location of AUF was at the common iliac artery ureteral crossing. AUF-specific mortality before 2000 vs after 2000 is 19% vs 7%, coinciding with increasing use of endovascular stents. CONCLUSIONS: AUF should be considered in patients with a medical history of vascular surgery, pelvic oncologic surgery, irradiation and/or chronic indwelling ureteral stents presenting with intermittent (micro)hematuria. A multidisciplinary consultation is necessary for diagnosis and treatment. The most sensitive test is angiography and the preferred initial treatment is endovascular.

Oncology and complications.

This collection of cases describes some unusual urological tumors and complications related to urological tumors and their treatment. Case 1: A case of uretero-arterial fistula in a patient with long-term ureteral stenting for ureteral oncological stricture and a second case associated to retroperitoneal fibrosis were described. Abdominal CT, pyelography, cystoscopy were useful to show the origin of the bleeding. Angiography is useful for confirming the diagnosis and for subsequent positioning of an endovascular prosthesis which represents a safe approach with reduced post-procedural complications. Case 2: A case of patient who suffered from interstitial pneumonitis during a cycle of intravesical BCG instillations for urothelial cancer. The patient was hospitalized for more than two weeks in a COVID ward for a suspected of COVID-19 pneumonia, but he did not show any evidence of SARS-CoV-2 infection during his hospital stay. Case 3: A case of a young man with a functional urinary bladder paraganglioma who was successfully managed with complete removal of the tumor, leaving the urinary bladder intact. Case 4: A case of a 61 year old male suffering from muscle invasive bladder cancer who was admitted for a radical cystectomy and on the eighth postoperative day developed microangiopathic hemolytic anemia and thrombocytopenia, which clinically defines thrombotic microangiopathy.

[Diagnostic management of primary megaureter : Voiding cystourethrography obligatory, scintigraphy useful?] / Diagnostisches Management des primären Megaureters : Miktionszysturethrographie obligat, Szintigraphie sinnvoll?

A primary, congenital megaureter means a dilatation of the ureter with a ureteric diameter ≥7 mm due to a structural or functional obstruction of the ureterovesical junction and represents the second most likely cause of neonatal hydronephrosis. Conservative management is the primary treatment option for many patients due to a high spontaneous remission rate of up to 85%. Concerning diagnostic management, meticulous and repeat postnatal evaluation by ultrasound is mandatory to identify patients who are at risk of renal deterioration. Routine voiding cystourethrography or contrast-enhanced voiding urosonography is currently recommended for all patients to detect vesicoureterorenal reflux and other concomitant pathologies. The relevance of the additional information provided by this examination must be critically questioned considering the lack of clinical consequences. Moreover, the question arises as to whether these examinations should be prolonged until clinical symptoms occur. Nevertheless, a subvesical obstruction should still be ruled out for male patients with a bilateral megaureter. The same critical discussion is necessary for the routine use of diuretic renography in patients with primary megaureter. In principal, this examination is used to determine the global as well as the split renal function and in addition is considered to offer an evaluation of the extent of obstruction. Similarly, the question arises of whether this examination should be mandatory for every child with a primary megaureter or whether the decision should be based on the extent of the upper urinary tract dilatation. The trend of diagnostic management should go towards individualized and risk-adapted diagnostic measures.

Approach to Ureterovaginal Fistula: Examining 13 Years of Experience.

OBJECTIVE: We describe the management and outcomes of ureterovaginal fistulas over a 13-year period and present a treatment algorithm. METHODS: We performed a review of ureterovaginal fistula cases between January 2005 and December 2017 at our tertiary academic center. Demographics, diagnostic approaches, and treatment outcomes were assessed. RESULTS: Nineteen cases of ureterovaginal fistula were identified. Fistulas developed after hysterectomy in 18 cases and cesarean delivery in 1 case. Our primary treatment was conservative management with ureteral stenting in 12 and reimplantation in 6 cases. There was 1 case of spontaneous resolution. Ureteral stenting was successful in 11 (92%) of 12 patients. Stents were left in place for an average of 66 days (27-92 days). Complications of stents included pyelonephritis in 2 cases (18%) and stricture in 1 case (9%). Ultimately, conservative management was successful in treating ureterovaginal fistulas in 10 (83%) of 12 cases. The indications for primary ureteral reimplantation were concurrent vesicovaginal fistula in 3 cases, history of ureteral injury with surgical repair during the index surgery in 2 cases, and a 1-year delay in diagnosis in 1 case. A variety of follow-up surveillance methods were used, including tampon tests, computed tomographic urograms, retrograde pyelograms, and MAG-3 Lasix renal scans. CONCLUSIONS: In carefully selected patients, ureteral stenting results in high cure rates for posthysterectomy ureterovaginal fistulas and should be considered first-line therapy. Complicated ureterovaginal fistulas may be best managed by primary ureteral reimplantation.

