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‘Ooosh’ haematuria syndrome from eroded and kinked vascular graft in the bladder

With an ageing society comes an increase in vascular pathology and their associated interventions. What follows is an increased risk of vascular graft erosion into surrounding genitourinary and gastrointestinal structures. Arteriourinary fistulas may be primary or secondary. Primary fistulas (<15% of cases) are usually associated with aneurysmal degeneration of arteries or arteriovenous malformation, whereas secondary fistulas are associated with oncological surgery of the pelvis, radiation therapy and previous vascular surgery. Arteriourinary fistulas may occur between 2 and 25 years after the initial surgical procedure and seem to be more common in women. Mortality rates of 0–23% have been reported. Erosion or fistulation into adjacent gastrointestinal structures such as stomach or intestine is more common than into the genitourinary tract. Fistulas as a result of degenerated artery and ureter or synthetic graft and ureter have been well described. Erosion of prosthetic material into the bladder is well known, for example, synthetic slings for continence surgery and meshes used for hernia repairs. The erosion of vascular prosthesis into the bladder, however, is very rare and the expected average time to secondary fistulation is unknown. Arteriovesical fistulae may present with different degrees of haematuria ranging from microscopic to exsanguinating haemorrhage. Useful diagnostic modalities range from ultrasound, computed tomography, magnetic resonance angiography to cystoscopy. In this case, an 88-year-old female presented with a history of intermittent frank haematuria. She described an ‘ooosh’ sensation in her pelvis followed by massive haematuria. Her past medical history reveals she had a femoral–femoral crossover graft 22 years ago for peripheral vascular disease. Five years ago the graft blocked, she was taken back for a laparotomy, the graft was disconnected from the right side, sutured closed, left in situ and a left-sided axillary-femoral bypass was done. The patient was admitted now with urosepsis and bladder pain. She was only mildly anaemic. A urinary tract infection was confirmed and treated. A computed tomography scan showed the graft entering the bladder through the left lateral wall (Fig. 1). Cystoscopy demonstrated the vascular graft in the bladder (Fig. 2). We proceeded to do an open exploration via Pfannenstiel incision. We clipped the graft on the left side, opened the bladder with graft in situ (Fig. 3, blue arrows), removed the graft, excised any infected or inflammatory tissue and closed the bladder. We suspect the suture at the end of the graft had come undone. We postulated that when the patient urinated the graft unfolded and blood rushed out and then it kinked cutting the flow of blood. The patient has remained asymptomatic since surgery. Entire erosion of a vascular graft into the bladder has not been reported in the literature. Three cases of vascular grafts eroding into the bladder with varying presentations and management have been described. A crossover femoral–femoral graft eroded into the anterior bladder wall and was incidentally found as an adherent bladder stone during cystoscopy for right ureteral stent insertion. The encrusted graft was left in situ and the patient subsequently had the old graft removed and a new bypass graft inserted by vascular surgery. Another vascular graft eroded 5 years after original arterial reconstruction into the bladder and was managed conservatively. In the third case, a calcification in the bladder wall suggestive of a urinary stone was detected on imaging. Flexible cystoscopy revealed a friable vascular mass high on the left wall of the bladder, which was biopsied. There was a torrential bleed after the biopsy that necessitated an emergency laparotomy. The bleeding was from a fistulation of an old Dacron iliofemoral graft into the bladder wall 16 years after the initial vascular reconstruction. Collaboration between urologists, radiologists and vascular surgeons with careful preoperative planning is essential. Surgical management has several objectives which include haemorrhage