Ureteroarterial Fistula — Repair
This operative atlas covers control of ureteroarterial (arterio-ureteral) fistula, abbreviated UAF or AUF. See Vascular-Urinary Fistula for risk factors and diagnostic evaluation. Treatment requires coordinated vascular surgery, interventional radiology, urology and resuscitation support; the evidence consists mainly of retrospective series and case reports.[1][2][3]
Immediate Priorities
Suspected UAF with major hematuria is a vascular emergency. Resuscitation and preparation for arterial hemorrhage control proceed together. A negative angiogram does not exclude an intermittently bleeding fistula; persistent strong suspicion requires multidisciplinary reassessment, not reassurance or an unprotected stent exchange.[2][3]
| Priority | Practical approach |
|---|---|
| Resuscitate | Restore perfusion with blood products and other support according to hemorrhage severity; activate the team able to obtain immediate arterial control. |
| Avoid disrupting tamponade | An existing ureteral stent may tamponade the tract. Avoid unnecessary manipulation before vascular support is ready. |
| Control arterial bleeding | Covered stent-grafting is the usual initial option when anatomy and the infection/contamination context permit; open or hybrid control may be necessary. |
| Plan urinary drainage and source control | Assess obstruction, renal function, infection and any bowel communication alongside the arterial repair. |
In the Heers multicenter series of 26 fistulas in 24 patients, 92.3% of fistula episodes required transfusion and 46.2% required inotropic support. These are selected-series observations, not thresholds for intervention.[4] Bladder catheter drainage and irrigation can address clot retention; irrigation itself does not identify the bleeding ureter.
Do not treat suspected UAF as a routine difficult stent exchange. Malgor reported massive bleeding during intentional ureteral manipulation in 3 of 14 cystoscopic evaluations. If removal, exchange, provocation or ureteral balloon tamponade is needed, perform it in a setting with immediate endovascular or operative arterial control and a plan to preserve access. An instruction to blindly reinsert a stent immediately after bleeding starts is unsafe.[5][7]
Endovascular Repair
Covered stent-grafting can exclude the communication while maintaining iliac arterial flow and avoiding hostile pelvic dissection. It is generally the preferred initial treatment in suitable cases; it does not eliminate every source of infection or the need for later reconstruction.[1][2]
Planning and deployment
- Define the likely fistula level, arterial anatomy and landing zones. Diagnostic angiography and treatment can occur in the same session; proof of extravasation is not always obtainable.[2][10]
- Select a covered stent appropriate to vessel diameter and anatomy. Published experience includes both self-expanding and balloon-expandable devices; a small series with one device does not establish device superiority.[8]
- Determine whether the internal iliac artery needs exclusion to prevent continued fistula filling. Balance hemorrhage control against pelvic perfusion; selective embolization or a branched reconstruction depends on the anatomy.[9][10]
- Common iliac occlusion requires an explicit distal and pelvic perfusion plan. Embolization of an isolated internal iliac source and occlusion of the common iliac artery are not interchangeable procedures.[10][14]
Failure and complications
Recurrent hematuria, infection, thrombosis, embolic/ischemic events and device migration can require urgent reintervention. A reported case of late thrombosis with migration into the bladder illustrates a possible complication, not its population frequency.[12] In Sachsamanis's nine-patient series, three of six initially endovascularly treated patients later required open conversion for recurrent bleeding or infection; this cannot be presented as a universal recurrence rate.[9]
Open and Hybrid Repair
Consider open or hybrid treatment for enteric contamination, abscess or infected graft requiring source control, failed endovascular exclusion, recurrent bleeding, or anatomy that cannot be treated while preserving necessary perfusion. A pre-existing arterial graft increases planning complexity but is not, by itself, an absolute reason to reject endovascular hemorrhage control.[7][9][13][15]
| Reconstruction | Selection considerations |
|---|---|
| Arterial exclusion with extra-anatomic bypass | Iliac ligation or embolization combined with a femoral crossover or other suitable bypass can avoid direct reconstruction in an infected/hostile field. Plan limb and pelvic circulation before arterial exclusion. |
| Direct repair or patch | Selected accessible defects with suitable arterial tissue; extensive radiation injury or infection may make local repair inappropriate. |
| Interposition reconstruction | Replacement of an affected segment when required; material and route depend on infection and perfusion requirements. |
| Staged endovascular-to-open treatment | Initial hemorrhage control followed by definitive drainage, debridement or reconstruction when the patient's condition permits. |
These choices are individualized vascular reconstructions, rather than obligatory sequential stages.[7][13] Vandersteen's historical experience included five fistulas in four patients treated with provocative arteriography, common iliac embolization and extra-anatomic bypass, without death, limb loss or renal loss. It is a small series, not a comparison proving superiority.[14] Limited prognosis alone does not make arterial ligation without a perfusion assessment appropriate.
