Vol. 115, February
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1976 by The Williams & Wilkins Co.
A CASE REPORT: SALPINGOURETERAL FISTULA GERALD T. KEEGAN*
W. REDD TURNER, JR.
AND
From the Department of Urology, Medical University of South Carolina, Charleston, South Carolina
ABSTRACT
A case of an acquired salpingoureteral fistula occurring in a 63 year-old woman with recurrent urinary tract infection and recurrent urinary lithiasis is presented. The literature is replete with references to acquired ureterovaginal fistulas, occasional ureterouterine 1 and ureteroperitoneal fistulas,2- 5 and unusual salpingoenteric 6 • 7 and salpingovaginal fistulas. 8 However, an extensive review of the English and foreign literature including a computerized search fails to reveal a previously reported case of an acquired salpingoureteral fistula. Herein we describe a woman with recurrent urinary calculi in whom a salpingoureteral fistula developed. Diagnosis was made by an excretory urogram (IVP) and confirmed by retrograde pyelography and abdominal exploration.
branched stl'lghorn calculus in the left kidney, possible left ureteral stone, bilateral ureteropyelocaliectasis and bilateral pyelonephritis. There was a peculiar density in the left lower quadrant that looked as if it might communicate with the ureter and was believed probably to be a fallopian tube (fig. 1). Cystoscopy demonstrated diffuse inflammation throughout the bladder. There was a stone in the bladder that was removed. A left retrograde pyeloureterogram revealed that the ureter did indeed communicate with the fallopian tube and there was a stone in the ureter distal to the fistula (fig. 2). Because of the persistence of fever to 102F and the rebound tenderness within the abdomen, an exploration was performed through the previous Gibson incision. A stone was found in the distal left ureter. There was a distinct pinpoint fistula between the ureter
CASE REPORT
Mrs. G. W., a 63-year-old woman, had a history of a right pyelolithotomy and a left distal ureterolithotomy 20 years before hospitalization. She was referred from another hospital where she had been confined for 3 days with complaints or persistent left flank and abdominal pain associated with frequency and dysuria. History and review of systems were not additionally revealing except for complaints of recurrent cystitis, occasional stone passage and an appendectomy in 1932. There was no history of urinary incontinence or pelvic inflammatory disease. A urine culture at the referring hospital revealed Escherichia coli more than 100,000 and the patient had been started on ampicillin. Because of persistent nausea, vomiting and physical findings suggestive of a bowel obstruction the patient was admitted to a general surgery service. Admission examination revealed a temperature of 102F, rales at both lung bases and diffuse abdominal tenderness with maximal tenderness in the left lower quadrant and rebound tenderness throughout the abdomen. The bowel sounds were hypoactive. Pelvic examination revealed tenderness in the left lower quadrant. Hemoglobin was 13.1, hematocrit 38.7, white blood count 8,800 with 66 polymorphonuclear leukocytes, 13 lymphocytes, 14 bands, 2 eosinophils and 5 monocytes. Urinalysis revealed 10 to 12 white cells with an occasional red cell per high power field. Amylase was normal but increased to as high as 800 during the next several days and then returned to normal following operation. Total bilirubin was 1.8, alkaline phosphatase 49, serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase normal, blood urea nitrogen (BUN) 62, creatinine 1.3, sodium 134, potassium 3.2, carbon dioxide 28 and chlorides 93. Posteroanterior and lateral films of the chest revealed a possible effusion at the left pleural base. A film of the kidneys, ureters and bladder (KUB) revealed bowel distension with partial obstructions suspected. The patient was treated with nasogastric suction as well as intravenous fluid and BUN returned toward normal. A barium swallow was performed and the barium passed through to the distal colon in about 36 hours. Urological consultation was obtained. An IVP revealed bilateral renal stones with a small Accepted for publication July 3, 1975. * Requests for reprints: 136 Alfred St., Biddeford, Maine 04005.
FIG. 1. A, KUB for IVP shows barium in intestine. B, 10-minute IVP shows salpingoureteral fistula in left lower quadrant.
FIG. 2. A, KUB for retrograde pyelogram shows stone in left distal ureter as well as bilateral renal stones. B, left ureteropyelogram shows salpingoureteral fistula. Barium in lower intestine may be seen in part A on KUB and there was no connection between fallopian tube and intestine.
