A Rare Cause of Life-threatening Hematuria: Uretero-arterial Fistula; Hard to Identify, Fatal to Miss

A Rare Cause of Life-threatening Hematuria: Uretero-arterial Fistula; Hard to Identify, Fatal to Miss | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Rare Cause of Life-threatening Hematuria: Uretero-arterial Fistula; Hard to Identify, Fatal to Miss Ege Alper Sarıkaya, Volkan Şen, Aytaç Gülcü, Ozan Bozkurt, Ömer Demir, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5582347/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Uretero-arterial fistula is a disease that is considered very rare but can cause life-threatening hematuria. However, with the increase in clinical recognition, the increase in the number of cases in recent years is remarkable. Case Presentation: We present the case and management of life-threatening hematuria due to uretero-arterial fistula in a patient with the classic triad as well as recent literature regarding uretero-arterial fistula. Conclusion Uretero-arterial fistula is a rare and mortal disease in which diagnosis can be easily missed as the tests routinely used in the differential diagnosis of hematuria are not diagnostic for uretero-arterial fistula. History of pelvic malignancy, radiotherapy and ureteral stent in a patient with unexplained hematuria along with bright-red coloured ureteral bleeding should guide clinicians to search for uretero-arterial fistula. Embolization Hematuria Uretero-arterial Fistula Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Uretero-arterial fistula (UAF) is an extremely rare conditionpresents with hematuria and flank painand it can be fatal if overlooked. Diagnosis is often delayed or even missed. In most of the cases, the only symptom is hematuria, and if hemodynamic instability develops, mortality rate is as high as 23% and increases with the delay of the diagnosis ( 1 , 2 ). Risk factors for UAF arehistory of pelvic surgery, pelvic organ malignancies (gastrointestinal, genitourinary or gynaecological), pelvic radiotherapy, and a history of vascular or ureteral intervention such as stenting. It was shown that 85% of cases develop secondary to these risk factors ( 3 ). Almost all (90%) of primary UAF cases occur as a complication of aortoiliac aneurysm ( 1 ). Pelvic angiography, which is not a part of routine hematuria evaluation, has a better sensitivity (62%) compared to pyelography, CT angiography and urethroscystoscopy/ureterorenoscopy (51%, 48%, 28%; respectively)( 4 ). Endovascular embolization (vascular plugs or coil), stent placement or open surgery are the treatment options of UAF. We aimed to present a case of life-threatening hematuria in a patient with multiple risk factors for UAF. CASE REPORT A 64-year-old female patient had a history of colectomy, coloanal anastomosis and adjuvant pelvic radiotherapy (50,5 Gy, mesorectum and pelvic lymph nodes were included) due to rectosigmoid carcinoma 3 years prior to hematuria onset. 6 months after colectomy patient was evaluated for abdominal and left flank pain; CT revealed left hydronephrosis due to multiple abscesses in left abdominal cavity. Percutaneousabscesses drainage, laparotomy, re-resection of colonic anastomosis and colostomy was performed. Retrograde pyelography revealed a ureteral stenosis at middle segment of ureter and dilatation in proximal segments, left ureteral double j stent was inserted. Patient was followed up with periodic left ureteral stent replacements for over 2 years. Nearly 3 years after colectomy, patient presented to ER withpersistent gross hematuria. Haemoglobin level was6.2 g/dL, bilateral hydronephrosisdue to clots in bladder was detected in CT and blood creatinine was raised despite of left indwelling ureteral stent.Radiation cystitis, rectosigmoid CA invasion andcolovesical fistula were considered among the preliminary diagnoses.Bladder irrigation was performed and bilateral nephrostomy catheters was inserted to improve urine drainage.In non-contrast abdomen CT,masses compatible with hematoma were observed in the left renal pelvis.In cystoscopy no signs of active bleeding or mucosal abnormalities were observed in the bladder, no findings consistent with radiation cystitis, enterovesical fistula or invasion were detected. Blood clots were observed next to the ureteral stent protruding from the left orifice. Stent was removed and ureterorenoscopy was performed. However, due to bleeding, the ureteral wall could not be visualized properly and ureteral stent were reinserted. Hematuria did not recur after stent