Arterio-Ureteral Fistula: Systematic Review of 445 Patients

Abstract

Arterio-ureteral fistula (AUF) is a rare, but potentially lethal, clinical entity. In spite of an increase in reported cases and clinical awareness, AUF is not always recognized in time. Delay between first presentation and treatment may adversely affect clinical outcome. What We Found: In this systematic review we found 245 published articles with 445 patients and 470 AUFs. Most patients had a medical history of chronic indwelling ureteral stents (80%), pelvic oncology (70%), irradiation (53%) or vascular surgery (26%), presenting with intermittent (micro) hematuria or building up to massive hematuria. The pathophysiologic hypothesis is presented in the figure . AUF was located at the crossing between ureter and artery, mostly the common iliac artery. The best modality to diagnose this entity was an angiography, with a sensitivity of 62%. Endovascular stent graft placement is preferred over open surgical repair in terms of AUF-related mortality (4% vs 11%). AUF-specific mortality before 2000 vs after 2000 is 19% vs 7%, coinciding with increasing use of endovascular stent graft placement.Limitations: The retrospective nature of this study, including many single case reports, results in a low level of evidence and high risk of bias. Furthermore, report bias could impact our findings such as better medical registration, electronic patient files, better imaging tests, less invasive treatment options, and better outcome. Interpretation for Patient Care: Clinical awareness as well as multidisciplinary approach is important to decrease unnecessary delay between first presentation and treatment of AUF. The best diagnostic tool is an angiography and the preferred treatment is endovascular stent graft placement.

Arterioureteral fistula after radical cystectomy and ureterocutaneostomy: two case reports and a systematic literature review

“…Pregnancy-associated AUF was discussed in 3 reports [ 9 ]. Moreover, a study including 445 patients showed that 80% had chronic indwelling ureteral stents while 70% with a history of pelvic oncology, and most AUFs occurred at the common iliac artery ureteral crossing [ 10 ]. We reviewed 216 cases of 92 studies in English from the past 10 years (2011–2021) in PubMed and summarized them in Table 1 .…”

Challenges in Diagnosis of Uretero–Arterial Fistulas after Complex Pelvic Oncological Procedures—Single Center Experience and Review of the Literature

“…Uretero–arterial fistulas represent a late complication after pelvic surgery and radiotherapy due to chronic inflammation that creates fibrous uretero–vascular adhesions [ 5 , 12 ]. The mechanical friction of the pulsatile artery in direct contact with the ureter combined with chronic indwelling stenting represents the main mechanism described in the formation of UAFs [ 1 , 2 , 3 ].…”

“…Although arteriography presents the highest sensitivity in detecting a UAF, it should not be performed only for diagnostic purposes due to its invasive nature and because it may worsen the hematuria [ 1 , 11 , 17 ]. A direct image can be seen in cases with large or complex fistulas, but most often, arteriography can detect indirect signs of UAFs such as a nipple or pseudoaneurysm of the arterial wall at the crossing of the ureter, which is suggestive for the entry point of the fistula [ 2 , 18 ].…”

“…Uretero–arterial fistula (UAF) represents a rare condition that manifests as massive or intermittent hematuria and requires collaboration between a urologist, vascular surgeon and interventional radiologist [ 1 , 2 , 3 ]. Specific-cause mortality varies between 7–90%, depending on type of treatment (open vs endovascular), hemodynamic status of the patient and hospital infrastructure [ 1 , 4 , 5 , 6 ]. UAF incidence is increasing due to improved survival after aggressive management of pelvic tumors that involves large surgical resections, urinary diversions and radiotherapy [ 5 , 7 , 8 ].…”

“…UAF incidence is increasing due to improved survival after aggressive management of pelvic tumors that involves large surgical resections, urinary diversions and radiotherapy [ 5 , 7 , 8 ]. Diagnostic pathways and treatments are very heterogeneous, since most of the published articles are limited to case series or reports [ 1 , 9 , 10 , 11 ].…”