Papers of the Week

Ureteroarterial fistula (UAF) is a rare and potentially devastating diagnosis most often associated with a combination of pelvic oncologic or vascular surgery, radiation, and chronic ureteral stents. Herein we discuss a patient with an ileal conduit urinary diversion and left nephroureteral (NU) catheter who presented with gross hematuria and hemodynamic instability. He underwent multiple negative radiologic investigations and his clinical course highlights the need for a high index of suspicion for UAF and multidisciplinary coordination with vascular surgery and interventional radiology. Our patient is a 64-year-old male with a history of bladder cancer and atrial fibrillation on rivaroxiban who underwent cystoprostatectomy with ileal conduit urinary diversion. His postoperative course was complicated by subsequent mid-distal stricture of his left ureter, which was managed with balloon dilatation and a chronic indwelling NU catheter. He underwent a routine catheter exchange ∼1 year postradical cystectomy and subsequently experienced intermittent gross hematuria. He presented 5 weeks later with profound hematuria and clots through his urostomy accompanied by flank pain, weakness, and tachycardia. Throughout his hospital course he underwent two CT angiograms and a formal provocative angiogram that were all negative. He was taken to the operating room (OR) for attempted antegrade ureteroscopy, which was aborted because of pulsatile bleeding observed upon withdrawal of his stent. In collaboration with vascular surgery, he was eventually taken for provocative angiogram and covered stent graft placement that resolved the hematuria. This case highlights the diagnostic and care coordination challenges in patients with UAF. A high suspicion should be maintained in patients with hematuria and indwelling stents with a history of pelvic surgery and/or radiation.