The Efficacy of Early Extracorporeal Shockwave Lithotripsy for the Treatment of Ureteral Stones.

PURPOSE: To determine the efficacy of early extracorporeal shockwave lithotripsy (e-ESWL) in colic patients with ureteral stones and the patient criteria for the most effective e-ESWL. MATERIALS AND METHODS: 335 patients who received ESWL due to ureteral stone, were divide in two groups: e-ESWL and d-ESWL by the critical cut-off point. we performed the sensitivity and specificity cut-off analyses to identified the critical cut off point. To assess the difference in the factors affecting ESWL success, univariate and multivariate logistic analyses were implemented with using variables: ESWL success; age; gender; BMI; comor-bidity; serum creatinine; stone size; stone location; stone laterality; Hounsfield unit (HU); presence of hydrone-phrosis; and presence of tissue rim. The subgroup analysis for the screened variables was conducted. RESULT: Optimal e-ESWL was defined to occur within a 24-hour critical cut-off time. Multivariate regression anal-ysis concluded with screened variables: age, stone size, stone location, and HU, that ESWL success was 1.85-fold higher in the e-ESWL patient group. The subgroup analyses the following conditions: ? 65 years old by 1.784- fold; ?10 mm stone size by 1.866-fold; mid to distal stone location by 2.234-fold; and ? 815 HU by 2.130-fold. When all the conditions were met, the e-ESWL success was 3.22-fold higher. CONCLUSION: In case of colic due to ureteral stones, the patient is recommended to receive a lithotripsy within the first 24 hours. E-ESWL is recommended especially in patients who are ? 65 years, or with a ureteral stone HU ? 815, sized ? 10 mm, or in a mid to distal location.

Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility.

BACKGROUND: The ureter is the second most common site affected by urinary tract endometriosis, after the bladder. Optimal strategies in the diagnosis and treatment of ureteral endometriosis (UE) are not yet well defined. OBJECTIVE AND RATIONALE: The aim of this study was to systematically review evidence regarding the epidemiology, pathophysiology, diagnosis, medical and surgical treatment, impact on fertility and risk of malignant transformation of UE. SEARCH METHODS: A systematic literature review, by searching the MEDLINE and PUBMED database until April 2018, was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and was registered in the PROSPERO registry (www.crd.york.ac.uk/PROSPERO CRD42017060065). A total of 67 articles were selected to be included in this review. OUTCOMES: The involvement of the ureter by endometriosis is often asymptomatic or leads to non-specific symptoms. When the diagnosis is delayed, UE may lead to persistent hydronephrosis and eventually loss of renal function. Ultrasonography is the first-line technique for the assessment of UE; alternatively, magnetic resonance imaging provides an evaluation of ureteral type involvement. The surgical treatment of UE aims to relieve ureteral obstruction and avoid disease recurrence. It includes conservative ureterolysis or radical approaches, such as ureterectomy with end-to-end anastomosis or ureteroneocystostomy performed in relation to the type of ureteral involvement. Fertility and pregnancy outcomes are in line with those observed after surgical treatment of deep infiltrating endometriosis (DIE). Current evidence does not support the potential risk of malignant transformation of UE. WIDER IMPLICATIONS: In this article, we review available evidence on ureteral endometriosis, providing a useful tool to guide physicians in the management of this disease. Diagnosis and management of UE remain a challenge. In relation to the degree of ureteral involvement and the association with other DIE implants, the surgical approach should be planned and carried out in an interdisciplinary collaboration between gynecologist and urologist.

