Intermittent Hematuria and Shock due to Uretero-Arterial Fistula Diagnosed by Provocative Angiography

Uretero-arterial fistula is a rare but life-threatening cause of massive hematuria. A 78-year-old woman with a history of pelvic surgery, radiation therapy, ileal conduit diversion, and long-term ureteral stenting presented with gross hematuria and anemia. Contrast-enhanced computed tomography (CT) and repeated angiography failed to identify the bleeding source. During recurrent hemorrhage, provocative angiography with negative-pressure aspiration through a ureteral catheter demonstrated extravasation from the right common iliac artery. Endovascular stent-graft repair achieved immediate hemostasis. This case highlights the diagnostic value of provocative angiography in challenging cases of uretero-arterial fistula.