2.Case report
A 31-year-old male was rushed to our accident and emergency department
following multiple gunshot wounds to the left scrotum and pelvis.
He was hemodynamically stable with no abdominal distension, no signs of
peritonitis but had mild suprapubic tenderness and a palpable bladder.
We noted a through and through gunshot wound of the left hemi-scrotal ;
two wounds on the left upper thigh; one on the left groin and another
one on the right lower back. He had normal lower limbs pulses. The
focused assessment with sonography for trauma exam was negative.
The results of hemoglobin, serum urea, electrolytes, and creatinine were
within normal limits. A CT abdopelvis and angiography was done and
showed bladder clot and no vascular injury. The patient was taken to the
theatre for an emergency scrotal exploration and cystoscopy. Scrotal
exploration and left orchidectomy for shattered testis were performed
followed by cystoscopy. The cystoscopy was difficult and short due to
poor vision by bright red bleeding and sudden hemodynamic instability
after decompressing the bladder. The procedure was immediately
abandoned, and an exploratory laparotomy promptly commenced . Emergency
blood was ordered, and cell saver plugged in and connected for immediate
use. On entering the abdomen there was no obvious bleeding and the
patient was more stable. The bladder was noted to be distended and
erythematous. A longitudinal incision was made on the anterior wall of
the bladder (Fig.1) extended to the dome to evacuate the clots and
identify the bleeder. A large pulsatile blood gush was noted from the
left lateral wall, and it was suspicious for an arterio-vesical fistula.
The patient became unstable again, blood transfusion was started, pulses
were lost, and cardiopulmonary resuscitation was initiated with return
of spontaneous circulation in under a minute. The bladder was packed
with vascular swabs after which the Retzius space left to the bladder
was inspected and bluntly dissected to expose the external iliac artery.
The External iliac artery was noted to have an actively oozing
laceration on its anteromedial aspect. A compression with vascular swabs
was applied on it (Fig.2) and the trauma surgeon took over to repair
transversally the injury with prolene sutures after gaining proximal
control using a vessel loop on the left common iliac artery. All the
clots in the bladder were evacuated, a 20 Fr foley’s catheter was
inserted, a thorough bladder mucosa inspection done which revealed
another defect on the right lateral wall of the bladder (Fig.3) away
from the ureteric orifices and both ureters explored were intact. The
bladder injuries were debrided and repaired, and the bladder closed in
two layers (Fig.4) . 8 hours later, the patient bled again from the same
injury and demised.
3.DiscussionTraumatic arterio-vesical fistula and specifically between the external
iliac artery and the bladder is extremely rare [1,2,3]. The first
reported trauma case of external iliac artery related arterio-vesical
fistula was described by Rous et al in 1972 following a gunshot wound to
the lateral aspect of the bladder. The external iliac artery injury
resulted in a pseudoaneurysm that ruptured into the bladder a week after
the gunshot [3]. Three subsequent trauma related cases of
ilio-vesical fistula were reported of which only one was diagnosed at
presentation in an unstable patient [1,2,5]. Our patient was
initially hemodynamically stable, and no vascular injury was detected on
CT abdomen and angiogram expect a bladder clot that was noted. Patient
became unstable during cystoscopy after decompressing the bladder. The
arterio-vesical fistula was diagnosed intra-operatively on the day of
presentation during the laparotomy that ensued.
Other more common causes of this entity include previous pelvic surgery
and iatrogenic injury, radiotherapy, and vascular disease [2,5].
The rarity of this condition is evidenced by the paucity of literature
related to it. However, in cases of recurrent and/or persistent
unexplained hematuria following trauma, bladder or pelvic surgery,
radiotherapy or pelvic vascular disease angiography can be performed to
define the site, size, and extent of the fistula [2]. In our case,
hematuria was also present, but the angiography did not reveal any
vascular injuries. The injury was concealed by the bladder distended by
clots from the left external iliac artery bleeding into the bladder.
Interestingly, we have noted three signs which were linked to this acute
arterio-vesical fistula including bright red hematuria, clot
retention or distended bladder, and hemodynamic instability upon
disobstruction or catheterization . In a setting of penetrating pelvic
trauma, urologists and / or trauma surgeons should have a high index of
suspicion for an acute and traumatic arterio-vesical fistula in the
presence of this triad.
Once the diagnosis is made a therapeutic plan should promptly be put in
place. There is no agreement or guidelines in the literature with
regards to managing this entity . However, in the emergency setting and
when the patient is unstable an open surgical approach and repair of the
defects is the more likely option as there is a need to evaluate for
other injuries [2,3] . In a delayed diagnosis with pseudoaneurysm,
open options including repair, resection of the aneurysm or endovascular
option such as embolization [2,3] . This particular case was managed
with an open repair after proximal control at the level of the left
common iliac artery.
ConclusionExternal iliac artery injuries are extremely rare and should be promptly
recognized and urgently managed to reduce the already known high
mortality rate. Acute traumatic Ilio-vesical fistula is very uncommon,
and this report was the first to describe a case of bladder injury
concealing a concurrent external iliac artery injury.
In a setting of penetrating pelvic trauma, urologists and / or trauma
surgeons should have a high index of suspicion for an acute and
traumatic arterio-vesical fistula or shunt in the presence of the
following triad: bright red hematuri a, clot retention
or palpable bladder , hemodynamic instability after bladder
decompression “Mukendi’s triad”.