Endovascular and open surgical options in the treatment of uretero-arterial fistulas

Abstract

Objective

To report and analyze the indications and results of endovascular and open surgical treatment for uretero-arterial fistula.

Methods

We retrospectively reviewed the clinical data of 25 consecutive patients with uretero-arterial fistulas admitted to our hospital from 2011 to 2020. Endpoints were technical success, freedom from open conversion, stent-graft/graft-related complications, and 30-day and one-year mortality.

Results

The study included 25 patients (68% female, n = 17) with 27 uretero-arterial fistulas by bilateral pathologies in two patients. The mean age was 61 ± 11 years (range 35–80). The most common predisposing factors for uretero-arterial fistula were history of pelvic operations for malignancy in 21 patients (84%), radiotherapy in 21 patients (84%), previous pelvic vascular bypass in 2 patients (8%), and iliac aneurysms in 2 patients (8%). On average, the period between the primary pelvic surgery and the diagnosis of uretero-arterial fistulas was 46 months (range 7–255). Twenty patients (80%) underwent endovascular treatment of the uretero-arterial fistulas. The primary technical success of the endovascular treatment was 95%, and the freedom from open conversion was 40% at six months and 30% at one year. Thirteen uretero-arterial fistulas (48%) underwent delayed open conversion due to recurrent bleeding in six cases (46%), stent-graft infection in three cases (23%), or pelvic abscess in four cases (31%). Primary open surgery was applied for five (20%) patients. After a mean follow-up of 34 months, early (<30 days) mortality was 8% (2/25), one-year mortality 16% (4/25), and overall mortality was 24% (6/25).

Conclusions

Uretero-arterial fistula is a late complication of prior pelvic surgery, radiation, and indwelling ureteral stents. Endovascular treatment remains an effective and less invasive modality in controlling the related life-threatening arterial bleeding of the uretero-arterial fistula. Open surgical treatment is still required for patients with local sepsis, previously failed endovascular treatment or infected stent-grafts.

Keywords

Uretero-arterial fistula hematuria minimal invasive ureteral stent stent-graft

Introduction

Uretero-arterial Fistulas (UAFs) are uncommon but can lead to lethal hemorrhage. UAFs are most commonly found in women with a history of pelvic malignant disease, pelvic irradiation, or abdominal-pelvic surgery.^1,2

Conventional treatment entails open surgical repair of the UAF with the exclusion of the iliac artery, direct arterial repair, extra-anatomic bypass, or in-situ reconstruction. Currently, endovascular treatment has been proposed as an alternative strategy for surgical treatment.^3–5 Although less invasive, this technique presents limitations in treating UAF, mainly the high risk of graft contamination and the development of pelvic abscesses.

However, only a few studies focused on the rates of stent-graft infection, recurrent bleeding, and the need for reoperation after endovascular treatment.^3,6 This is due to the rarity of these conditions and the lack of large surveys in the current literature. This study aims to analyze the most common causes of UAFs and to evaluate the mid-term results of endovascular and open surgical treatment for uretero-arterial fistulas.

Material and methods

The Ethics Committee of the Charité – Universitätsmedizin Berlin approved this study (Number: EA4/018/19). The need for individual consent was waived. We identified 25 consecutive patients treated for UAFs by open surgical repair or endovascular techniques between January 2011 and June 2020.

We collected data on patient demographics (gender, age), cardiovascular risk factors, clinical presentation, imaging, and operative details from the patients’ records. Moreover, we included any kind of previous pelvic surgery, underlying iliac pathology, and malignancies.

Procedural data included the time of endovascular and open surgical procedures, elective or emergent intervention, number of stents, Stent type, length, diameter, and the need for redo-operation. Factors involved in choosing the stent-graft included tortuosity, calcification, and caliber of the iliac arteries and the availability of stent-grafts. The available stent-grafts included Fluency™ stent-grafts (Bard Peripheral Vascular, INC, Arizona, USA), Advanta V12™ (Getinge, Gothenburg, Sweden), and Gore® Viabahn® endoprosthesis (W. L. Gore & Associates, Inc., Flagstaff, Arizona, USA). During the study period, endovascular treatment was the preferred strategy. However, patients with pelvic abscess or occlusion of the iliac arteries needed primary open surgeries.