Percutaneous Treatment Options of Lower Urinary Tract Fistulas and Leakages.

BACKGROUND: Lower urinary tract fistulas are currently a rather rare, but severe condition associated with considerable morbidity. Treatment is challenging, especially in fistulas caused by pelvic malignancy or radiation therapy. Surgical treatment attempts fail in a considerable number of patients, especially in those with pelvic malignancies/prior radiation therapy or are precluded altogether due to severe comorbidity. For such patients percutaneous approaches can provide alternative treatment. METHOD: This review is based on case studies and case reports dealing with percutaneous treatment options of lower urinary tract fistulas and leakages from the past four decades (1979 - 2017). The included techniques were ureteral fulguration, tissue adhesive-based embolization, non-detachable and detachable balloon occlusion, ureteral coiling, ureteral clipping, silicone or nylon plug as well as modified vascular plug embolization. RESULTS AND CONCLUSION: Percutaneous treatment options of lower urinary tract fistulas and leakages allow for either permanent or temporary, instant ureteral occlusion. In general, transrenal ureteral occlusion is a safe and reliable alternative to surgical treatment of ureteral fistulas and leakages. So far, no technique has been proven to be superior to the others. Depending on the underlying disease, the optimal percutaneous technique may vary and should be chosen according to the individual needs of the patients. KEY POINTS: · Patients with therapy-refractory urerteral fistulas may benefit from transrenal ureteral occlusion.. · Transrenal ureteral occlusion allows for long-term symptom relief.. · Ureteral occlusion should be in the armamentarium of interventional radiologists.. CITATION FORMAT: · Kuetting D, Pieper CC . Percutaneous Treatment Options of Lower Urinary Tract Fistulas and Leakages. Fortschr Röntgenstr 2018; 190: 692 - 700.

Management of ureteric duplications identified during robotic cystectomy and intracorporeal urinary diversion.

Ureteral duplication is rarely seen malformation that could be diagnosed during radiological imaging. Herein, we present 5 patients with ureteral duplication who underwent robotic radical cystectomy with intracorporeal urinary diversion for bladder cancer. Preoperative computerized tomography did not show presence of a ureteral duplication in any patient and all were identified intraoperatively. A Wallace type uretero-ureteral anastomosis was performed in all patients. During the follow-up period, we did not detect any ureterointestinal anastomotic strictures or complication related to the presence of a ureteral duplication following robotic cystectomy. We conclude that ureteral duplication might be missed during preoperative radiological imaging, might be a surprising and challenging issue for the robotic surgeon that could be safely managed intraoperatively.

Endovascular Management of Ureteroarterial Fistula: Single Institution Experience and Systematic Literature Review.

BACKGROUND: Ureteroarterial fistula (UAF) represents an uncommon complication after urological surgery; however, this is a well-documented condition in patients with predisposing risk factors. The aim of the present study is to report and analyze the endovascular management of a series of patients with UAF, treated in authors' hospital, and to report and analyze the same data concerning patients retrieved from a systematic literature review. METHODS: Authors conducted a retrospective analysis of prospectively collected data and a systematic literature review. The research was carried out through PubMed database searching the following keywords: "uretero arterial fistula" and "uretero iliac fistula." It includes only articles reporting the endovascular management. RESULTS: Forty-six articles were included in the present study for a total of 94 patients. Risk factors were as follows: chronic indwelling ureteral stents, pelvic surgery, radiotherapy, iliac artery pseudo-aneurysm, and chemotherapy. All patients had gross hematuria at presentation. Stent graft placement was performed in 89 patients, embolization in 5 patients, and iliac internal artery embolization combined with stent graft placement was performed in 24 patients. Four postprocedural complications were observed (4.2%). During a median follow-up of 8 months, 10 complications related to UAF were observed (10.6%): rebleeding (7 cases) and stent thrombosis (3 cases). Two patients died for causes related to UAF (2.1%): rebleeding (1) and retroperitoneal abscess (1). CONCLUSION: Based on the present data, endovascular treatment is feasible and safe with low postprocedural complications and mortality rate. Considering the increase in surgery and radiotherapy performed, UAF should be always debated in patients with massive hematuria.

