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Abstract
IntroductionGross hematuria caused by rupture of an artery in the urinary tract is a rare but potentially fatal condition. Iliac artery aneurysms, pelvic surgery with radiation, vascular reconstructive surgery, surgery for stenosis of the ureteropelvic junction, and transplantation are reported to be associated with this condition. In the vascular reconstructive surgery group, the most common etiology is rupture of the degenerated artery or synthetic graft in the ureter.Case presentationWe present a case of rupture of the small anastomotic pseudoaneurysm at the proximal anastomosis of a right iliofemoral autogenous vein extra-anatomic graft in the urinary bladder. To our knowledge, this is the first report of a rupture of an autogenous vein graft in the urinary bladder. Our patient, a 24-year-old Albanian farmer, was admitted to the emergency department in severe hemorrhagic shock induced by exsanguinating hematuria. He underwent immediate surgery, during which direct sutures to the bladder were placed and the saphenous graft was replaced with a synthetic one. The patient recovered completely, was free of hematuria, and showed no signs of pathological communication between the urinary and arterial tracts on postoperative cystoscopy and computed tomographic angiography during 2 years of follow-up.ConclusionThe incidence of artery-to-urinary tract fistulas is growing due to the increasing use of urologic and vascular surgery, pelvic oncologic surgery, and radiation therapy. In addition to fistulas involving a degenerated artery and ureter or synthetic grafts and ureter, they can also involve an autogenous vein graft and the urinary bladder. In our patient, the fistula was a result of erosion of the bladder from a pseudoaneurysm at the proximal anastomosis of an autogenous vein iliofemoral bypass in an extra-anatomic position. Open surgery remains the best treatment option, although there is increasing evidence of successful endovascular treatment.
Highlights
Gross hematuria caused by rupture of an artery in the urinary tract is a rare but potentially fatal condition
The fistula was a result of erosion of the bladder from a pseudoaneurysm at the proximal anastomosis of an autogenous vein iliofemoral bypass in an extra-anatomic position
Artery-to-urinary tract fistulas (AUFs) are rare, erosive defects that occur between the segments of the urinary tract and adjacent blood vessels or vascular grafts
Summary
The incidence of AUFs is growing due to an increase in urologic and vascular surgery, pelvic oncologic surgery, and radiation therapy. In addition to the fistulas involving degenerated artery and ureter or synthetic grafts and ureter, they can involve autogenous vein graft and urinary bladder. The fistula was a result of erosion of the bladder from a pseudoaneurysm at the proximal anastomosis of an autogenous vein iliofemoral bypass in an extra-anatomic position. Open surgery aimed at hemorrhage control, restoration of vascular and urinary continuity, and resection of potentially infected tissue or prosthetic material remains the best therapeutic option for AUFs, even though there is increasing evidence of successful endovascular treatment. This is why AUFs should be suspected in all patients with hematuria and a history of the aforementioned surgical and radiological procedures
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