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Daniel Oppenheimer, M.D. [email protected] Brett Talbot, M.D. Shweta Bhatt, M.D. Ravinder Sidhu , M.D. Multi-modality Imaging of Urinary Diversion Complications. Purpose. - PowerPoint PPT Presentation
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Multi-modality Imaging of
Urinary Diversion Complications
Daniel Oppenheimer, [email protected]
Brett Talbot, M.D.Shweta Bhatt, M.D.
Ravinder Sidhu, M.D.
PurposeThis educational exhibit will discuss current options of surgical urinary diversion and detail the imaging findings of frequently encountered post operative complications
Introduction Radical Cystectomy (RC) and Urinary Diversion (UD) is a
technically challenging operation with significant morbidity Accurate and prompt identification of post-operative
complications is essential to preserving renal function, improving quality of life and survival
Complications can occur up to 20 years or more after surgery, emphasizing the need for close long-term follow-up
The radiologist plays a pivotal role in identifying postoperative complications by providing a timely diagnosis for the Urologist and other clinicians to intervene upon
Several other complications including urinary incontinence, sexual dysfunction, metabolic alterations and decreased renal function are common following RC and UD, but not well evaluated radiologically
Types of Urinary Diversion Ureterosigmoidostomy Ileal/colon conduit Continent Cutaneous Reservoir Orthotopic Neobladder
Ureterosigmoidostomy First developed technique in
surgical urinary diversion Continent, with rectal
voiding Increased risk of colorectal
cancer, metabolic acidosis and renal failure
Has now largely been replaced by other techniques
Axial CECT image of a ureterosigmoidostomy (arrows)
Ileal Conduit Urinary Diversion Ileal conduit urinary diversion
was gold standard until introduction of orthotopic neobladder
Ureters anastomosed to a segment of isolated ileum which is brought to the surface of the abdominal wall.
Urine continually drains from the ureters, through the anastomosed loop of bowel and is collected in a bag through the stoma
Advantages of Ileal loop urinary diversion Technically simpler operation, shorter
operative time compared to continent reconstructionsIdeal for patients with medical comorbidities to
decrease perioperative complications Short gut diverting segment limits enteric
absorption of urine waste products, limiting metabolic abnormalitiesRecommended diversion method in renal
insufficiency or hepatic dysfunction
Disadvantages of Ileal loop urinary diversion Requires external appliance and stoma care Altered self image/impact on quality of life Stomal complications including parastomal
hernia, stomal stenosis and bleeding/skin irritation
Continent Cutaneous Diversion
Low pressure reservoir is constructed from detubularized bowel and a catheterizable connection is created between the reservoir and the skin
The reservoir stores urine and is intermittently catheterized
Enables continence with no need for external appliance, but requires patient motivation/education regarding lifelong self catheterization using sterile technique Indiana Pouch continent cutaneous
urinary diversion
Orthotopic Neobladder Reservoir created from
detubularized bowel which is anastomosed to the native urethra
Relies upon natural sphincter muscles to maintain continence
Facilitates restoration of normal voiding mechanism and maintains patient self-image Gaining popularity Requires careful patient selection
○ Contraindicated if urethra is non-functional or involved with tumor
○ Requires active patient training/participation to ensure full return of spontaneous voiding
Complications of Urinary Diversion
*Complications can occur 20+ years after surgery, emphasizing the need for close monitoring and frequent follow up
Early Complications• Fluid collections
• Abscess• Lymphocele• Urinoma• Hematoma
• Bowel obstruction/Ileus• Hydronephrosis• Stomal complications• Pyelonephritis/infection• Fistula
Late Complications*• Anastomotic stricture/stenosis
• Recurrent UTIs/Pyelonephritis
• Urolithiasis
• Oncologic Recurrence
Post-operative Fluid Collections Urinoma
Best evaluated on delayed excretory phase images as enhancing fluid due to contrast accumulation
Usually treated with percutaneous drainage and stenting over the site of leak
HematomaHeterogeneous, non-enhancing collection near surgical
site Abscess
Air within a collection with thickened enhancing wall suggests infection, although air may also be seen if drainage catheters are present
Abscess
Axial CECT image demonstrates a thick walled enhancing collection in the pre-sacral region (dashed oval) with a focus of luminal gas (arrow) and surrounding infiltrative changes, consistent with abscess
Lymphocele Caused by surgical transection or injury to lymphatics,
often following lymphadenectomy Homogeneous collection with thin wall When large, lymphoceles can compress adjacent
structures including the ureters, blood vessels and bowel, resulting in pain, hydronephrosis, venous thrombosis, abdominal distension and bowel obstruction
Delayed CECT helpful to distinguish from urinoma If large or infected, treatment options include
percutaneous or surgical drainage, simple aspiration, sclerotherapy and peritoneal marsupialization
Lymphocele
Axial CECT and corresponding PETCT images in a patient recently post-op from radical cystectomy and ileal conduit urinary diversion demonstrates a thin walled peripherally enhancing, peripherally hypermetabolic low attenuation collection in the pelvis (arrow), later proven to be a lymphocele
