A 62-year-old female presented with a medical history of cervical cancer complicated by radiation cystitis, status post-cystectomy and ileal conduit, further complicated by ureteral strictures bilaterally. The patient, who had been managed with long-term bilateral upside-down percutaneous nephrostomy tubes (PCNs), presented with 3 days of crampy left lower back pain with radiation to the left lower abdomen, no modifying factors and decreased urine output. Patient stated that this pain felt similar to when the PCN was blocked. Her previous PCNU replacement was 1 month earlier.

She was admitted to the hospital due to oliguria and acute renal failure; her blood urea nitrogen (BUN)/creatinine (Cr) ratio was 46/6.1. Interventional radiology (IR) was consulted and a standard upside-down PCN exchange was planned. During removal of the right-sided PCN over a wire, massive hemorrhage and passage of a clot occurred through the urostomy site. What would be your next step? (“Remember, at a cardiac arrest the first procedure is to take your own pulse”–Samuel Shem, The House of God).

The patient became tachycardic and hypotensive, fluid boluses were administered and concomitantly the PCN was immediately replaced. This is the second case of this presentation we have observed. The previous case occurred during a routine stent exchange in a patient with a history of pelvic radiation and ureteral strictures.

At this point, an angiogram was performed using right femoral access via a 7Fr sheath. The right upside nephrostomy was then removed, resulting in hemorrhage from the ileal conduit ostomy site again (fig. 1). An over-the-wire angiogram demonstrated active extravasation from the right common iliac artery into the right ureter. The diagnosis was erosion of the chronic indwelling nephrostomy into the right common iliac artery. A VBX balloon expandable covered stent (Gore® Medical) was deployed at the right common iliac artery, and the final angiogram demonstrated no active extravasation into the ileal conduit (fig. 2). The patient was transferred to the medical intensive care unit (MICU) in stable condition.

Figure 1. Over-the-wire angiogram demonstrates significant extravasation (red arrow) from right common iliac artery (white arrow) into ileal conduit (pink arrow) on removal of right-sided PCNU (blue arrow). Left PCNU is still in place (black arrow).

Figure 2. Final angiogram shows stent in place (black arrow) with no extravasation into ileal conduit (red arrow).

Patients who undergo cystectomy require a urinary diversion, which is often via an ileal conduit.¹ As many as 15% of patients develop strictures at the ureteroenteric junction, resulting in obstruction to urinary outflow and hydronephrosis.² In these cases, the kidney is typically decompressed anterograde via percutaneous nephrostomy placement, which may then be replaced by a retrograde percutaneous nephroureteral catheter (PCNU).³ PCNUs are associated with complications, most commonly occlusion, which result in frequent exchanges.

The etiology for iliac arterial injury can be multifactorial and diagnosed as well as treated during angiography. Uretero-iliac arterial fistula is a unique presentation of iliac arterial injury, although it can be treated in a similar manner to other etiologies with exclusion of the fistula via covered stent deployment.⁴ Endovascular iliac artery stent graft deployment has a high efficacy and primary patency for treating iliac injury, although long-term data have not been recorded in the setting of uretero-iliac arterial fistulas given the limited sample size.⁵

Teaching Points

Long-term PCNU may result in uretero-iliac arterial fistula, which may not be evident until the PCNU is removed or exchanged. If hemorrhage occurs during PCNU replacement, immediately replace the tube to tamponade bleeding and consult interventional radiology for an emergency angiogram with possible covered stent placement or embolization to prevent life threatening hemorrhage.