Diagnosis, Treatment, and Outcome of Arterioureteral Fistula: The Urologist's Perspective.

INTRODUCTION: Arterioureteral fistula (AUF) is a rare but potentially life-threatening disease that primarily arises as a long-term complication in oncological patients who have permanent ureteral stenting. The incidence is rising. The objective of this study was to outline the risk factors for management and outcome of AUF in a large individual case series. PATIENTS AND METHODS: Twenty-six AUF cases in 24 patients from six German tertiary referral centers occurring between 2008 and 2016 were identified retrospectively and entered into a dedicated database by using patient notes and out-patient visits. RESULTS: Of 24 patients, 23 had a history of abdominopelvic surgery for oncological disease, 21/24 had undergone radiotherapy, and 23/24 had long-term ureteral stenting. All cases presented with visible hematuria, 11/26 at the time of a stent exchange. Blood transfusions were required in 92.3%, and intravenous inotropes were needed in 46.2%. Of 26 patients, 11 had flank pain. CT angiogram was positive in 35.7%. Angiography and endovascular fistula repair was performed in 88.5%, and the rest received open surgical repair. Mortality was 7.7%. Endovascular treatment was technically successful in 91.3%, and open surgery was successful in 3/4 cases. Recurrent AUF developed in 3/24 patients. Stent-related complications occurred in 15%. Vascular complications were common. Long-term survival was limited due to progression of the underlying malignant disease. CONCLUSION: AUF results in major hemorrhage and warrants time-efficient diagnosis and treatment. Awareness is key. When AUF is considered, interventional angiography should promptly be performed. Fistula detection can be improved by guidewire manipulation. Pre-interventional CT angiogram may be omitted due to low sensitivity. Endovascular repair with stenting and/or coiling is effective and safe.

Office stent placement under local anesthesia is a safe and efficient procedure for the management of multiple ureteral disorders. / La colocación de catéteres doble J con anestesia local en régimen ambulatorio es un procedimiento seguro y eficiente para el manejo de distintas patologías ureterales.

OBJECTIVE: To assess the outcomes of ureteral stent placement under local anesthesia for the management of multiple ureteral disorders. METHODS: Retrospective study of 45 consecutive ureteral stents placed under local anesthesia from January 2015 to July 2016. Inclusion criteria were hemodynamically stable patients with urinary obstruction, urinary fistula or for prophylactic ureteral localization during surgery. Five minutes before the procedure, 10ml of lidocaine gel and 50ml of lidocaine solution were instilled in the bladder. A 4.8Fr ureteral stent was placed using a 15.5Fr flexible cystoscope under fluoroscopic control. Characteristics of procedures and outcomes were analysed. RESULTS: A total of 45 procedures (33 placement, 12 replacements) were attempted in 37 patients, of which 40 (89%) were successful. There were 10 male (27%) and 27 female patients (73%) with a mean age of 58.6 years (±17.5). Main indications for stent placement were stones (37.8%), extrinsic ureteral compression (28.9%) and surgery ureteral localization (22.2%). The reasons for failing to complete a procedure were the inability to pass the guidewire/stent in 4 cases (8.8%) or to identify the ureteral orifice in 1 (2.2%). Postoperative complications occurred in 8 patients (17.8%) (7 Clavien I, 1 Clavien IIIa). No procedure was prematurely terminated due to pain. Statistical analysis did not find significant successful predictors. The outpatient setting provided a fourfold cost decrease. CONCLUSIONS: Ureteral stent placement can be safely and effectively performed under local anesthesia in the office cystoscopy room. This procedure could free operating room time, reduce costs and minimize side effects of general anesthesia.

[Modern interdisciplinary management of a uretero-iliac artery fistula (case report)]. / Modernes interdisziplinäres Management einer uretero-iliakalen Fistel (Fallbericht).

