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Ureteroarterial Fistula — Repair

This is the surgical-technique atlas for ureteroarterial (arterio-ureteral) fistula (UAF / AUF). For epidemiology (~3.5 cases/year nationally in the Netherlands), the anatomy and pathophysiology of the iliac–ureter crossing, full etiology and risk-factor data (chronic stent 72–87%, prior pelvic surgery 87–100%, radiation 45–74%, pelvic malignancy 67–70%), clinical presentation (the "wolf in sheep's clothing" hematuria pattern), and the full diagnostic algorithm (CT angiography, DSA, provocative angiography, cystoscopy, ureterography), see the clinical-conditions page: Vascular-Urinary Fistula. This page focuses on the stepwise repair framework, surgical and endovascular repair options, and outcomes.

Stepwise Repair Framework​

UAF is a vascular emergency. Management proceeds along three sequential phases. Most patients now enter endovascular repair at Stage 2 once diagnostic angiography confirms the fistula in the same session; open surgery is reserved for contaminated fields, stent-graft infection, failed endovascular repair, or prior arterial reconstruction at the fistula site.[1][2][3]

StageGoalModalities
1. Acute stabilizationTamponade, transfuse, prevent clot retentionAggressive resuscitation, blood products, vasopressors, CBI Foley, keep the indwelling ureteral stent in situ for tamponade or reinsert / balloon-tamponade urgently if removed
2. Endovascular repair (preferred)Exclude the fistula while preserving distal perfusionCovered stent-graft across the iliac fistula ± internal-iliac coil embolization ± iliac-branched device
3. Open surgical repair (selective)Definitive control in contaminated / failed / infected casesArterial ligation + extra-anatomic bypass, direct arterial repair / patch angioplasty, interposition graft, ureteral ligation, nephrectomy

Stage 1 — Acute Stabilization​

  • Aggressive fluid and blood-product resuscitation — transfusion required in 92%, vasopressors in 46%[4]
  • Maintain ureteral stent for tamponade — the indwelling stent is often the only thing blocking the fistula tract; do not remove it until angiographic control is established. If recently removed (e.g., during a stent exchange that precipitated bleeding), reinsert immediately or balloon-tamponade the ureter[5][2]
  • Foley catheter with continuous bladder irrigation (CBI) to prevent clot retention and lateralize hematuria
  • Emergent angiography suite — diagnostic and therapeutic in the same session; intervene immediately when fistula is identified[4]

Stage 2 — Endovascular Repair (Preferred Initial Treatment)​

Endovascular repair is the preferred initial approach and has driven UAF-specific mortality down from 19% (pre-2000) to 7% (post-2000).[6][1][4]

Covered stent-graft deployment​

  • Self-expanding or balloon-expandable covered stent-graft placed across the fistula segment of the iliac artery[2][7][8]
  • Balloon-expandable grafts (e.g., ADVANTA) offer precise deployment — Guntau series reported zero 30-day mortality in 10 UAFs[8]
  • Can be performed immediately after diagnostic angiography in the same session

Internal iliac artery (IIA) exclusion​

Frequently combined with iliac stent-grafting to prevent retrograde flow through the fistula via the IIA — performed in 9 of 11 stent-graft cases in the Malgor series.[7] Trade-off is buttock claudication from IIA loss; iliac-branched devices can preserve IIA flow in select anatomy.[9]

Coil embolization​

  • Used alone or in combination with stent-grafting — embolization of the common or internal iliac artery at the fistula site[9][10]
  • One report described IIA coiling alone as sufficient for fistula management[9]

Endovascular limitations / complications​

ComplicationFrequencyNotes
Stent-graft infection14–15% (especially ileal conduit)Leading indication for reintervention (50% of reinterventions)[11]
Recurrent hematuria10–50%3 of 6 endovascularly treated patients in Sachsamanis required conversion to open surgery[9]
Stent thrombosis / migrationRareOne case of late thrombosis with migration into bladder[12]
Lower-extremity ischemia / ulceration / amputation53% (all UAF patients across both groups)Despite anticoagulation[6]
Buttock claudicationVariableFrom IIA exclusion[7]

Stage 3 — Open Surgical Repair (Selective)​

Indicated when endovascular repair is contraindicated, has failed, or is unsafe.[2][9][7][13]

Indications​

  • Enteric contamination or concurrent enterovesical / enterocutaneous fistula
  • Active abscess or local sepsis
  • Stent-graft infection after prior endovascular repair
  • Failed endovascular treatment (recurrent bleeding, stent complications)
  • Pre-existing aortoiliac vascular reconstruction at the fistula site

Open techniques​

Arterial ligation + extra-anatomic bypass (workhorse)​

The most commonly described open approach:[7][14]

  • Ligation (or proximal embolization) of the common iliac artery at the fistula site
  • Femoral-femoral crossover bypass or axillofemoral bypass to restore distal perfusion
  • Deliberately avoids operating in the hostile, irradiated pelvis
  • Vandersteen described provocative arteriographic embolization of the common iliac followed by extra-anatomic bypass with no mortality, limb loss, or renal loss[14]