Bowel Obstruction Most commonly secondary to adhesions
near the enteroenteric anastomosis Radiologic findings:
Dilated bowel loops with air-fluid levels proximal to site of obstruction
Abrupt change in intestinal caliber Acute complete/high grade obstruction
requires immediate surgical correction, whereas partial obstruction is usually managed conservatively
Small Bowel Obstruction
Axial CECT images demonstrate stomal stenosis (arrow) resulting in bowel obstruction, evidenced by dilated small bowel loops with multiple air fluid levels
Hydronephrosis Common with conduit urinary diversion due
to reflux Can also be seen in the setting of urinary
obstruction secondary to oncologic recurrence, stomal stenosis, stricture or calculus
Chronic hydronephrosis can result in renal parenchymal scarring, atrophy and deterioration of renal function
Hydronephrosis
Grayscale sonographic image demonstrates moderate right hydronephrosis in a patient with an ileal conduit urinary diversion
Hydronephrosis
Initial axial CECT image demonstrates moderate right and severe left hydronephrosis. Chronic hydronephrosis has resulted in parenchymal volume loss in the left kidney one year later
Initial Exam 1 year later
Stomal Complications Include parastomal hernia, stomal stenosis
and bleeding/skin irritation Majority occur within first 5 years of surgery Stenosis or hernia may be recognized by
difficulty catheterizing or decreased urostomy output
Obesity and old age are risk factors of developing parastomal hernia
Surgical revision is an option for hernias, although they frequently recur
Parastomal Hernia
Axial and sagittal reformatted CECT images demonstrate herniation of small bowel loops (thin arrows) through the stoma defect (thick arrow)
Pyelonephritis/Ureteritis Bacterial colonization occurs in nearly 100% after
continent cutaneous diversion, but clinical symptoms are rare if urine flow remains unobstructed
Stasis of urine secondary to reflux, incomplete voiding or obstruction (caused by oncologic recurrence, stricture, stomal stenosis or urolithiasis) can result in infection
While asymptomatic bacteriuria is seen in the majority of patients, symptomatic infection is less common, and urosepsis is rare.
Chronic suppressive antibiotic therapy is only indicated in patient’s with recurrent UTIs
Ureteritis
Axial CECT images demonstrate enhancement of the left renal pelvis and bilateral ureters (arrows), consistent with inflammation due to infection
Fistula Affects approximately 0.2-2% of patients after
urinary diversion Enterourinary, enterogenital or enterocutaneous Prior pelvic radiation predisposing factor Can be reduced with careful closure of the
anastomosis or pouch, stenting of the ureteroenteric anastomosis
Early treatment with percutaneous drainage often results in spontaneous closure of fistula, although surgical revision may be required
Fistula
Loopogram image demonstrates contrast filling the normal loops of diverting bowel and refluxing up both ureters (arrows), but also extraluminal contrast in the left upper pelvis in an enterocutaneous fistula (dashed oval)
Stricture Affects approximately 3-10% of patients after urinary
diversion Most commonly at ureteroenteric anastomosis, usually
secondary to ischemia of the distal ureter resulting in fibrosis Left ureter > right ureter due to angulation and longer
mobilization Benign strictures usually smooth and short segment Malignant strictures often irregular and long with enhancing
soft tissue component on CT 4-50% success with endoscopic management, surgical
ureteral re-implantation ~80% successful May be reduced with meticulous surgical technique, minimal
ureteral dissection, assuring well-perfused segment, and careful apical suture placement
Anastomotic Stricture
Fluoroscopic images from a nephrostogram demonstrate a stricture at the ureteroenteric anastomosis (arrow), which was subsequently dilated with a 7 mm x 4 cm balloon
Stricture
Loopogram image (left) demonstrates abrupt non-opacification of the distal left ureter extending proximally secondary to a stricture (arrow). Corresponding coronal reformatted CECT image demonstrates non-opacification of mid-distal ureter secondary to a distal ureteral stricture (arrow).
Stricture
Nephrostogram/loopogram image demonstrates an irregular stricture in the mid right ureter (arrow), later biopsy proven urothelial carcinoma
Urolithiasis Late complication – rare within first 2 years of
surgery Best evaluated on NECT More common in continent reconstructions Multifactorial etiology
Incomplete emptying/residual urineExposed surgical material/staplesChronic bacteriuriaMetabolic alteration of urine contentObstruction
Urolithiasis
Axial CECT demonstrates a large calculus (arrow) layering dependently in the Indiana pouch
Oncologic Recurrence Local recurrence rate ~5-15% within 5 years, often within
2 years of surgery Higher stage and malignant nodal disease associated
with greater risk of recurrence and poor survival Up to 70% with local recurrence also have distant
metastasis May manifest as an obstructing stricture, pelvic soft tissue
mass or lymphadenopathy Symptoms include macrohematuria and pain Symptomatic recurrence has worse prognosis compared
to incidentally discovered recurrence because symptoms are often due to locally advanced disease
Oncologic Recurrence
Loopogram (left) and coronal reformatted CECT images (right) demonstrate a lobulated filling defect in the distal left ureter (dashed oval, arrow), later biopsy proven urothelial carcinoma recurrence
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