罕見病例 – 輸尿管髂動脈瘻管
許智凱、張廷瑞、陳世亮
台南市立醫院 泌尿科
Uretero-iliac Artery Fistula - A rare case report
Chih-Kai Hsu, Ting-Jui Chang, Shih-Liang Chen
Divisions of Urology, Tainan Municipal Hospital, Tainan, Taiwan
Background: Uretero-Iliac artery fistulas (UAF) are very uncommon condition in urological field. The rarity and the difficulty in diagnosis may lead to a delayed or inappropriate treatment that can result in life-threatening situation. We present a case of right side UAF and successful treatment with endovascular stenting.
Case Report: An 72 years-old man has history of HCVD, diabetes, and chronic renal insufficiency. He also received surgery for stage III rectal cancer, followed by CCRT 6 years ago. As a consequence, bilateral radiation ureteritis with stenosis developed 2 years ago. After that, long-term D-J stent indwelling with regular revision had been arranged. But, recurrent gross hematuria with episodes of blood clot formation was observed in the recent months. An expectedly massive bleeding from the right ureter was noted while removing the old stent in the revision procedure. Bladder blood clot temponade happened immediately, and patient has hypovolemic shock at the operation room. Arterial bleeding in the upper urinary tract was suspected, and angiography was performed that showed a Pseudoaneurysm with rupture near common iliac bifurcation. Percutaneous stent grafting of right external iliac artery fistula and permanent nephrostomy diversion was done. Bleeding from the fistula completely resolved in the next day and recovery well without renal function deterioration.
Discussion: UAF is a rare but potentially life-threatening condition. The symptom varies from intractable microscopic hematuria to gross hematuria occurring intermittently. A variety of medical conditions and activities can predispose to the formation of UAF which include vascular factors such as degenerative vascular diseases and previous vascular surgery. Non-vascular factors include pelvic radiation and chemotherapy, pelvic surgery, previous urinary diversion, and ureteral stenting.
Clinical awareness of the possibility of this condition is the most important of all diagnostic steps. Diagnostic tools included retrograde pyelography, CT scan and angiography, which the sensitivity only yielded 23%~69%. Treatment varies from open vascular repair/bypass, TAE, and endovascular stenting. If an exploratory laparotomy was attempted without any adequate preoperative diagnosis, mortality rate would raise up to 64%. The endovascular techniques are the first choice in modern time, which had proven not only to be effective but also very rapid in this emergency condition.