replacement and blood creatinine levels regressed.Hematuria of glomerular or haematological origin was excluded and no pathological findings were present in renal angiography.Within a month massive hematuria reoccurred and left ureteral stent spontaneously migrated from urethra due to clots. During ureteral stent replacement, massive bright-red bleeding (arterial in colour) was observed from left ureteral orifice after removal of ureteral stent and bleeding stopped immediately after placement of new ureteral stent. Revision of abdomen CT angiography revealed no signs of fistula but there was a pseudoaneurysm in internal iliac artery right next to left ureter (Fig. 1 ). Pelvic angiography confirmed the presence of pseudoaneurysm next to ureteral stent but there was no active contrast passage to ureter (Fig. 2 ).It was thought that compression of indwelling ureteral stent prevented the contrast passage to the ureter. Left internal iliac artery total embolization was performed with endovascular approach (Fig. 3 ).After embolization, patient's ureteral stent was removed and hematuria did not recur in three years of follow-up. DISCUSSION Our main finding that guided us to right diagnosis was provocation of massive, bright coloured hemorrhage from left ureteral orifice during stent replacement. We had already excluded renal arteriovenous malformation, and other renal vascular pathologies with CT angiography and renal angiography. Since ureter is not a common site of massive bleeding and unfortunately awareness of UAF is mandatory to perform a pelvic angiography, we could not make the right diagnosis initially. Unilateral arterial bleeding that provoked by stent removal and immediately stopped with re-insertion of the stent guided us to further look for ureteral etiologies of massive hematuria. UAF was first reported by Moschcowitz in 1908, and its incidence is extremely low. In 2009, Van den Bergh et alstated that there were only 139 published cases in literature and patient series consisted of small numbers such as 8–11 patients( 2 ). However, Turo reported that 23 new cases in the last 9 years, and 19 of these cases were diagnosed in the same centre( 5 ).In a review that has been published in 2022, 445 patients were reported( 4 ). It appears that the incidence isgradually increasing. Given the facts that awareness of UAF is crucial for diagnosis and one centre have reported 19 cases in only 9 years, true incidence is probably much higher due to overlooked cases. The success achieved in oncological treatments, the prolongation of the life expectancy of cancer patients, the increase in the use of radiotherapy, and the widespread use of ureteral stent, which was first inserted in 1978, contribute to the increase in the incidence of UAF. Pelvic angiography is the most superior diagnostic test for UAF, however it is not a part of routine haematuria assessment according to the current international guidelines( 6 , 7 ). Renal or abdominopelvic USG, CT angiography/urography and urethroscystoscopy/ureterorenoscopy are the initial tools for hematuria evaluation and none has higher sensitivity than %51. Even renal angiography cannot reveal UAF and unfortunately, pelvic angiography comes to mindonly when the diagnosis of UAF is suspected. Therefore, when risk factors such as chronic indwelling ureteral stent (%80), pelvic oncologic surgery history (%70) and history pelvic radiotherapy (%53) are present, pelvic angiography must be performed in case of life-threatening hematuria( 4 ). In addition, the presence of hematoma in the renal pelvis/ureter or evidence of unilateral (particularly arterial coloured) bleeding should lead clinicians to UAF.However, indwelling ureteral stent may blockade blood flow to ureter during angiography and provocation of haematuria during removal or replacement of ureteral stent is common ( 2 ). Therefore, a multidisciplinary approach -arteriography combined with ureteral manipulation (via balloon catheter)- was described by Vandersteen in 1997, and had been performed successfully in 20–25 cases up-to-date( 4 ).However, this method can cause massive haemorrhage and must be done with adequate preparation. Endovascular treatment and open surgery are treatment options for UAF. Endovascular techniques (coil or stent) are effective, rapid, less invasive and suitable for unstable patients( 8 ). Kahmprost et al. reported that total of 248 cases were treated with endovascular approach and 132 cases were treated with open repair worldwide. Mortality rates were 4% and 11% for