Ureteral-Arterial-Enteric Fistula As A Complication Of Indwelling Ureteral Stents

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Since the first double-J stent by Finney in 1978, ureteral stents have been a safe and effective way to maintain ureteral patency in various benign and malignant conditions.1 Common early complications include stent discomfort, irritative bladder symptoms, hematuria, urinary tract infections and flank pain. Late complications include encrustation, breakage, migration and hydronephrosis. A more serious and life threatening complication, although much less common, is erosion into a major vessel resulting in life threatening hemorrhage. There have been several reported cases of ureteral-enteric and ureteral-arterial fistulas and its management. We report a ureteral-arterial-enteric fistula as a complication of chronic indwelling double-J ureteral stents. CASE REPORT A 59-year-old female with a history of cervical carcinoma underwent a radical hysterectomy followed by external beam radiation to the pelvis. She did well for two years but then developed bowel obstruction secondary to metastasis to the colon and required a left hemicolectomy and Hartman's pouch colostomy. Six months later, she presented in acute renal failure with an elevated creatinine of 2.5 mg/dl (normal 0.6-1.2 mg/dl) and bilateral hydronephrosis believed to be secondary retroperitoneal fibrosis from pelvic radiation or recurrent disease. A right ureteral stent was placed retrograde and a left stent was placed antegrade by interventional radiology with normalization of renal functions. Stent changes at three monthly intervals were performed by interventional radiology for one year. During this time, she maintained a stable creatinine of 1.2-1.4 mg/dl but had reported periodic episodes of painless gross hematuria following stent changes, which was attributed to instrumentation. Subsequently, she developed acute onset of painless gross hematuria and bleeding from her Hartman's pouch. Upon admission, she had a hematocrit of 15% (normal 42-50%) and a creatinine of 1.3mg/dl. Following multiple transfusions, urgent cystoscopic and colonoscopic evaluation was performed. Cystoscopy revealed no active bleeding from the ureteral orifices or stents. Endoscopic evaluation of the pouch revealed a segment of the ureteral stent extruding into the lumen of the pouch. A Hartman's pouchogram