Regarding ureteral stents, we used two types, including double-J (DJ) ureteral stents and Allium® ureteral stent (URS) (Allium™ Medical, Caesarea, Israel). Whereas DJ stents are widely used in endourologic procedures, Allium® ureteral stent (URS), which is a self-expanding stent and made of nitinol and coated with a co-polymer, is intended mainly for malignant or benign ureteral strictures.⁷

Outcomes evaluated were mortality (intra-operative, 30-day, one- year, and overall mortality), morbidity, complications requiring re-intervention, and freedom from open conversion.

Statistical methods

We analyzed the data on an individual level and used descriptive methods only. Furthermore, continuous variables were displayed as mean ± SD or median and range, and categorical variables as frequency and percentages. Survival curves were computed using Kaplan-Meier. The statistical analysis was performed using SPSS Statistics 25 (IBM, Armonk, NY, USA).

Results

Patients demographics and clinical presentation

In total, the study enrolled 17 females (68%) and eight males (32%) with the mean age of 61 ± 11 years (range 35–80). All patients had hematuria at presentation, which was massive with hemorrhagic shock in 10 patients (40%). Three patients (12%) had to be resuscitated due to massive blood loss upon the diagnosis of UAF. Demographics, clinical presentation, and diagnostics are depicted in Table 1.

Table 1.

Demographics, clinical presentation, and diagnostics (n = 25).

Demographics and risk factors
Age, y	61 ± 11
Female	17 (68)
Hypertension	12 (48)
Coronary artery disease	7 (28)
Hyperlipidemia	1 (4)
Renal insufficiency	14 (56)
Diabetes mellitus	6 (24)
COPD	4 (16)
Obesity (BMI > 25 kg/m²)	4 (16)
Smoking	4 (16)
Clinical presentation
Hematuria	25 (100)
Gross hematuria	20 (80)
Hemorrhagic shock	10 (40)
Cardiopulmonary resuscitation	3 (12)
Fever >38°	12 (48)
Pelvic abscess at presentation	8 (32)
Chronic infection of urinary tract	19 (76)
Flank pain	10 (40)
Diagnostics
Cystoscopy	17 (68)
Computed tomography	23 (92)
Active bleeding in CT	7 (28)
Obliteration of the fatty layer	23 (100)
Angiography	21 (84)
Active bleeding	4 (16)

All patients underwent diagnostic investigations, including cystoscopy in 17 patients (68%), CTA in 23 (92%), and angiography in 21 (84%) to identify the source and location of the UAFs. The location of the fistula was confirmed by the presence of active bleeding in CT or angiography in 11 patients (44%) or suspected based on the patients’ history and nonspecific findings in CT in 14 patients (56%).

Bacteriologic specimens were collected for culture studies from urine, blood, and intraabdominal tissues. All patients showed colonization of the pathogens in the urinary tract due to the use of chronic indwelling ureteral stents and ureteral strictures.

Intraabdominal specimens were obtained from 22 patients (positive in 19 and negative in 3). Blood cultures were obtained from 23 patients (positive in 17 and negative in 6). The most common microorganisms in urine and tissues were Enterococcus spp. in 16 patients and Escherichia coli in 15. In blood cultures, Staphylococcus spp. were identified in nine patients and E. coli in eight patients. There was no relationship between urine culture and blood cultures in most cases, and the samples showed different pathogens. Predisposing risk factors associated with UAF were present in all patients (see Table 2). The most common risk factor was a history of malignancy and radiotherapy in 21 patients (84%). Two patients (8%) had undergone a previous pelvic vascular bypass for PAD, and two (8%) had iliac aneurysms. On average, the period between the primary pelvic surgery and the diagnosis of UAFs was 46 months (range 7–255).

Table 2.

Demographics, underlying diagnosis, predisposing factors, and ureteral pathologies.