Direct arterial repair / patch angioplasty​

  • Primary repair or patch angioplasty of the arterial defect; feasible when the arterial wall is not extensively diseased
  • Performed in 3 patients in the Malgor series[7]

Interposition graft​

  • Replacement of the diseased arterial segment with prosthetic or autologous graft
  • Higher risk of graft infection in the contaminated pelvic field[7][13]

Arterial ligation alone​

  • Without bypass, when collateral circulation is adequate or the patient's prognosis is limited

Concomitant urologic procedures during open repair​

  • Ureteral ligation + percutaneous nephrostomy — when the ureter cannot be preserved (extensive disease, radiation damage)
  • Nephrectomy — when the ipsilateral kidney is non-functioning or the ureter is unsalvageable (4 of 6 open cases in one series)[6]
  • Ureteral exclusion — ligation of the ureter with permanent nephrostomy drainage

Open repair complication profile​

ComplicationFrequency
Perioperative mortality0–18%
Overall complication rate27–63%
Enterocutaneous fistula37.5% (3/8) — reflects hostile irradiated pelvis[7]
Wound infection25% (2/8)[7]
Recurrent hemorrhage10–33%
Bypass revision / thrombectomy33% (2/6)[9]

Hybrid Approach​

Combined endovascular + open repair is used in select cases:[13][14]

  • Endovascular stent-graft for acute hemorrhage control → delayed open repair when stable
  • Iliac embolization + extra-anatomic bypass — percutaneous embolization avoids laparotomy in the irradiated pelvis while definitively excluding the fistula

Urologic Management After Arterial Repair​

Often underemphasized but central to preventing recurrence:[6][5][7]

  • Address the underlying ureteral obstruction that necessitated chronic stenting in the first place — otherwise the inciting cause persists
  • Percutaneous nephrostomy placed at the time of endovascular repair to divert urine off the fistula; used alongside endovascular repair in most modern series
  • Remove the offending chronic ureteral stent once arterial control is established and the kidney is diverted via PCN
  • Ureteral ligation with permanent nephrostomy when the ureter is unsalvageable
  • Nephrectomy when the ipsilateral kidney is non-functioning
  • Long-term ureteral stenting — 12 of 14 endovascularly treated patients in the Fox series continued long-term stenting, perpetuating the risk factor; PCN is preferred when feasible[6]

Special Considerations​

UAF after ileal conduit urinary diversion​

Systematic review of 40 patients (Matsunaga):[11]

  • Fistula involved the common iliac artery in 90.7%
  • Combined endovascular + endoureteral and surgical approaches achieved similar outcomes — UAF-related mortality 7.1% vs. 13.3%; complication rates 28.6% vs. 26.7%
  • Stent-graft infection rate 14.3% — particular concern given bacterial colonization of ileal conduits
  • Close follow-up within the first year is critical
  • Postprocedural antibiotics "uncertain but likely prudent"

UAF with prior aortoiliac reconstruction​

Prosthetic graft–ureteral interface creates a unique risk. Open surgery is generally preferred in these cases because stent-graft infection in a contaminated, previously grafted field is poorly tolerated.[9][15]

Metallic ureteral stents​

Self-expanding metallic mesh stents and high-pressure balloon dilation during metallic stent placement are themselves associated with UAF formation. Place cautiously in patients with prior pelvic surgery or radiation.[16]

Long-term surveillance​

Patients require rigorous follow-up regardless of treatment modality, given high rates of recurrent bleeding, stent-graft complications, and lower-extremity morbidity. Recurrent hematuria, claudication, fever, or rising inflammatory markers should prompt immediate imaging.[9]

Outcomes Summary​

ParameterEndovascularOpen surgery
Technical success91–100%75–100%
Perioperative / 30-day mortality0–7.7%0–18%
Complication rate28–36%27–63%
Recurrent bleeding10–24%10–33%
Stent-graft infection0–14.3%n/a
Primary patency at 3 y81%—
Secondary patency at 3 y92%—
Freedom from stent-graft infection at 3 y100%—
Freedom from recurrent bleeding at 3 y76%—
UAF-related mortality7% (post-2000)19% (pre-2000)
5-year all-cause survival42% (all UAF patients)—

Overall non–cause-specific mortality in UAF patients is ~47%, with 10–20% directly fistula- or treatment-related — the remainder reflecting underlying advanced malignancy.[6]

Key Takeaways​

  • UAF is a vascular emergency — keep the ureteral stent in place for tamponade until angiographic control is achieved
  • Endovascular covered stent-graft is the preferred initial treatment, often combined with IIA exclusion to prevent retrograde flow
  • Open surgery (arterial ligation + extra-anatomic femoral-femoral or axillofemoral bypass) is reserved for contamination, infection, failed endovascular repair, or pre-existing vascular reconstruction
  • Always divert the urine (PCN ± long-term stent) and address the underlying obstruction to prevent recurrence
  • Stent-graft infection (~14%) is the dominant late complication, especially with ileal conduits; long-term surveillance is mandatory

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.

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