endovascular approach and open repair respectively and AUF related mortality rate in general was 9%. CONCLUSION UAF is a rare disease that can be fatal if overlooked.Diagnosis can be easily missed as the tests in routine hematuria evaluation are incapable to diagnose UAF. Along with defined risk factors, presence of unilateral arterial coloured hematuria during cystoscopy or stent replacement should guide clinicians in diagnosis of UAF. Declarations Ethics approval and consent to participate The protocol for this research project has been approved by Ethics Committee of the institution and it conforms to the provisions of the Declaration of Helsinki. Consent for publication Informed consent was obtained from reported subject for participation and publication Availability of data and materials Data of the patient is available upon request. Competing interests The authors declare no conflict of interest. Funding This study was not funded by any organization. Authors' contributions Data collection were performed by Ege S., Volkan S. and Ozan B. The first draft of the case report was written by Ege S, endovascular treatment was performed by Aytaç G. and first version of manuscript was revised by Ömer D. and Adil E. All authors read and approved the final manuscript Clinical trial number: not applicable. References Bergqvist D, Pärsson H, Sherif A. Arterio-ureteral fistula - A systematic review. Eur J Vasc Endovasc Surg. 2001;22(3):191–6. van den Bergh RCN, Moll FL, de Vries JPPM, Lock TMTW. Arterioureteral Fistulas: Unusual Suspects-Systematic Review of 139 Cases. Urology [Internet]. 2009;74(2):251–5. Available from: http://dx.doi.org/10.1016/j.urology.2008.12.011 Subiela JD, Balla A, Bollo J, Dilme JF, Soto Carricas B, Targarona EM, et al. Endovascular Management of Ureteroarterial Fistula: Single Institution Experience and Systematic Literature Review. Vasc Endovascular Surg. 2018;52(4):275–86. Kamphorst K, Lock TMTW, Van Den Bergh RCN, Moll FL, De Vries JPPM, Lo RTH, et al. Arterio-Ureteral Fistula: Systematic Review of 445 Patients. J Urol. 2022;207(1):35–43. Turo R, Hadome E, Somov P, Hamid B, Gulur DM, Pettersson BA, et al. Uretero-Arterial Fistula - Not so Rare? Curr Urol. 2018;12(1):54–6. Gontero P, Comperat E, Dominguez Escrid J, Liedberg F, Mariappan P, Masson-Lecomte A, et al. EAU Guidelines on Non-muscle-invasive Bladder Cancer. In: 2023rd ed. AU Guidelines Office, Arnhem, The Netherlands. http://uroweb.org/guidelines/compilations-of-all-guidelines/.; 2023. Barocas DA, Boorjian SA, Alvarez RD et al: Microhematuria: AUA/SUFU guideline. J Urol 2020; 204: 778. Aslam MZ, Kheradmund F, Patel N, Cranston D. Uretero-Iliac artery fistula: A diagnostic and therapeutic challenge. Adv Urol. 2010;2010. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5582347","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":391432210,"identity":"a6db4f81-f574-43ac-9a30-1ae565b12437","order_by":0,"name":"Ege Alper 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CT-angiography: A internal iliac artery pseudoaneurysm next to ureteral stent\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5582347/v1/6e60610d41c8ebc3977d867c.png"},{"id":72287823,"identity":"9353d4fb-3d38-4bdc-8b45-4876d29d782c","added_by":"auto","created_at":"2024-12-24 17:11:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":222071,"visible":true,"origin":"","legend":"\u003cp\u003ePelvic angiography image representing close relation between pseudoaneurysm and ureteral stent\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5582347/v1/376ee7d3f72b1e5b9592c0c5.png"},{"id":72287822,"identity":"d7d9a7d8-1904-4f3c-957c-a208e48e1689","added_by":"auto","created_at":"2024-12-24 17:11:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":175619,"visible":true,"origin":"","legend":"\u003cp\u003ePelvic angiography image during coil embolization of internal iliac artery\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5582347/v1/7c5c6c990080134974d8736c.png"},{"id":99686931,"identity":"2ded9469-1ffb-422e-b9eb-1a739a981fab","added_by":"auto","created_at":"2026-01-07 09:40:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":844493,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5582347/v1/c1d16cb5-1f8f-4467-9d8b-8d389c7016e4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eA Rare Cause of Life-threatening Hematuria: Uretero-arterial Fistula; Hard to Identify, Fatal to Miss\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eUretero-arterial fistula (UAF) is an extremely rare conditionpresents with