No.	Gender/Age (Y)	Etiology	Previous initial operations	PPLND (Y/N)	Radiation(Y/N)	Previous ureteral pathology/treatment
1	F/54	EA	TLH	Y	Y	RUS, DJ
2	F/75	EA, BC	VH	Y	Y	RUS, DJ
3	F/66	EA, BC	VH	Y	Y	PUS, DJ
4	F/69	CC	TAH	Y	Y	PUS, DJ
5	M/67	PC	RP	Y	Y	IC, MJ
6	F/39	CC	VH	Y	Y	RUS, DJ, IC
7	F/52	CC	TAH	Y	Y	PUS, DJ
8	M/65	AC	APR	Y	Y	PUS, DJ
9	F/72	PAD	IFB	N	N
10	M/60	UC	ORN	Y	Y	RUS, DJ
11	M/60	IA	-	N	N	PUS, DJ
12	F/56	PAD	ABF	N	N	PUS, DJ
13	F/57	CC	TAH	Y	Y	PUS, DJ
14	M/67	CRC	LAR	Y	Y	IC, MJ
15	F/80	CC	TAH	Y	Y	IC, MJ
16	F/46	CC	TLH	Y	Y	IC, MJ
17	F/51	CC	TLH	Y	Y	PUS, Allium stent
18	M/60	CRC	APR	Y	Y	PUS, DJ
19	M/69	PC	RP	Y	Y	PUS, Allium stent
20	F/48	CC, BC	TLH	Y	Y	PUS, DJ
21	F/79	IA	ABF	N	N	PUS, DJ
22	F/70	UC	RC	Y	Y	IC, DJ
23	F/35	CC	TAH	Y	Y	PUS, DJ
24	F/55	CC	TAH	Y	Y	PUS, DJ
25	M/69	UC	RC, EVAR	Y	Y	IC, DJ

ABF: aortobifemoral bypass; APR: abdominoperineal resection; BC: breast cancer; CC: cervix carcinoma; CRC: colorectal cancer; DJ: double J-stent; EA: endometrial adenocarcinoma; F: female; IA: iliac aneurysm; IC: ileal conduit; IFB: iliofemoral bypass; LAR: low anterior resection; m: male; MJ: Mono J stent; ORN: open radical nephrectomy; PAD: peripheral arterial disease; PC: prostate cancer; PCN: percutaneous nephrostomy; PPLND: pelvic and paraaortic lymph node dissection; PUS: postoperative ureteral stricture; RC: radical cystectomy; RP: radical prostatectomy; RUS: radiogenic ureteral stricture; TAH: total abdominal hysterectomy; TLH: total laparoscopic hysterectomy; UC: urothelial carcinoma; VH: vaginal hysterectomy.

Treatment

We illustrated our treatment algorithm in Figure 1. The detailed treatments of the patients are described and summarized in Table 3.

Figure 1.

Treatment algorithm for dealing with uretero-arterial fistulas (UAF).

Table 3.

Location of the UAFs, surgical technique applied, outcome, and follow-up.

Nr	Side/Location	Treatment	Stent-graft/number of stents/embolization of IIA	Open surgery (art, material)	Ureteral treatment	Death (Y/N)	F/U(m)
1	R/EIA	EV	Fluency 10 × 80 /1/Y	–	DJ	N	69
2	R/CIA	dOC	Fluency 12 × 40 /1/N	ISR (IAPP, GSF)	UU	N	14
3	R/CIA	dOC	Fluency 12 × 60 /1/Y	EAR (AXF, PTFE)	PCN	N	64
4	L/IIA	dOC	Fluency 10 × 60 /1/Y	ISR (IFB, GSV)	UL, PCN	Y	14
5	L/CIA	EV	Fluency 12 × 60 /1/N	–	PCN	N	99
6	R/CIA	pOS	–	EAR (FFB, PTFE), ISR (IFB, GSV)	Allium stent	N	62
7	R/EIA	EV	Advanta V12 7 × 60 /1/N	–	IC	N	57
8	R/IIA	dOC	Fluency 12 × 60 /1/Y	ISR (IIAL)	PCN	N	34
9	R/CIA	pOS	–	ISR (IFB, GSV)	UU, PCN, DJ	N	59
10	L/CIA	dOC	Advanta V12 8 × 56 /1/N	ISR (IAPP, BPP)	UL, PCN	Y	1
11	L/CIA	pOS	–	ISR (IFB, GSV)	UL, PCN	N	76
12	R/CIA	pOS	–	ISR (IFB, GSV)	DJ	N	66
13	R/EIA	dOC	Fluency 10 × 40 /1/Y	EAR (FFB, Silver)	UL, PCN	Y	19
14	R/EIA	dOC	Advanta V12 7 × 22 /1 /N	EAR (AXF, PTFE)	URI	N	18
15	R/IIA	dOC	Advanta V12 8 × 59 /1/Y	ISR (IIAL)	IC	Y	1
16	L/EIA	pOS	–	ISR (IFB, Silver),	URI	N	19
17	R/IIA	EV	Advanta V12 7× /1/N	–	Allium stent	N	26
18	R/CIA	EV	Fluency 9 × 60 /1/N	–	DJ	N	93
19	B/CIA	dOC	Fluency 13.5 × 80 /1/N	ISR (IAPP, BPP)	Allium stent	N	20
20	L/EIA	dOC	Fluency 8 × 60 /1/N	EAR (FFB, PTFE)	UL, PCN	N	16
21	R/IIA	EV	Fluency 10 × 60 /1/N	–	Allium stent	Y	5
22	L/EIA	EV	Fluency 10 × 40, 7 × 30 /2/Y	–	URI	N	13
23	R/EIA	EV	Viabahn 6 × 38 /2/N	–	IC	N	10
24	B/EIA	dOC	Viabahn 6 × 38 /2/N	ISR (IAPP, GSV), EAR (FFB, PTFE)	IC	N	13
25	R/CIA	dOC	Medtronic 16 × 124 /1/Y	ISR (IAPP, BPP)	PCN	Y	1