Concomitant urinary procedures
Assess ipsilateral renal function, obstruction, ureteral viability and the burden of future exchanges. Options include continued ureteral drainage, nephrostomy, ureteral exclusion with nephrostomy, or nephrectomy in selected circumstances. An unsalvageable ureter does not automatically require nephrectomy. Fox reported ureteral ligation or nephrectomy in four of six open repairs; that combined category must not be described as four nephrectomies.[6]
Urinary Drainage After Arterial Control
A urinary drainage plan is essential, but nephrostomy is not obligatory after every stent-graft. Published series include substantial continued ureteral stenting: 12 of 14 endovascularly treated patients in Fox's cohort remained stented. Balance reliable drainage, renal preservation, infection and the hazards of repeated instrumentation. Plan future exchanges jointly with the vascular/interventional team.[5][6]
Diversion or ureteral exclusion alone does not reliably treat the arterial lesion; if used without arterial repair as palliation, explicitly acknowledge the risk of further bleeding.[7] Antimicrobial and antithrombotic plans require assessment of contamination, cultures, implanted material, thrombosis risk and ongoing bleeding; these small series do not establish a universal drug regimen.[9][11]
Interpreting Outcomes
| Source and population | Observed result | Limit |
|---|---|---|
| Kamphorst systematic review: 445 patients, 470 fistulas | UAF-specific mortality was 19% before 2000 and 7% thereafter. | An era comparison coinciding with increased endovascular treatment, not 19% for open versus 7% for endovascular repair or proof of causation.[3] |
| Guntau: eight patients, ten fistulas | No 30-day deaths after balloon-expandable covered stent treatment. | Small selected series; no device or open-surgery comparator.[8] |
| Fox: 19 patients, 20 fistulas | Ten patients developed lower-extremity morbidity during follow-up. | The 53% figure belongs to this cohort across treatments; it is not a general UAF complication rate or an endovascular-specific risk.[6] |
| Matsunaga: 40 patients, 43 fistulas after ileal conduit | Reported stent-graft infection was 14.3%; reported UAF mortality was 7.1% with combined endovascular/endoureteral treatment and 13.3% with surgery. | Heterogeneous, nonrandomized reports in a specific diversion population; neither equivalence nor a universal 14% infection rate is established.[11] |
Published patency, survival and freedom-from-bleeding estimates use different follow-up periods and small denominators. They should not be assembled into an apparently comparative endovascular-versus-open prognosis table.