hematuria and flank painand it can be fatal if overlooked. Diagnosis is often delayed or even missed. In most of the cases, the only symptom is hematuria, and if hemodynamic instability develops, mortality rate is as high as 23% and increases with the delay of the diagnosis (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRisk factors for UAF arehistory of pelvic surgery, pelvic organ malignancies (gastrointestinal, genitourinary or gynaecological), pelvic radiotherapy, and a history of vascular or ureteral intervention such as stenting. It was shown that 85% of cases develop secondary to these risk factors (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Almost all (90%) of primary UAF cases occur as a complication of aortoiliac aneurysm (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePelvic angiography, which is not a part of routine hematuria evaluation, has a better sensitivity (62%) compared to pyelography, CT angiography and urethroscystoscopy/ureterorenoscopy (51%, 48%, 28%; respectively)(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Endovascular embolization (vascular plugs or coil), stent placement or open surgery are the treatment options of UAF.\u003c/p\u003e \u003cp\u003eWe aimed to present a case of life-threatening hematuria in a patient with multiple risk factors for UAF.\u003c/p\u003e"},{"header":"CASE REPORT","content":"\u003cp\u003eA 64-year-old female patient had a history of colectomy, coloanal anastomosis and adjuvant pelvic radiotherapy (50,5 Gy, mesorectum and pelvic lymph nodes were included) due to rectosigmoid carcinoma 3 years prior to hematuria onset. 6 months after colectomy patient was evaluated for abdominal and left flank pain; CT revealed left hydronephrosis due to multiple abscesses in left abdominal cavity. Percutaneousabscesses drainage, laparotomy, re-resection of colonic anastomosis and colostomy was performed. Retrograde pyelography revealed a ureteral stenosis at middle segment of ureter and dilatation in proximal segments, left ureteral double j stent was inserted. Patient was followed up with periodic left ureteral stent replacements for over 2 years. Nearly 3 years after colectomy, patient presented to ER withpersistent gross hematuria. Haemoglobin level was6.2 g/dL, bilateral hydronephrosisdue to clots in bladder was detected in CT and blood creatinine was raised despite of left indwelling ureteral stent.Radiation cystitis, rectosigmoid CA invasion andcolovesical fistula were considered among the preliminary diagnoses.Bladder irrigation was performed and bilateral nephrostomy catheters was inserted to improve urine drainage.In non-contrast abdomen CT,masses compatible with hematoma were observed in the left renal pelvis.In cystoscopy no signs of active bleeding or mucosal abnormalities were observed in the bladder, no findings consistent with radiation cystitis, enterovesical fistula or invasion were detected. Blood clots were observed next to the ureteral stent protruding from the left orifice. Stent was removed and ureterorenoscopy was performed. However, due to bleeding, the ureteral wall could not be visualized properly and ureteral stent were reinserted. Hematuria did not recur after stent replacement and blood creatinine levels regressed.Hematuria of glomerular or haematological origin was excluded and no pathological findings were present in renal angiography.Within a month massive hematuria reoccurred and left ureteral stent spontaneously migrated from urethra due to clots. During ureteral stent replacement, massive bright-red bleeding (arterial in colour) was observed from left ureteral orifice after removal of ureteral stent and bleeding stopped immediately after placement of new ureteral stent. Revision of abdomen CT angiography revealed no signs of fistula but there was a pseudoaneurysm in internal iliac artery right next to left ureter (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Pelvic angiography confirmed the presence of pseudoaneurysm next to ureteral stent but there was no active contrast passage to ureter (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).It was thought that compression of indwelling ureteral stent prevented the contrast passage to the ureter. Left internal iliac artery total embolization was performed with endovascular approach (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).After embolization, patient's ureteral stent was removed and hematuria did not recur in three years of follow-up.