AXF: axillofemoral bypass; BPP: bovine pericardial patch; B: bilateral; CIA: common iliac artery; DJ: double J-stent; dOC: delayed open conversion; EAR: extra-anatomic reconstruction; EIA: external iliac artery; EV: endovascular; FFB: femorofemoral bypass (crossover); F/U: follow-up; GSV: great saphenous vein; IAPP: iliac artery patch plasty; IC: ileal conduit; IFB: ileofemoral bypass; IIA: internal iliac artery; IIAL: internal iliac artery ligation; ISR: in-situ reconstruction; L: left; MJ: Mono J stent; PCN: percutaneous nephrostomy; pOS: primary open surgery; R: right; Silver: silver-coated polyester protheses; URI: ureteral reimplantation; UL: ureteral ligation; UU: ureteroureterostomy; UAF: uretero-arterial fistula.

Endovascular treatment

Primarily, 20 patients (80%), including 12 emergencies (60%) and 8 electives (40%), were treated by endovascular methods in the hybrid operating room. A transfemoral percutaneous approach with 6 F sheath was used in all patients to implant stent-grafts in the iliac arteries (Figure 2). Of those, two patients (10%) underwent iliac stent-graft placement on both sides for bilateral UAFs. We used covered stents with polytetrafluoroethylene (PTFE) in all cases. The stent-grafts were self-expandable (Fluency®, Viabahn®, Endurant II®) in 15 cases (75%) or balloon-expandable Advanta V12® covered stent in 5 cases (25%). The size, number, and location of the stent-grafts are detailed in Table 3.

Figure 2.

A 57-year-old woman with a history of cervical cancer and kissing stents for aortoiliac stenosis. (a, b, arrows). Contrast-enhanced CT shows a pseudoaneurysm between the ureter and the external iliac artery (EIA). (c) Placement of stent-graft in the iliac arteries. The internal iliac artery had to be covered to achieve a sufficient landing zone.

The internal iliac artery was excluded in all patients, either by stent-graft coverage alone in 12 patients (60%) or with coil embolization in 8 patients (40%).

Open surgery

A total of 18 UAFs in 17 patients underwent open surgery, including primary open surgery (pOS) in 5 UAFs (28%) and delayed open conversion (dOC) in 13 (72%). Ten (77%) of the patients with dOC had early conversion at the same admission, and 3 (23%) late conversion after discharge from the hospital.

The decision for primary open surgery (n = 5) was based on the presence of occlusion of the femoral arteries in two patients, local sepsis requiring surgical drainage in two patients, and untreated iliac aneurysm in one patient.

The causes for conversion to open surgery were infection of the stent-graft in three patients (23%), presence of local sepsis or abscess in four patients (31%), and recurrence of the UAF in six patients (46%). However, some of the patients who were treated primarily with stent-graft to control the life-threatening hemorrhage showed signs of infection and pelvic sepsis at admission. In these patients, endovascular treatment was considered as a bridge to open surgery.

Regardless of the timing, primary open surgery and delayed open conversion have the same techniques and approaches, with the exception that it is imperative to remove the stent-graft before reconstructing the iliac artery in cases of delayed open conversion.

The open surgical procedures included in-situ reconstructions (ISRs) of the iliac artery in 12 cases (67%), and extra-anatomic reconstructions (EARs) in six cases (33%). The UAFs were approached through a lower quadrant retroperitoneal incision in 16 patients (94%). A midline incision was required in one case with bilateral UAFs (6%).

