Embolization of Iliac Artery to Rectum Fistula and Occlusive Nephroureteral Stent Diversion of Ureterorectal Fistula

Purpose: Iliac artery to rectum fistula and ureterorectal fistula are rare conditions that are infrequently described in the literature. Previously reported treatments for iliac artery to distal gastrointestinal tract fistula include Hartmann’s procedure, endovascular stenting, and vascular bypass. Previously reported treatments for ureterorectal fistula include endoscopic injection of fibrin glue and surgical repair. Occlusive nephroureteral stents divert urine away from the ureter and impose a degree of obstruction in the ureter. We describe a case of an internal iliac artery to rectum fistula treated with embolization and a ureterorectal fistula treated with an occlusive percutaneous nephroureteral stent.

Materials and Methods: A 60-year-old male patient with a history of stage IV adenocarcinoma of the colon; post chemotherapy, radiation, and sigmoid colon resection with colostomy; and known right ureterorectal fistula presented with a 2-week history of rectal bleeding. He underwent rectal stump endoscopy with argon plasma coagulation but continued to have profound rectal bleeding. Interventional radiology was consulted, and the patient was treated with Gelfoam and coil embolization of a right internal iliac artery to rectum fistula. Later, the patient began passing a high volume of urine through his rectal stump because of a ureterorectal fistula. Interventional radiology was reconsulted for urinary diversion. Eight days after the embolization, a nephroureteral stent was modified with steam to be occlusive and placed by interventional radiology.

Results: Before embolization of the right internal iliac artery to the rectum fistula, the patient received 22 units of packed red blood cells. After embolization, the rectal stump bleeding resolved. During the 2 days before occlusive nephroureteral stent placement, the patient had a recorded total of 2073 mL of urine output from his rectum. After the procedure, there was no further rectal stump output. At 33 days’ follow-up, the patient’s occlusive nephroureteral stent continued to function well without further urine output from the rectal stump. The patient reported no bleeding from the rectal stump and improved quality of life.

Conclusions: For a patient with cancer who has multiple fistulae including an internal iliac artery to rectum fistula, arterial embolization can be effective. For a cancer patient with a ureterorectal fistula in whom a short-term diversion of urine is desired to improve quality of life, occlusive nephroureteral stent placement is a viable option.