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur main finding that guided us to right diagnosis was provocation of massive, bright coloured hemorrhage from left ureteral orifice during stent replacement. We had already excluded renal arteriovenous malformation, and other renal vascular pathologies with CT angiography and renal angiography. Since ureter is not a common site of massive bleeding and unfortunately awareness of UAF is mandatory to perform a pelvic angiography, we could not make the right diagnosis initially. Unilateral arterial bleeding that provoked by stent removal and immediately stopped with re-insertion of the stent guided us to further look for ureteral etiologies of massive hematuria.\u003c/p\u003e \u003cp\u003eUAF was first reported by Moschcowitz in 1908, and its incidence is extremely low. In 2009, Van den Bergh et alstated that there were only 139 published cases in literature and patient series consisted of small numbers such as 8\u0026ndash;11 patients(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, Turo reported that 23 new cases in the last 9 years, and 19 of these cases were diagnosed in the same centre(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).In a review that has been published in 2022, 445 patients were reported(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). It appears that the incidence isgradually increasing. Given the facts that awareness of UAF is crucial for diagnosis and one centre have reported 19 cases in only 9 years, true incidence is probably much higher due to overlooked cases. The success achieved in oncological treatments, the prolongation of the life expectancy of cancer patients, the increase in the use of radiotherapy, and the widespread use of ureteral stent, which was first inserted in 1978, contribute to the increase in the incidence of UAF.\u003c/p\u003e \u003cp\u003ePelvic angiography is the most superior diagnostic test for UAF, however it is not a part of routine haematuria assessment according to the current international guidelines(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Renal or abdominopelvic USG, CT angiography/urography and urethroscystoscopy/ureterorenoscopy are the initial tools for hematuria evaluation and none has higher sensitivity than %51. Even renal angiography cannot reveal UAF and unfortunately, pelvic angiography comes to mindonly when the diagnosis of UAF is suspected. Therefore, when risk factors such as chronic indwelling ureteral stent (%80), pelvic oncologic surgery history (%70) and history pelvic radiotherapy (%53) are present, pelvic angiography must be performed in case of life-threatening hematuria(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In addition, the presence of hematoma in the renal pelvis/ureter or evidence of unilateral (particularly arterial coloured) bleeding should lead clinicians to UAF.However, indwelling ureteral stent may blockade blood flow to ureter during angiography and provocation of haematuria during removal or replacement of ureteral stent is common (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Therefore, a multidisciplinary approach -arteriography combined with ureteral manipulation (via balloon catheter)- was described by Vandersteen in 1997, and had been performed successfully in 20\u0026ndash;25 cases up-to-date(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).However, this method can cause massive haemorrhage and must be done with adequate preparation.\u003c/p\u003e \u003cp\u003eEndovascular treatment and open surgery are treatment options for UAF. Endovascular techniques (coil or stent) are effective, rapid, less invasive and suitable for unstable patients(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Kahmprost et al. reported that total of 248 cases were treated with endovascular approach and 132 cases were treated with open repair worldwide. Mortality rates were 4% and 11% for endovascular approach and open repair respectively and AUF related mortality rate in general was 9%.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eUAF is a rare disease that can be fatal if overlooked.Diagnosis can be easily missed as the tests in routine hematuria evaluation are incapable to diagnose UAF. Along with defined risk factors, presence of unilateral arterial coloured hematuria during cystoscopy or stent replacement should guide clinicians in diagnosis of UAF.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe protocol for this research project has been approved by Ethics Committee of the institution and it conforms to the provisions of the Declaration of Helsinki.