Archivio Italiano di Urologia e Andrologia 2013; 85, 296 INTRODUCTION Rupture of an aneurysm of the retroperitoneal or pelvic vessels represents an extremely rare cause of macroscop- ic haematuria (1, 2). The diagnosis is difficult but should be considered whereas conditions as neoplasms, lithiasis or infections have been excluded and there is a history of retroperitoneal/pelvic surgical treatment. CASE REPORT In the present report, we describe the case of a 65 years- old-woman who underwent a diagnostic laparoscopy for a suspected ovarian cancer. The procedure consisted in a peritoneal washing, right oophorectomy and multiple biopsies of the right and left diaphragmatic dome of the peritoneum with an intraoperative diagnosis of peri- toneal carcinomatosis. The histological examination con- firmed the presence of an ovarian serous carcinoma. The patient underwent an operative laparoscopy with extrafascial radical isterectomy, left oophorectomy, pelvic peritonectomy and pelvic-lomboaortic lymphadenecto- my. During the procedure the right ureter was acciden- CASE REPORT Massive hematuria due to ruptured iatrogenic aortic pseudoaneurysm: A case report Valerio Vagnoni 1, Caterina Gaudiano 2, Giovanni Passaretti 1, Riccardo Schiavina 1, Eugenio Brunocilla 1, Cristian Vincenzo Pultrone 1, Marco Borghesi 1, Giuseppe Martorana 1 1 Department of Urology, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy; 2 Department of Radiology, Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy. We report an interesting case of massive haematuria secondary to a rupture of a pseudoa- neurysm of the abdominal aorta below the renal vessels. A 65-year-old woman present- ed at our institution with a painful massive haematuria and anaemia. Two months before, she undergone a pelvic surgery complicated by an accidental injury of the right ureter sutured with a end-to-end anastomosis. An abdominal computed tomography (CT) scan with intravenous contrast showed a right-sided hydronephrosis with clots in the lumen of the right pelvis with a massive retroperitoneal hematoma due to a rupture of a iatrogenic pseudoaneurysm of the abdominal aorta below the origin of the renal arteries. KEY WORDS: Haematuria; Aortic pseudoaneurysm; Pelvic surgery. Submitted 25 October 2012; Accepted 31 December 2012 No conflict of interest declared Summary tally injured; therefore a laparotomic surgery has been required and an end-to-end ureteral anastomosis with placement of a renovesical “JJ stent” was performed. The stent was removed after 45 days and after 65 days from surgery the patient presented at our institution with massive haematuria and severe anaemia (haemoglobin 7.6 g/dl, haematocrit 23%). Bladder irrigation was initi- ated and cystoscopy showed a little clot from the right ureteric orifice in the absence of urothelial bladder lesions: a right ureteral catheter was inserted, some clots were removed from the right pelvis and a right retro- grade pyelography showed the dehiscence of the ure- theral anastomosis with a mild passage of contrast medi- um in the left retroperitoneum; thereafter, a second reno- vesical “JJ stent” was inserted. An abdominal computed tomography (CT) scan was per- formed: we noted a right-sided hydronephrosis with clots in the lumen of the right pelvis and the presence of a massive hematoma between the abdominal aorta and the vena cava, ahead the ileo-psoas muscle in the left retroperitoneum (Figure 1); after the administration of Vagnoni_Stesura Seveso 24/06/13 11:07 Pagina 96 97Archivio Italiano di Urologia e Andrologia 2013; 85, 2 Hematuria after ruptured aortic pseudoaneurysm la due to the rupture of a iatrogenic pseudoaneurysm of the abdominal aorta was diagnosed and, after consulting the vascular surgeon, the patient underwent an urgent placement of aortic endoprothesis. Afterwards, the hematuria was controlled. A further CT exam showed the correct positioning of the prosthesis and the patient was discharged with ureteral stent. DISCUSSION We described an extremely rare cause of macroscopic hematuria due to the rupture of a iatrogenic pseudoa- neurysm of the abdominal aorta. The recent uretero- uretero-anastomosis due to the accidental injury of the ureter was the obligatory condition in order to have an aorto-ureteric fistula after the rupture of the aneurysm. The iatrogenic injury of the aortic wall during the lym- phadenectomy may explain the pseudoaneurysm. Surgical treatment procedures like vascular reconstruc- tive surgery or retroperitoneal/pelvic surgery for uro- gynecolocic or abdominal malignancies