Severe hematuria after transurethral electrocoagulation in a patient with an arteriovesical fistula
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Arteriovesical fistulas are extremely rare. Only eleven cases were previously reported in the literature. They can occur iatrogenically, traumatically or spontaneously.
We report an unusual case of a 62-year-old woman with arteriovesical fistula that developed fatal hematuria after transurethral electrocoagulation. Computed tomography (CT) and selective angiography revealed a pseudoaneurysm of the right superior vesical artery with arteriovesical fistula formation, which was managed by transarterial embolization.
Contrast enhanced CT or CT angiography should be performed when a pulsatile hemorrhage is revealed during cystoscopy. Therapeutic vesical arterial embolization should be considered as a safe and effective procedure for arteriovesical fistulas. Transurethral electrocoagulation may cause severe hematuria for pulsatile bladder bleeding in patients with pelvic vascular malformation.
KeywordsHematuria Arteriovesical fistula Vesical pseudoaneurysm
Computed tomography angiography.
Arteriovesical fistulas are extremely rare. To our best knowledge, only eleven cases were previously reported in the literature. They can occur iatrogenically, traumatically or spontaneously . We report an unusual case of a 62-year-old female with arteriovesical fistula formed spontaneously that developed fatal hematuria after transurethral electrocoagulation.
Hematuria due to arteriovesical fistula is an extremely rare clinical entity and we identified only a few cases in the literature. Arteriovesical fistulas can occur iatrogenic injury [2, 3, 4, 5, 6], secondary to trauma [1, 7, 8, 9] and spontaneously [10, 11]. Rous et al reported the first case of a ruptured posttraumatic pseudoaneurysm of the external iliac artery 1 week after a gunshot wound to the lateral aspect of the bladder . Arteriovesical fistulas are mostly associated with previous pelvic surgeries [2, 3, 4], radiotherapy  and urologic interventions  in patients with vascular disease. There are only two cases where an arteriovesical fistula formed spontaneously due to a ruptured iliac artery aneurysm with hematuria as initial presentation [10, 11].
A pseudoaneurysm, also known as a false aneurysm, is a leakage of arterial blood from an artery into the surrounding tissue with a persistent communication between the originating artery and the resultant adjacent cavity. The development of pseudoaneurysm of a vesical artery is extremely rare, and Pontin et al reported one similar case due to radiation therapy . In this unique case presented, arteriovesical fistula was not recognized at first, and developed fatal hematuria after transurethral electrocoagulation for vesical bleeding. Further CT and selective angiography revealed a pseudoaneurysm of the right superior vesical artery with arteriovesical fistula formation. We postulated that a pulsatile bladder hemorrhage suggested a vascular malformation, maybe owing to rupture of a submucosal branch of vesical artery, and transurethral electrocoagulation causes damage to an arterial wall, which was responsible for the formation of the vesical arterial pseudoaneurysm. Rupture of a pseudoaneurysm is potentially a fatal event, particularly pseudoaneurysms that occur in large visceral arteries .
Establishing a precise diagnosis of superior vesical arterial pseudoaneurysm is often difficult since it used to be of rare occurrence. Still, it is important to be aware that vascular abnormality, such as aneurysm, fistula or malformation, could be a possible diagnosis for hematuria, especially when the bladder hemorrhage refractory to bladder irrigation, intra-vesical instillation or endo-urological intervention. Or characteristic pulsative bleeding was presented in cystoscopy inspection. Contrast enhanced CT or CTA would be a useful tool to identify the bleeding source.
There is no agreement in the literature on a specific course of treatment for arteriovesical fistula. Management options for the patients include embolization, open repair and aneurysm resection . Selective and superselective embolization is the preferred treatment for patients with vascular pseudoaneurysms . It is a safe and effective method, especially for those who are poor surgical candidates. Percutaneous vesical arterial embolization was first described in 1980 by Kobayashi et al . In the present case, right internal iliac artery embolization successfully achieved an immediate hemorrhage control and no major post-embolization complications were noted, which indicated that vesical arterial embolization would be well-tolerated.
In summary, we report a case of arteriovesical fistula formed spontaneously that developed fatal hematuria after transurethral electrocoagulation. Awareness of this as a possible cause of hematuria can assist in immediate diagnosis and appropriate treatment. Contrast enhanced CT or CT angiography should be performed when a pulsatile hemorrhage is revealed during cystoscopy. Therapeutic vesical arterial embolization should be considered as a safe and effective procedure for bleeding control. Transurethral electrocoagulation may cause severe hematuria for pulsatile bladder bleeding in patients with pelvic vascular malformation.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
The work was supported by grants from National Key Clinical Specialty Construction Project of China, Health sector scientific research special project (Grant No.201002010) Zhejiang Provincial Natural Science Foundation of China (LY12H05006).
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