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInformed consent was obtained from reported subject for participation and publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData of the patient is available upon request.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare no conflict of interest.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThis study was not funded by any organization.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData collection were performed by Ege S., Volkan S. and Ozan B. The first draft of the case report was written by Ege S, endovascular treatment was performed by Ayta\u0026ccedil; G. and first version of manuscript was revised by \u0026Ouml;mer D. and Adil E. All authors read and approved the final manuscript\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e\u0026nbsp;not applicable.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBergqvist D, P\u0026auml;rsson H, Sherif A. Arterio-ureteral fistula - A systematic review. Eur J Vasc Endovasc Surg. 2001;22(3):191\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003evan den Bergh RCN, Moll FL, de Vries JPPM, Lock TMTW. Arterioureteral Fistulas: Unusual Suspects-Systematic Review of 139 Cases. Urology [Internet]. 2009;74(2):251\u0026ndash;5. Available from: http://dx.doi.org/10.1016/j.urology.2008.12.011\u003c/li\u003e\n\u003cli\u003eSubiela JD, Balla A, Bollo J, Dilme JF, Soto Carricas B, Targarona EM, et al. Endovascular Management of Ureteroarterial Fistula: Single Institution Experience and Systematic Literature Review. Vasc Endovascular Surg. 2018;52(4):275\u0026ndash;86. \u003c/li\u003e\n\u003cli\u003eKamphorst K, Lock TMTW, Van Den Bergh RCN, Moll FL, De Vries JPPM, Lo RTH, et al. Arterio-Ureteral Fistula: Systematic Review of 445 Patients. J Urol. 2022;207(1):35\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eTuro R, Hadome E, Somov P, Hamid B, Gulur DM, Pettersson BA, et al. Uretero-Arterial Fistula - Not so Rare? Curr Urol. 2018;12(1):54\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eGontero P, Comperat E, Dominguez Escrid J, Liedberg F, Mariappan P, Masson-Lecomte A, et al. EAU Guidelines on Non-muscle-invasive Bladder Cancer. In: 2023rd ed. AU Guidelines Office, Arnhem, The Netherlands. http://uroweb.org/guidelines/compilations-of-all-guidelines/.; 2023. \u003c/li\u003e\n\u003cli\u003eBarocas DA, Boorjian SA, Alvarez RD et al: Microhematuria: AUA/SUFU guideline. J Urol 2020; 204: 778. \u003c/li\u003e\n\u003cli\u003eAslam MZ, Kheradmund F, Patel N, Cranston D. Uretero-Iliac artery fistula: A diagnostic and therapeutic challenge. Adv Urol. 2010;2010. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Embolization, Hematuria, Uretero-arterial Fistula","lastPublishedDoi":"10.21203/rs.3.rs-5582347/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5582347/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eUretero-arterial fistula is a disease that is considered very rare but can cause life-threatening hematuria. However, with the increase in clinical recognition, the increase in the number of cases in recent years is remarkable.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eWe present the case and management of life-threatening hematuria due to uretero-arterial fistula in a patient with the classic triad as well as recent literature regarding uretero-arterial fistula.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eUretero-arterial fistula is a rare and mortal disease in which diagnosis can be easily missed as the tests routinely used in the differential diagnosis of hematuria are not diagnostic for uretero-arterial fistula. History of pelvic malignancy, radiotherapy and ureteral stent in a patient with unexplained hematuria along with bright-red coloured ureteral bleeding should guide clinicians to search for uretero-arterial fistula.\u003c/p\u003e","manuscriptTitle":"A Rare Cause of Life-threatening Hematuria: Uretero-arterial Fistula; Hard to Identify, Fatal to Miss","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-24 17:10:56","doi":"10.21203/rs.3.rs-5582347/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"31807f40-78e4-4bee-b9af-d11855a044ca","owner":[],"postedDate":"December 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-07T09:40:08+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-24 17:10:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5582347","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5582347","identity":"rs-5582347","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}