represent condi- tions with a potential risk for a hemorrhagic fistula from an artery into the urinary outflow tract; furthermore, previous radiation therapy or presence of aortic or iliac aneurysm may represent a potential risk conditions for the development of a fistula between an artery and the urinary tract; in the latter cases the pathophysiology is unclear but seems to be related to the inflammatory reac- tion around the aneurysm caused by surgery, radiation, malignancy, pulsatile trauma with the fixation and sub- sequent perforation of ureteral or bladder wall (1, 2). Also the endourological treatment such as holmium laser endoureterothomy or acucise ballon endopielotomy for ureteropelvic junction obstruction may represent a rare cause of iatrogenic arterio-urinary fistula (3). In the pres- ent case, hematuria represented the sole symptom. However the passage of the clots in the renal pelvis and ureter could have been the cause of the abdominal pain. In literature is anecdotally reported that, in the absence of the intravenous contrast (arterial phase), we noted the presence of a breach of the right wall of the abdominal aorta, 4 cm below the origin of the renal arteries, with a large loculated pseudoaneurysm (axial diameters 37 x 22 mm) (Figures 2-3) in the right retroperitoneum with a massive hematoma due to a recent rupture of the aneurysm. Hematuria caused by an aorto-ureteral fistu- Figure 1. Non-enhanced abdominal CT scan in the axial plane showing a right-sided hydronephrosis with clots in the lumen of the right pelvis. Figure 2. Contrast enhanced abdominal CT scan in arterial phase (MPR-reconstruction in oblique axial plane) showing the abdominal aortic pseudoaneurysm in the context of a massive retroperitoneal hematoma. Note the metallic clip utilized during pre-aortic lymphadenectomy and the right ureteral stent (red arrow). Figure 3. Contrast enhanced abdominal CT scan in arterial phase (MIP-reconstruction in oblique coronal plane) showing the pseudoaneurysm below the right renal artery in the context of a massive retroperitoneal hematoma. Vagnoni_Stesura Seveso 24/06/13 11:07 Pagina 97 Archivio Italiano di Urologia e Andrologia 2013; 85, 2 V. Vagnoni, C. Gaudiano, G. Passaretti, R. Schiavina, E. Brunocilla, C.V. Pultrone, M. Borghesi, G. Martorana 98 REFERENCES 1. Honma I, Takagi Y, Shigyo M, et al. Massive hematuria after cys- toscopy in a patient with an internal iliac artery aneurysm. Int J Urol. 2002; 9:407-409. 2. Bergqvist D, Parsson H, Sherif A. Arterio-Ureteral fistula - a sys- tematic review. Eur J Vasc Endovasc Surg. 2001; 22:191-196. 3. Preminger GM, Clayman RV, Nakada SY, et al. A Multicenter clinical trial investigating the use of a fluoroscopically controlled cutting balloon catheter for the management of ureteral and ureteropelvic junction obstruction. J Urol. 1997; 157:1625-1629. 4. Levi N, Sonksen JR, Iversen P, Helgstrand U. Rupture of an iliac artery pseudo-aneurysm into a ureter - Case Report. Eur J Vasc Endovasc Surg. 1999; 17:264-265. a correct diagnosis of the arterio-ureteral fistula, a nephro- ureterectomy has often been performed, in emergency and life-threatening cases (2, 4); however, it is clear that the goal of the treatment is to solve the vascular lesion. Open or endovascular procedures generally allow to stop the hematuria even if postoperative morbidity and mor- tality still remains high but less than thirty years ago. In conclusion, the present case report represents a rare cause of massive hematuria due to a double iatrogenic surgical injury of the aortic wall and the right ureter. After the initial rupture of the pseudoaneurysm (with subsequent spontaneous closing), a massive hemorrhage of the retroperitoneum and the dehiscence of a recent uretero-ureteral anastomosis caused a massive aorto- ureteral fistula that was promptly corrected by the place- ment of aortic endoprothesis. Correspondence Valerio Vagnoni, MD (Corresponding Author) vagno07@libero.it Giovanni Passaretti, MD giovannipassaretti@hotmail.it Riccardo Schiavina, MD rschiavina@yahoo.it Eugenio Brunocilla, MD Eugenio.brunocilla@unibo.it Cristian Vincenzo Pultrone, MD cristian28@libero.it Marco Borghesi, MD Mark.borghesi@gmail.com Giuseppe Martorana, MD Giuseppe.martorana@unibo.it Department of Urology, University of Bologna, S. Orsola-Malpighi Hospital, via P. Palagi 9 - 40138, Bologna, Italy Caterina Gaudiano, MD Department of Radiology, Bologna, S. Orsola-Malpighi Hospital, via P. Palagi 9 - 40138, Bologna, Italy Caterina.gaudiano@aosp.bo.it Vagnoni_Stesura Seveso 24/06/13 11:07 Pagina 98