==inizio objective==

The aim of the present study was to report and analyze the management of a series of patients with ureteral-iliac artery fistula (UAF) treated in author’s hospitals.

==fine objective==

==inizio methodsresults==

We conducted a retrospective analysis of prospectively collected data about three patients of two different high volume public hospitals (San Filippo Neri Hospital of Rome and Cardarelli Hospital of Naples) with UAF. We analyzed patients’ characteristics, presenting symptoms, and diagnostic work out. Also, we reviewed treatment and postoperative outcomes.

==fine methodsresults==

==inizio results==

Our series included 1 men and 2 woman treated in the last two years. First patient was a 83 y.o. male underwent ureteral stenting and emicolectomy with adjuvant abdominal radiotherapy for colic neoplasia. Second patient was a 64 y.o. female underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy followed by pelvic radiatherapy for carcinoma of the cervix. Third patient was a 52 y.o. female underwent radical cistectomy and bilateral ureterocutaneostomy for local advanced bladder cancer followed by pelvic radiotherapy. They all had inaugural and persistent macroscopic haematuria. Initially, a clear evidence of a fistula was not possible – neither through CT scan nor through selective angiography. Definitive diagnosis was obtained only by a provacative maneuver that means mobilizing the ureteral cateter and performing retrograde pielography during ureteroscopy. All patients were succesfully treated with endovascular iliac stenting plus nefrostomy tube.

==fine results==

==inizio discussions==

Etiology of UAF includes a variety of medical conditions including previous vascular surgery, pelvic radiation therapy or pelvic surgery, previous urinary diversion, and ureteral stenting [1]. Clinical symptoms can range from refractory microscopic haematuria to severe gross haematuria that can lead to serious anemia. The exact mechanism of the devolopment of UAF is still uncertain, but it seems that the previous conditions (surgery or radiation therapy) can affect the integrity of ureteral vasa vasorum. This results in a weakening of arterial walls with disruption of adventitia and media layers. This condition can lead to ureteral necrosis and formation of a fistula [3]. Mortality rate is very high: up to 64% [1] because the diagnosis is difficult. In approximately one third of the patients with UAF angiography may not reveal abnormal findings [4]. Provocative pielography involving manipulation of ureteral stent during ureteroscopy can show active and detectable bleeding of the fistula [fig.1]. Open surgery has represented the first line treatment [5-6] but nowadays endovascular techniques have proven to be effective and minimally invasive in patients already higly debilitated.

==fine discussions==

==inizio conclusion==

UAF has to be considered a rare but potentially life-threatening condition [2] that requires a high index of suspicion for prompt diagnosis in patients with heamaturia. Our series highlight the need of a multidisciplinary approach (urologist, radiologist, and vascular surgeons) for a succesfull managment of this challenging condition.

==fine conclusion==

==inizio reference==

1. S. P. Quillin, M. D. darcy, and D. Picus, “Angiographic evaluation and therapy of ureteroarterial fistulas, “American Journal of Roentgenology, vol. 162, no. 4, pp. 873-878, 1994.
2. S.J. Batter, F. J. McGovern, and R.P. Cambria, “Ureteroarterial fistula: case report and review of the literature,” Urology, vol. 48, no. 3, pp. 481-489, 1996.
3. G.F. Abercrombie and W. F. Hendry, “Ureteric obstruction due to peri-aneurysmal fibrosis”. BJOU, vol 43, no.2, pp 170-173, 1971.
4. E. Di Grazia, T. La Malfa, G. Gasso, “ureteral iliac artery fistula in idiopathic retroperitoneal fibrosis: a casa report”. Archivio Italiano di Urologia e Andrologia, 2020.
5. Y. Matsui, K. Fujikawa, H. Oka, S. Fukuzawa, and H. Takeuchi, “Ureteroarterial fistula in a patient with a single functioning kidney”, International Journal of urology, vol 8, no 3, pp 128-129, 2001.
6. N. Muraoka, T. Sakai, H. Kimura et al. “Endovascular treatment for an iliac artery-ureteral fistula with a covered stent”. Journal of Vascular and Interventional Radiology, vol. 17, no. 10, pp 1681-1685, 2006.

==fine reference==

==inizio objective==

The ureteral strictures and defects represent one of the most serious reconstructive challenges for urologists, especially in case of very long lesions of proximal ureter and in case of involvement of middle ureter. When these lesions cannot be treated with end-to-end anastomosis, they might require more advanced surgical techniques like bowel replacement, trans-uretero-uretero-stomy or auto transplantation of the kidney. These procedures need high technical competence and are associated with high rates of complications and long-term morbidity [1,2,3,4].
The aim of the study is to describe a new technique of complex ureteral reconstruction using a free peritoneal graft

==fine objective==

==inizio methodsresults==

Between 2006 and 2021 we treated 11 patients with long complex ureteral strictures involving the middle ureter in 9 cases and the proximal ureter in 2 cases. Stricture length ranged from 3 to 12 cm (mean 7 cm). Three cases were secondary to retroperitoneal fibrosis after vascular surgery in 2 cases and to Ormond disease in 1 case; 4 cases followed an extensive resection for large intra-ureteral masses, 3 cases were secondary to repeated endoscopic procedures for urinary stones and 1 case followed repeated pyeloplasty. After a longitudinal ureteral incision, a free peritoneal flap was harvested from nearby healthy peritoneum and fixed as an onlay-patch with running suture to the remaining ureteral plate after placement of a ureteral catheter. The ureter was finally wrapped with omentum

==fine methodsresults==

==inizio results==

Follow-up has ranged from 12 to 122 months (mean 61.6 months). Seven patients were free from recurrence after 12, 18, 60, 78, 98, 99 and 122 months (mean 69.5 months), without dilatation of the upper urinary tract and normal renal function. Four patients had a recurrence: in 1 patient the recurrence was detected after 60 months without symptoms and with mild hydronephrosis with no need for surgery. In 1 patient with Ormond disease, the recurrence occurred 6 months after the procedure without symptoms with involvement of the distal part of the 10 cm of treated ureter: a resection of the stenotic segment with psoas-hitch was performed. In the 2 other patients an obstruction below the reconstructed segment with hydronephrosis occurred 3 and 6 months after the procedure without impairment of renal function. No further surgery was performed in these patients.

==fine results==

==inizio discussions==

The limitation of this study is the small sample series, due to the high selective indications.

==fine discussions==

==inizio conclusion==

This technique allows the preservation of any remaining vascular supply of the ureter and can be a feasible and useful alternative to nephrectomy, ileal ureter, uretero-uretero-stomy and auto-transplantation in highly selected cases.

==fine conclusion==

==inizio reference==

1. Schoeneich G, Winter P, Albers P et al. Management of complete ureteral replacement. Experiences and review of the literature. Scand J Urol Nephrol 1997; 31 (4): 383-388
2. Bazeed MA, El-Rakhawy M, Ashamallah A et al. Ileal replacement of the bilharzial ureter: is worthwhile? J Urol 1983; 130 (2): 245-248
3. Benson MC, Ring KS, Olsson CA. Ureteral reconstruction and by pass: experience with ileal interposition, the Boari flap-psoas hitch and renal autotransplantation. J Urol 1990; 143: 20-23
4. Bonfig R, Gerharz EW, Riedmiller H. Ileal ureteric replacement in complex reconstruction of the urinary tract. BJU Int 2004; 93: 575-580.

==fine reference==