Uretero-vascular fistula is an uncommon pathology. So, we aimed to report a rare case of iatrogenic uretero-iliac artery fistula post vascular surgery that was repaired by appendiceal interposition ureteroplasty and iliac artery bypass graft.

A 9-year-old girl, presented with total hematuria and clot retention with right flank pain. She had past history of repair of right common iliac artery aneurysm using a synthetic graft, which was complicated by right ureteral injury and right resection-ureteral reanastomosis was then performed. Few months later, she underwent balloon dilation at the site of the arterial graft. Following the arterial dilation, she developed hematuria and clot retention. On examination, her vital signs were within the normal limits. Her hemoglobin level was 9 g/dL. Renal and bladder ultrasound (RBUS) showed right grade III hydronephrosis, with a big hematoma occupying the right pelvicalyceal system as well as the urinary bladder. Computed tomography angiography (CTA) demonstrated right external iliac artery aneurysm measuring 1.7 x 2.6 cm, inseparable from the right iliac ureter, suggesting the presence of right uretero-iliac artery fistula with right pelvicalyceal and bladder hematomas (Figure 1). Therefore, surgical exploration was then performed.

Surgical exploration showed large fistula associated with severe inflammatory reaction. The decision was made to bypass the fistula at both the ureteral and vascular levels. A stented ureteral replacement was conducted using the appendix as a conduit. A right common iliac to external iliac artery bypass graft was also performed using the right superficial femoral vein (Figure 2). Postoperatively, the patient showed resolution of hematuria and viable right lower limb by clinical examination. RBUS and duplex ultrasound also showed resolution of hydronephrosis and intact vascularity of right lower limb, respectively.

The uretero-iliac artery fistula was bypassed at both the ureteral and vascular levels by creating a stented appendiceal interposition ureteroplasty and an iliac artery bypass graft. Hematuria then resolved and the right lower limb remained viable by both clinical and radiological evaluation.

Iatrogenic uretero-iliac artery fistula is an uncommon complication that needs high index of suspicion to diagnose and innovative surgical techniques to treat.