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and the fallopian tube and this communicated with a uroma present in the left lower quadrant. A silastic stent was left indwelling in the ureter. The drains were placed down into the ureterotomy. The stent was removed endoscopically 11 days postoperatively and the drains were advanced. Convalescence was uneventful. The excised tube and ovary showed only acute and chronic inflammation. Culture of the uroma revealed no micro-organisms. DISCUSSION
There have been no previously reported cases of acquired salpingoureteral fistulas in the literature. We theorized that the potential fistula developed 20 years ago, at the time of the left distal and was made manifest the obstrnction of the left distal ureter stones. The elevated amylase levels may be explained the severe obstructed the tail of the pancreas. These levels 6
REFERENCES
1. Jequier, A. M. and Piper, J. V.: Uretero-uterine fistula after lower segment caesarian section. J. Obst. Gynaec. Brit. Commonw., 80: 276, 1973. 2. Runner, G. L. and Everett, R. S.: Ureteroperitoneal fistula with urinary ascites and chronic peritonitis. J.A.M.A., 95: 327, 1930. 3. Runner, G. L. and Everett, H. S.: Ureteroperitoneal fistula with urinary ascites. A second case. J. Urol., 28: 333, 1932. 4. Everett, H. S.: Ureteroperitoneal fistula with urinary ascites. J. Urol., 78: 585, 1957. 5. Bourdeau, G. V., ,Jindal, S. C., Gillies, R. R. and Berry, J. V.: Urinary ascites secondary to ureteroperitoneal fistula. Urology, 4: 209, 1974. 6. Rokatgi, M. and Mukherjee, A. K.: Tubointestinal fistula. J. Obst. Gynaec. Brit. Commonw., 80: 379, 1973. 7. Terzi, J. and Bordino, S.: Unusual hysterosalpingographic finding: salpingocolic fistula. G. Batteriol. Virol. Immunol., 64: 92, 1971. 8. Thompson, G. J. and Counseller, V. S.: Salpingovaginal fistula: report of a case. J. Urol., 65: 853, 1951.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1976 by The Williams & Wilkins Co.
A CASE REPORT: SALPINGOURETERAL FISTULA GERALD T. KEEGAN*
W. REDD TURNER, JR.
AND
From the Department of Urology, Medical University of South Carolina, Charleston, South Carolina
ABSTRACT
A case of an acquired salpingoureteral fistula occurring in a 63 year-old woman with recurrent urinary tract infection and recurrent urinary lithiasis is presented. The literature is replete with references to acquired ureterovaginal fistulas, occasional ureterouterine 1 and ureteroperitoneal fistulas,2- 5 and unusual salpingoenteric 6 • 7 and salpingovaginal fistulas. 8 However, an extensive review of the English and foreign literature including a computerized search fails to reveal a previously reported case of an acquired salpingoureteral fistula. Herein we describe a woman with recurrent urinary calculi in whom a salpingoureteral fistula developed. Diagnosis was made by an excretory urogram (IVP) and confirmed by retrograde pyelography and abdominal exploration.