ISRs (n = 12) of the iliac arteries included: surgical ligation of the internal iliac artery (IIA) and direct repair of the fistula in two patients (17%), venous patch (GSV) in two patients (17%), bovine pericardial patch in three patients (25%), iliofemoral bypass using an autologous reversed greater saphenous vein (GSV) graft in four patients (33%) (Figure 3), and silver-coated polyester prosthesis in one patient (8%). The last patient developed an infection of the silver graft on the 35th postoperative day and needed a surgical explanation of the infected graft and reconstruction with axillofemoral.

Figure 3.

A 69-year-old woman with a history of cervical cancer. (a, b, arrows). Contrast-enhanced CT shows a close anatomic relationship between the ureteral stent and the arterial stent-graft. (c, arrows) Retroperitoneal exposure shows a complete erosion of the arterial and ureteral walls. (d) In-situ surgical repair with iliofemoral venous bypass and percutaneous ureterostomy.

EARs (n = 6) included axillofemoral bypass in two patients (33%) and femorofemoral crossover bypass in four patients (67%). No patient developed stenosis or occlusion after a femoral crossover or axillofemoral bypass. However, one patient had a revision of the femoral crossover anastomosis with partial replacement of the PTFE graft with a vein because of an inguinal abscess.

Two patients (2/25, 8%) had bilateral UAFs. One of them underwent removing the infected stent-grafts on both sides, and patch angioplasty of the right external iliac arterial defect with the great saphenous vein and femoral crossover reconstruction with ligation of the left iliac artery. The other patient with UAFs on both sides received a bilateral endovascular stent-graft placement. Eighty days later, the patient needed a redo-operation on the right side and vascular repair with a bovine pericardial patch.

Ureter reconstruction

Twenty-four patients (96%) had a history of chronic indwelling ureteral stents that were present prior to treatment for the UAFs. These stents were exchanged every three months on average. Of those patients, 18/24 (75%) had a history of radiogenic (RUS) or postoperative (PUS) ureteral strictures, and 6/24 (25%) had an ileal conduit following cystectomy. Management of the ureteral defects after diagnosis of UAFs included: exchange of the DJ in three patients (12%), allium stent in four patients (16%), ureteral reimplantation in the ileal conduit in three (12%), ureteroureterostomy in two (8%), ileal conduit in four (16%), and percutaneous nephrostomy in 10 patients (40%). In four cases (16%), the ureter had to be ligated.

Outcomes

Of 20 patients treated with stent-grafts, 12 patients (60%) underwent a revision of the fistula with open surgery. The average time between the placement of stent-graft and redo-operation was 26 days (range 1–486). The freedom from open conversion was 40% (8/20) at six months and 30% (6/20) at one year (Figure 4). After a mean follow-up of 34 months, two patients (8%) died of causes related to UAF, and four (16%) of non–UAF-related causes. In-hospital mortality was 8% (2/25), one-year mortality 16% (4/25), and overall mortality during the follow-up was 24% (6/25) (Figure 5). The causes of deaths were a progression of underlying cancer (n = 2), hemorrhagic shock (n = 2), epilepsy (n = 1), and heart failure (n = 1).

Figure 4.

Freedom from open conversion in 20 patients treated with endovascular stent-grafts for uretero-arterial fistulas (UAFs).

Figure 5.

Kaplan–Meier patient survival estimates in 25 patients treated for uretero-arterial fistula (UAFs).

One of the patients who died during the hospital stay had massive hematuria with a fistula between the ileal conduit and the right IIA. The patient underwent an emergency embolization of the IIA and stent-graft of the CIA. Later, the patient required an open conversion with ligation of the IIA due to recurrent bleeding. The patient died on the next day due to recurrent bleeding and hemorrhagic shock.

Another patient initially treated with stent-graft for UAF, developed a recurrent fistula fourteen months later. The patient underwent open conversion and ISR (iliofemoral bypass) with a vein. She died on the 17th postoperative day with hemorrhagic shock due to an erosion of the vein.

Regarding the complications of the stent-graft, there was one case of buttock claudication after stent-graft and embolization of the IIA with a recurrence of cervical cancer. The patient underwent a new vascular reconstruction with an ileofemoral bypass using silver-coated prosthesis three months later. During the follow-up, the patient developed critical limb ischemia and needed transfemoral amputation. However, he died in the fifth postoperative months.