INTRODUCTION: Abnormal links between the arterial system and other luminal systems are a challenge to those in charge of their adequate diagnostic and therapeutic management. OBJECTIVE: Scientific case report on an individual who underwent successful treatment combining vascular-surgical and interventional radiology techniques for a rare right uretero-iliac artery fistula based on personal clinical experience, a selective literature research and a detailed discussion of current recommendations for diagnostic workup and subsequent treatment. CASE CHARACTERISTICS: A 79-year-old patient was admitted with haematuria : and bladder tamponade : in the presence of bilateral actinic ureteral strictures secondary to neoadjuvant radiochemotherapy followed by abdominoperineal rectum exstirpation due to suprasphincteric rectal cancer (ypT3ypN0M0). Laboratory tests revealed anaemia; transabdominal ultrasound demonstrated bilateral urinary retention. A complementary CT scan did not reveal any manifest bleeding resulting from intermittent haemorrhage. SURGICAL PROCEDURE: Initially, the bladder haematoma was removed and ureteral catheters were changed. Due to endoluminal bleeding in the right ureter, a combined procedure was initiated, involving a vascular-surgical approach (access to the right femoral artery, ultimate disobliteration and intimal refixation in the right superficial femoral artery due to dissection) and an interventional radiology approach (insertion of an Amplatzer [AMPLATZER™Vascular Plug II; St. Jude Medical, Saint Paul, Minnesota, USA] into the right internal iliac artery and iliac stenting by a cross-over manoeuvre from the left femoral access site) although no acute bleeding was detected in the CT scan (but acute haemorrhage from the right ureteric ostium was confirmed during cystoscopy). CLINICAL COURSE: The patient stabilised in due time in response to periinterventional treatment in the ICU. He was discharged on the 15th day after surgery without evidence of recurrent haemorrhage. SUMMARY: In the presented case, this promptly initiated (vascular-surgical and interventional radiology) hybrid operation was absolutely indicated, being the approach with the best prospects for recurrent arterial bleeding with clinical manifestation of haematuria and haemorrhage within the urinary bladder due to a uretero-iliac artery fistula. CONCLUSION: Today, a minimally invasive approach with stenting is the method of choice in the sequential, urgent management of a potentially life-threatening uretero-iliac fistula in the presence of arterial endoluminal bleeding and an imminent haemorrhagic shock.

Different Successful Management Strategies for Obstructing Renal Parapelvic Cysts.

Parapelvic cysts originate in the renal parenchyma and extend into the renal sinus. A series of 3 patients with symptomatic obstructing parapelvic cysts is described, 2 with acute presentations, and 1 with chronic symptoms. In 2 of the 3 cases, there was a significant delay in establishing a diagnosis. Although one individual was successfully managed by image-guided cyst aspiration, the second patient required repeated aspiration due to cyst re-accumulation. A high index of clinical suspicion and a combination of imaging modalities, including serial ultrasound, excretory-phase CT, and MAG3 renogram, are necessary to establish the diagnosis and monitor response to treatment.

Original flow chart for the management of hydroureteronephrosis caused by pessary placement.

INTRODUCTION: The use of a pessary to treat a pelvic organ prolapse (POP) is a valid non-invasive option. Severe complications are usually associated with neglected, oversized, or misplaced pessaries. Major complications include fistulas, bowel or bladder erosion, and hydroureteronephrosis (HUN). MATERIALS AND METHODS: We reviewed the literature and our experience in the management of HUN in the last decade, as a consequence of pessary placement. RESULTS: We used flow charts to take an accurate medical history of each patient. Blood and urine analyses were taken at admission to assess the potential presence of sepsis, renal failure, and urinary tract infection. Physical examination included vaginal examination. In cases of pessary presence with a concomitant increase of serum creatinine value, a possible ureteral obstruction is suspected. In order to assess the presence of HUN and its underlying causes, a computed tomography (CT) scan should be performed to assess the mechanism of urinary tract obstruction. However, in case of renal insufficiency, abdominal ultrasonography (US) could be sufficient. If HUN is detected in a patient with no signs of urosepsis, we suggest a conservative management by the removal of the pessary and catheter placement. When urosepsis is suspected, it is mandatory to administer antibiotic therapy and evaluate the HUN drainage by nephrostomy. CONCLUSIONS: There is no uniform management of women with HUN and a concomitant pessary. For this reason, and based on the literature and our experience, we propose an original management flowchart.