Nearly Fatal Injury of Iliac Artery After Inaccurate Incision of Ureterointestinal Stricture in Orthotopic Neobladder

Abstract

A 59-year-old man with invasive bladder cancer was treated with radio-chemotherapy1 elsewhere, which was discontinued due to incompatibility. He was referred to our institution, where cystoprostatectomy and ileal orthotopic bladder substitution were performed.' A year later obstruction of the left kidney developed. Preoperative evaluation, including computerized tomography, revealed no recurrent cancer or abnormal location of bowel, distal ureter or blood vessels. Left renal function was 31% by dynamic radionuclide renograp hy . Retrograde incision of the anastomotic stricture was done.3 After antegrade percutaneous puncture of the malrotated kidney an irregular distal ureter was visualized with at least 2 strictures: 1 at the intersection with the iliac vessels and 1 more distal (fig. 1). Without using a hydrophilic guide wire a polytetrafluoroethylene coated guide wire was placed in the neobladder with some difficulty and extracted through the cystoscope. After transurethral retrograde introduction of the cold knife ureterotome the ureter was visualized by antegrade pyelography. Depth of incision depended on the diameter of the knife (14F) and the medioventral direction of the knife was fluoroscopically controlled. The first pass of the cold knife was successful but was repeated due to strong resistance in the unusually narrow ureter. Antegrade pyelography was done after the 2 incisions. However, the subsequent attempt to place a 14/7F tapered endo-ureterotomy stent was unsuccessful. During the fluoroscopically controlled third incision the fluoroscope malfunctioned. However, because we had just fluoroscopically confirmed the actual position of the knife in the distal ureter, we continued to cut the proximal section of the stricture. Approximately 1 minute later during the second attempt to introduce a ureteral stent the patient experienced shock. No gross hematuria was immediately observed. Emergency laparotomy revealed massive intra-abdominal and retroperitoneal bleeding. Rapidly performed dissection, including opening of the renal pelvis to exclude injury of the intrarenal vessels, showed injury of the left iliac artery a t the site of intersection with the ureter. The vascular wall was sutured by a vascular surgeon. Blood loss was 4 1. The incision in the ureter appeared irreparable and extended 5 cm. above the sacroiliac joint. There-