Discussion

UAF is a rare cause of hematuria. With a period of about 10 years and total of 25 patients, this study represents the largest one about UAFs in the English literature. Most of UAFs are reported as isolated cases or small series of patients. Until 2019, about 150 cases of UAFs are described in total.^8–16

Several mechanisms may account for the formation of UAFs. Inflammation and chronic degenerative processes caused by ischemia and radiation damage may lead to erosion of the ureteral wall into the adjacent artery.^1,17 Another mechanism is the mechanical friction of the pulsatile artery in direct contact with the ureter, as we see in UAFs associated with iliac aneurysms.^18–20 Chronic indwelling ureteral stents in patients with a history of pelvic malignancy can also precipitate the formation of UAFs.^18,21,22

Clinical features of our cohort show no difference to those in current literature. UAF predominantly affects women (68%) with an average time of 3.8 years between the initial operative pelvic procedure and the formation of UAF, ranging from 1 to 21 years.^1,3

The diagnostic of UAF remains challenging. In the literature and our cohort, there was no conclusively specific and sensitive method for the determination of UAF.^2,10,23 Contrast-enhanced computed tomography (CT), angiography, and cystoscopy are usually the ﬁrst line tests. Negative findings do not exclude the diagnosis of a UAF if there is no other detectable source of urinary bleeding.^18,24 In addition, a preoperative CT angiography is useful to determine the location of UAF and to identify periarterial fluid, pelvic abscess, and the status of pelvic perfusion.

On the other hand, angiography offers an immediate treatment possibility in patients with massive hematuria. In patients with intermittent bleeding, it might be challenging to identify the specific location of the fistula. Therefore, we recommend removing the ureteral stent during cystoscopy in the hybrid angio-suite and then manipulating the suspected location of UAF carefully. This maneuver can induce the bleeding and help to identify the fistula (provocative mechanical testing). Other studies reported about the administration of thrombolytics or high-pressure ureteropielography as a provocative maneuver.²⁵ In the cases of massive bleeding after these maneuvers, we recommend using an Allium® ureteral stent, which can usually stop the bleeding.

The ideal treatment of UAFs remains a controversial question. Some studies prefer the endovascular treatment of the fistula, which is a less-invasive method performed percutaneously under local anesthesia in most patients.^26–28 Other studies report on recurrent complications related to this treatment, like infection of the stent-graft with the need to convert to open surgery.^6,29–31 However, all of these studies did not determine the rate of stent-graft infection and recurrent bleeding. In our study, we used endovascular treatment in 80% of our patients. Sixty percent of these patients needed a conversion to open surgery due to the development of complications. In our opinion, treatment with stent-graft has an essential role in stopping the massive bleeding of UAFs in instable patients with a hostile abdomen. The durability of this treatment depends on the accompanying factors like comorbidities, presence of local infection or enteric contamination, and the status of pelvic and peripheral perfusion. Therefore, stent-graft may represent a bridge to open surgery in cases of apparent sepsis or abscess accompanying the critical bleeding. If the patients show no signs of sepsis, we give prophylactic antibiotics and then wait and see. Another idea, like using an antibiotic-soaked endograft, might be controversial for infected aorta but may be a good idea to use for UAFs; however, the feasibility of this method necessitates further investigations. On the other hand, the patients treated primarily with open surgery or delayed open conversion showed a better tendency to heal from the pelvic infection. However, most of them needed a percutaneous nephrostomy or an ileal conduit urinary diversion.

Regarding the options of open surgery, extra-anatomic reconstruction was the conventional and standard treatment for UAF for many years.^3,18 However, recent studies prefer the in situ reconstructions with autologous veins.³² In our study, we found that in situ reconstructions, using materials resentence to infection, represent a reliable option. We prefer the great saphenous vein or deep femoral vein to replace the iliac artery.

All our patients were treated with intravenous broad-spectrum antibiotics depending on the microorganisms. Most of the patients had long-term postoperative antibiotics due to the use of ureteral stents and recurrent urinary tract infections. An antibiotic treatment protocol was not in place. All patients treated with stent-graft had to take clopidogrel for the first six weeks, followed by aspirin indefinitely.

Limitations

This study is a retrospective study and thus has certain limitations. We could not compare the results of endovascular treatment to open surgery because most of the patients underwent both methods. Some patients who underwent stent-graft for UAF to stop the emergent bleeding had local sepsis or abscess at presentation, representing an indication for open surgery.

Conclusions

Endovascular treatment is recommended as initial treatment for UAFs to control the life-threatening hematuria. However, most patients develop early or late local complications like stent-graft infection, recurrent bleeding, or pelvic abscess and require a delayed open surgical procedure.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Safwan Omran

Jan Paul Bernhard Frese

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