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”.