|Year : 2019 | Volume
| Issue : 3 | Page : 198-200
“Internal iliac artery pseudoaneurysm communicating with orthotopic neobladder:” A rare complication of radical cystectomy
Uma Kant Dutt1, Sunil Kumar1, Kaliyaperumal Muruganandham1, Lalgudi Narayanan Dorairajan1, Ajith Ananthakrishna Pillai2
1 Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Web Publication||29-Aug-2019|
Dr. Lalgudi Narayanan Dorairajan
Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
Source of Support: None, Conflict of Interest: None
Iliac artery–orthotopic neobladder fistulas are very rare following radical cystectomy. Only two cases are reported in literature. We report a case of a 58-year-old male who had undergone radical cystectomy with orthotopic neobladder surgery about 2 months earlier at our institute and now presented with a history of hematuria and pain abdomen. He was found to have a pseudoaneurysm of the right internal iliac artery communicating with the orthotopic neobladder. Angio-embolization of the right internal iliac artery resolved the problem.
Keywords: Bladder cancer, fistula, neobladder, pseudoaneurysm
|How to cite this article:|
Dutt UK, Kumar S, Muruganandham K, Dorairajan LN, Pillai AA. “Internal iliac artery pseudoaneurysm communicating with orthotopic neobladder:” A rare complication of radical cystectomy. Indian J Vasc Endovasc Surg 2019;6:198-200
|How to cite this URL:|
Dutt UK, Kumar S, Muruganandham K, Dorairajan LN, Pillai AA. “Internal iliac artery pseudoaneurysm communicating with orthotopic neobladder:” A rare complication of radical cystectomy. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Nov 18];6:198-200. Available from: http://www.indjvascsurg.org/text.asp?2019/6/3/198/265774
| Introduction|| |
Arterio-urinary tract fistulas are well documented in urologic literature mainly in the context of arterio-ureteral fistula (AUF) although these are very few. AUFs occur in patients with risk factors such as prior pelvic surgery, pelvic radiotherapy, chronic ureteral stents, and other vascular diseases. These are likely to become more common because of more extended lymph node dissections and multimodality treatments being used more extensively for the management of muscle-invasive bladder cancer. A fistula between an artery and an orthotopic neobladder is a very rare complication following radical cystectomy. Only two cases are reported in literature. The diagnosis requires a multidisciplinary approach, and if delayed, it can be rapidly fatal. Hence, it requires prompt intervention either in the form of endovascular repair or open repair. We report a case of a pseudoaneurysm of right internal iliac artery communicating with the orthotopic neobladder and discuss its management.
| Case Report|| |
A 58-year-old male presented with the complaints of hematuria associated with the passage of blood clots and abdominal pain. The patient had been operated for carcinoma of the urinary bladder 2 months earlier, by laparoscopic radical cystectomy that was converted to open, and at that time, the orthotopic neobladder was performed by Abol-Enein and Ghoneim technique. There was no history of fever, vomiting, or flank pain. On physical examination, the abdomen was soft, and there was no palpable fullness of the neobladder. On laboratory investigation, his hemoglobin was 9 g/dL and serum creatinine was 1.2 mg/dL. Rest of the laboratory investigations were normal. On ultrasonographic (USG) examination, there was evidence of a multiseptate collection of size 5.5 cm × 5 cm noted in the right iliac fossa. Doppler USG suggested the possibility of a pseudoaneurysm of the right internal iliac artery communicating with the neobladder with the presence of bladder clots. These findings were confirmed with computed tomography (CT) angiography [Figure 1]. The patient was treated with angioembolization of the right internal iliac artery by using metallic coils and after that, clot evacuation of the neobladder was done [Figure 2]a and [Figure 2]b. After 2 weeks postembolization, repeat USG showed no residual collection in the right iliac fossa. Further, at 1-year of follow-up with repeat USG, no evidence of any collection was noticed in the previous region.
|Figure 1: Computed tomography angiography demonstrates pseudoaneurysm of the right internal iliac artery; vertical arrow shows the external iliac artery and a horizontal arrow shows the internal iliac artery|
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|Figure 2: Angiographic demonstration of preangioembolization (a) and postangioembolization (b) views of the right internal iliac artery|
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| Discussion|| |
Fistulas between the vascular and urinary systems are not very common. An AUF is a rare but life-threatening condition. A review of 139 patients by van den Bergh et al. suggested that previous pelvic cancer or vascular surgery is a risk factor for fistula formation. According to their study, angiography most often confirms the diagnosis of a fistula and endovascular technique has a favorable outcome. In their study, 13% died of an AUF-related cause. In another systemic review of eighty cases of AUF by Bergqvist, it was suggested that primary fistulas were mainly seen in combination with aortoiliac aneurysmal disease. Secondary fistulas were seen after pelvic cancer surgery, often associated with radiation, fibrosis, and ureteral stenting or after vascular surgery with synthetic grafting. Nearly 85% were secondary fistulas, and according to this review, 29 patients (36%) had various types of urinary diversion. Sasaki et al. reported arterial-ileal conduit urinary diversion fistula, where the patient presented with conduit bleed. On contrast CT, the possibility of a pseudoaneurysm of the external iliac artery with fistulation into the ileal conduit was suspected. This fistula was repaired by open technique, though the patient did not survive for more than 1 month and died of sepsis.
The multiple causes of arterial pseudoaneurysm that lead to fistula formation include trauma to the vessel, tumor, infection causing inflammation and vasculitis, chemotherapy, and radiotherapy. Other factors that predispose to pseudoaneurysm formation include atherosclerosis, infarction, iatrogenic damage from surgery, and angiography. Regarding arterial–neobladder fistula, limited data are available in literature. Only two cases have been reported. In the first case that was reported in 2006, Gallucci et al. described a case of a 62-year-old male who, following radical cystectomy and orthotopic neobladder, presented with an episode of hematuria and clot urinary retention. He was diagnosed to have an arterial–neobladder fistula by angiography. This case was treated successfully by an endovascular approach, and no relapse resulted. In the second case report, Kuntz and Inman described the case of a 63-year-old male who presented, after radical cystectomy and a studer ileal neobladder, with an episode of gross hematuria and was diagnosed to have an external iliac artery–neobladder fistula that was managed by open repair.
However, the patient in our case did not have any predisposing factors such as chemotherapy or radiotherapy before or after the operation that might have led to pseudoaneurysm formation. The usage of large-sized ligating clips, unnoticed inadvertent thermal injury by the use of diathermy near the internal iliac artery area during pelvic lymphadenectomy, or inadequately controlled bleeding from vessels deep into the pelvis that are occasionally difficult to control may have led to inflammation and fibrosis that could probably have predisposed to pseudoaneurysm development in this case. There is very little data on pseudoaneurysms of the pelvic vessels, following major pelvic surgeries for cancer.
Radical cystectomy with orthotopic neobladder patients can rarely present with arterial–orthotopic neobladder fistula. Most of the times in urology, fistulas occur between an artery and a ureter, but can also occur rarely as a direct connection of an iliac artery to an orthotopic urinary diversion as happened in this case. Episodes of gross hematuria in these patients need to be evaluated appropriately. First, one has to rule out the common causes, but one should also be vigilant to keep surprises in mind as in this case. We present this case along with a review because it will add to the literature of this rare complication of radical cystectomy and a rare cause of hematuria postoperatively. It is always important to coordinate with other subspecialties to achieve the correct diagnosis and best treatment for these types of patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]