Special Situations and Follow-up
Ileal conduit: contamination and stent-graft infection deserve particular attention; Matsunaga supports close follow-up, especially in the first year, while acknowledging uncertainty about antibiotic strategy.[11]
Prior arterial reconstruction: review graft infection, bowel involvement and feasible perfusion-preserving options. Treatment may require removal or bypass of infected material; a temporary endovascular bridge remains a case-specific decision.[13][15]
Metallic ureteral stents: Song reported three UAFs among seven patients selected because they had serious stent-related complications. This warns about possible injury in high-risk anatomy but supplies neither an incidence estimate nor evidence that all metallic stents are contraindicated.[16]
Arrange vascular and urologic follow-up for recurrent bleeding, infection, patency and urinary drainage. New hematuria can signal recurrent UAF even after a technically successful repair; fever or new limb ischemic symptoms also require prompt evaluation.[2][9]
References
1. Ebata Y, Morisaki K, Matsubara Y, et al. "A Systematic Review of Management of Ureteroarterial Fistula." J Vasc Surg. 2022;76(5):1417–1423.e5. doi:10.1016/j.jvs.2022.05.015
2. Pillai AK, Anderson ME, Reddick MA, Sutphin PD, Kalva SP. "Ureteroarterial Fistula: Diagnosis and Management." AJR Am J Roentgenol. 2015;204(5):W592–8. doi:10.2214/AJR.14.13405
3. Kamphorst K, Lock TMTW, van den Bergh RCN, et al. "Arterio-Ureteral Fistula: Systematic Review of 445 Patients." J Urol. 2022;207(1):35–43. doi:10.1097/JU.0000000000002241
4. Heers H, Netsch C, Wilhelm K, et al. "Diagnosis, Treatment, and Outcome of Arterioureteral Fistula: The Urologist's Perspective." J Endourol. 2018;32(3):245–251. doi:10.1089/end.2017.0819
5. Krambeck AE, DiMarco DS, Gettman MT, Segura JW. "Ureteroiliac Artery Fistula: Diagnosis and Treatment Algorithm." Urology. 2005;66(5):990–4. doi:10.1016/j.urology.2005.05.036
6. Fox JA, Krambeck A, McPhail EF, Lightner D. "Ureteroarterial Fistula Treatment With Open Surgery Versus Endovascular Management: Long-Term Outcomes." J Urol. 2011;185(3):945–50. doi:10.1016/j.juro.2010.10.062
7. Malgor RD, Oderich GS, Andrews JC, et al. "Evolution From Open Surgical to Endovascular Treatment of Ureteral-Iliac Artery Fistula." J Vasc Surg. 2012;55(4):1072–80. doi:10.1016/j.jvs.2011.11.043
8. Guntau M, Hegele A, Rheinheimer S, Hofmann R, Mahnken AH. "Balloon-Expandable Stent Graft for Treating Uretero-Iliac Artery Fistula." Cardiovasc Intervent Radiol. 2017;40(6):831–835. doi:10.1007/s00270-017-1586-4
9. Sachsamanis G, Pfister K, Kasprzak PM, et al. "Midterm Results After Open Surgical and Endovascular Management of Arterioureteral Fistula." Ann Vasc Surg. 2021;73:280–289. doi:10.1016/j.avsg.2020.11.014
10. Quillin SP, Darcy MD, Picus D. "Angiographic Evaluation and Therapy of Ureteroarterial Fistulas." AJR Am J Roentgenol. 1994;162(4):873–8. doi:10.2214/ajr.162.4.8141010
11. Matsunaga F, Dambaeva A, Ponsky LE, Kashyap VS, Tavri S. "Systematic Review of the Management of Ureteroarterial Fistulas After Ileal Conduit Urinary Diversion." AJR Am J Roentgenol. 2021;216(6):1452–1461. doi:10.2214/AJR.20.23132
12. Liang NL, Avgerinos ED, Hager ES, Singh MJ. "Endovascular Repair of an Iliac Ureteroarterial Fistula With Late Stent Thrombosis and Migration Into the Bladder." Ann Vasc Surg. 2016;35:204.e5–7. doi:10.1016/j.avsg.2016.01.026
13. Hong SY, Noh M, Ko GY, et al. "Management Strategy for Ureteral-Iliac Artery Fistula." Ann Vasc Surg. 2016;36:22–27. doi:10.1016/j.avsg.2016.02.033
14. Vandersteen DR, Saxon RR, Fuchs E, et al. "Diagnosis and Management of Ureteroiliac Artery Fistula: Value of Provocative Arteriography Followed by Common Iliac Artery Embolization and Extra-Anatomic Arterial Bypass Grafting." J Urol. 1997;158(3 Pt 1):754–8. doi:10.1016/S0022-5347(01)64307-6
15. van den Bergh RC, Moll FL, de Vries JP, Yeung KK, Lock TM. "Arterio-Ureteral Fistula: 11 New Cases of a Wolf in Sheep's Clothing." J Urol. 2008;179(2):578–81. doi:10.1016/j.juro.2007.09.087
16. Song G, Lim B, Han KS, et al. "Complications After Polymeric and Metallic Ureteral Stent Placements Including Three Types of Fistula." J Endourol. 2015;29(4):485–9. doi:10.1089/end.2014.0394