branched stl'lghorn calculus in the left kidney, possible left ureteral stone, bilateral ureteropyelocaliectasis and bilateral pyelonephritis. There was a peculiar density in the left lower quadrant that looked as if it might communicate with the ureter and was believed probably to be a fallopian tube (fig. 1). Cystoscopy demonstrated diffuse inflammation throughout the bladder. There was a stone in the bladder that was removed. A left retrograde pyeloureterogram revealed that the ureter did indeed communicate with the fallopian tube and there was a stone in the ureter distal to the fistula (fig. 2). Because of the persistence of fever to 102F and the rebound tenderness within the abdomen, an exploration was performed through the previous Gibson incision. A stone was found in the distal left ureter. There was a distinct pinpoint fistula between the ureter
CASE REPORT
Mrs. G. W., a 63-year-old woman, had a history of a right pyelolithotomy and a left distal ureterolithotomy 20 years before hospitalization. She was referred from another hospital where she had been confined for 3 days with complaints or persistent left flank and abdominal pain associated with frequency and dysuria. History and review of systems were not additionally revealing except for complaints of recurrent cystitis, occasional stone passage and an appendectomy in 1932. There was no history of urinary incontinence or pelvic inflammatory disease. A urine culture at the referring hospital revealed Escherichia coli more than 100,000 and the patient had been started on ampicillin. Because of persistent nausea, vomiting and physical findings suggestive of a bowel obstruction the patient was admitted to a general surgery service. Admission examination revealed a temperature of 102F, rales at both lung bases and diffuse abdominal tenderness with maximal tenderness in the left lower quadrant and rebound tenderness throughout the abdomen. The bowel sounds were hypoactive. Pelvic examination revealed tenderness in the left lower quadrant. Hemoglobin was 13.1, hematocrit 38.7, white blood count 8,800 with 66 polymorphonuclear leukocytes, 13 lymphocytes, 14 bands, 2 eosinophils and 5 monocytes. Urinalysis revealed 10 to 12 white cells with an occasional red cell per high power field. Amylase was normal but increased to as high as 800 during the next several days and then returned to normal following operation. Total bilirubin was 1.8, alkaline phosphatase 49, serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase normal, blood urea nitrogen (BUN) 62, creatinine 1.3, sodium 134, potassium 3.2, carbon dioxide 28 and chlorides 93. Posteroanterior and lateral films of the chest revealed a possible effusion at the left pleural base. A film of the kidneys, ureters and bladder (KUB) revealed bowel distension with partial obstructions suspected. The patient was treated with nasogastric suction as well as intravenous fluid and BUN returned toward normal. A barium swallow was performed and the barium passed through to the distal colon in about 36 hours. Urological consultation was obtained. An IVP revealed bilateral renal stones with a small Accepted for publication July 3, 1975. * Requests for reprints: 136 Alfred St., Biddeford, Maine 04005.
FIG. 1. A, KUB for IVP shows barium in intestine. B, 10-minute IVP shows salpingoureteral fistula in left lower quadrant.
FIG. 2. A, KUB for retrograde pyelogram shows stone in left distal ureter as well as bilateral renal stones. B, left ureteropyelogram shows salpingoureteral fistula. Barium in lower intestine may be seen in part A on KUB and there was no connection between fallopian tube and intestine.
218
219
SALPINGOURETERAL FISTULA
and the fallopian tube and this communicated with a uroma present in the left lower quadrant. A silastic stent was left indwelling in the ureter. The drains were placed down into the ureterotomy. The stent was removed endoscopically 11 days postoperatively and the drains were advanced. Convalescence was uneventful. The excised tube and ovary showed only acute and chronic inflammation. Culture of the uroma revealed no micro-organisms. DISCUSSION
There have been no previously reported cases of acquired salpingoureteral fistulas in the literature. We theorized that the potential fistula developed 20 years ago, at the time of the left distal and was made manifest the obstrnction of the left distal ureter stones. The elevated amylase levels may be explained the severe obstructed the tail of the pancreas. These levels 6
REFERENCES
1. Jequier, A. M. and Piper, J. V.: Uretero-uterine fistula after lower segment caesarian section. J. Obst. Gynaec. Brit. Commonw., 80: 276, 1973. 2. Runner, G. L. and Everett, R. S.: Ureteroperitoneal fistula with urinary ascites and chronic peritonitis. J.A.M.A., 95: 327, 1930. 3. Runner, G. L. and Everett, H. S.: Ureteroperitoneal fistula with urinary ascites. A second case. J. Urol., 28: 333, 1932. 4. Everett, H. S.: Ureteroperitoneal fistula with urinary ascites. J. Urol., 78: 585, 1957. 5. Bourdeau, G. V., ,Jindal, S. C., Gillies, R. R. and Berry, J. V.: Urinary ascites secondary to ureteroperitoneal fistula. Urology, 4: 209, 1974. 6. Rokatgi, M. and Mukherjee, A. K.: Tubointestinal fistula. J. Obst. Gynaec. Brit. Commonw., 80: 379, 1973. 7. Terzi, J. and Bordino, S.: Unusual hysterosalpingographic finding: salpingocolic fistula. G. Batteriol. Virol. Immunol., 64: 92, 1971. 8. Thompson, G. J. and Counseller, V. S.: Salpingovaginal fistula: report of a case. J. Urol., 65: 853, 1951.
