URINARY DIVERSIONS. Susan Hilton, MD and Nicholas Papanicolaou, MD Co-Chiefs, CT Section Hospital of the University of Pennsylvania

Transcription

1 URINARY DIVERSIONS Susan Hilton, MD and Nicholas Papanicolaou, MD Co-Chiefs, CT Section Hospital of the University of Pennsylvania

2 Neither of us has any financial relationships with commercial interests to disclose. Susan Hilton, MD Nicholas Papanicolaou, MD

3 Types of Urinary Diversions Conduits Ileal or colon conduit Pouches Continent cutaneous diversions (catheterizable pouch) Colon Indiana pouch (later versions Florida and Miami pouches) Mainz pouch Ileal reservoirs Kock pouch Orthotopic neobladder (Ileum)

4 Orthotopic neobladders Studer pouch Hautmann pouch Hemi-Kock pouch Ileum

5 Ileal Conduit Oldest, simplest, most commonly performed urinary diversion Drawing from Parekh DJ and Donat SM. Semin Oncol 34:98-109, 2007.

6 Ileal Conduit Often used for patients with significant comorbidities Terminal ileum preserved to absorb bile salts, fatsoluble vitamins, and vitamin B12

7 Colon conduit

8 Ileal Reservoir: Kock Pouch (1982) Isolate ileum Unite legs of U Drawings from Kock NG et al. J Urol 128: , 1982

9 Kock Pouch Creation of valves 1 Finished pouch 1 Pouchogram 2 1 Drawings from Kock NG et al. J Urol 128: , Image from Sung DJ et al. J Comput Assist Tomogr 2004;28:

10 Continent Cutaneous Diversion: Mainz Pouch (1983) Isolate asc colon & ileum Side to side anastomosis with opened ileum and antireflux ureteral anastomoses *Illustrations from Thuroff JW et al. BJU International. 106: , 2010 illustrations by STEPHAN SPITZER, Intussusception nipple created from terminal ileum

11 Mainz Pouch Intussusception nipple fixed to ileocecal valve by staples Completed pouch *Illustrations from Thuroff JW et al. BJU International. 106: , 2010 illustrations by STEPHAN SPITZER,

12 *Illustrations from Thuroff JW et al. BJU International. 106: , 2010 illustrations by STEPHAN SPITZER, Mainz Pouch with appendiceal stoma (Mitrofanoff, 1992) A submucosal cecal tunnel is created to imbed the appendix Completed pouch

13 Continent Cutaneous Diversion: Indiana Pouch (1985) Isolated ileocecum Drawings from Fisch M et al. BJU International. 102: , 2008 Construction of tailored terminal ileum and plicated ileocecal valve

14 Indiana Pouch 62 year old woman s/p cystectomy for bladder cancer

15 *Illustrations from Studer UE et al. BJU International. 93: , 2004 illustrations by STEPHAN SPITZER, Orthotopic Neobladder: Studer Pouch (1985) Ileum isolated Ileal segment opened along antimesenteric border

16 *Illustrations from Studer UE et al. BJU International. 93: , 2004 illustrations by STEPHAN SPITZER, Studer Pouch Bricker ureteral anastomoses Medial borders of U-shaped distal ileum oversewn

17 *Illustrations from Studer UE et al. BJU International. 93: , 2004 illustrations by STEPHAN SPITZER, Studer Pouch Bottom of U folded up, urethral anastomosis created Final reservoir

18 Studer Pouch: Two Patients

19 *Illustrations from Hautmann RE. BJU International 105: , Illustrations by STEPHAN SPITZERwww.spitzer-illustration.com Hautmann Pouch (1988) Ileal segment arranged in W shape with chimneys on each side Construction of urethral anastomosis

20 *Illustrations from Hautmann RE. BJU International 105: , Illustrations by STEPHAN SPITZER, Hautmann Pouch Ureters anastomosed to chimneys Completed pouch

21 Hautmann Pouch: pouchogram

22 Hemi-Kock Ileal Reservoir Kock ileal reservoir began as a continent cutaneous reservoir with intussuscepted nipple valves for both afferent (antireflux) and efferent (continent) limbs Evolved into an orthotopic diversion with an afferent intussuscepted limb, to prevent reflux Complications associated with the antireflux nipple-- stenosis, prolapse, stone formation

23 Hemi-Kock Pouch on CTU

24 Postoperative Radiologic Imaging Cross-sectional imaging US important to look for hydronephrosis CT and CTU mainstay of imaging in early postoperative period To search for leak, CTU protocol may be abbreviated MRI and MRU also helpful to detect complications

25 Postoperative Radiologic Imaging Fluoroscopic studies with direct injection of contrast (loopogram, pouchogram, abscessogram, injection of ureteral catheters) often helpful to define site of leak Conventional IVU may be used to assess postoperative anatomy and detect leaks Imaging-guided interventional procedures

26 Urinary Diversions: Early Complications Bowel Anastomotic leaks and/or fistulas Prolonged ileus Adhesive SBO, often near enteroenteric anastomosis

27 Urinary Diversions: Early Complications Urinary tract Ureteroenteric anastomotic leak (2%) Ureteroenteric stricture (7%)--causes include scarring & fibrosis due to leak, tension at anastomosis, or ischemia Infection Fluid collections Urinomas or abscesses from either GI or urinary leak Hematomas or lymphoceles

28 Ileal Conduit Stump Leak: Loopogram

29 Postoperative Anastomotic Leak after Ileal Conduit

30 Postoperative Anastomotic Leak after Ileal Conduit

31 Ileal-ileal anastomotic leak

32 Urinary Diversions: Late Complications Urinary Tract Calculi Infection Common in ileal conduits Continent diversions also at risk due to contamination by catheterization

33 Urinary Diversions: Late Complications Ureteral and ileal conduit stricture Can occur in first two years or several years after surgery

34 Distal Left Ureteral Stricture, patient 2.5 months post Studer Pouch

35 Urinary Diversions: Late Complications Parastomal hernias

36 Parastomal Hernia in a Patient with Ileal Conduit 11 months after surgical relief of SBO, with lysis of adhesions, the hernia now compresses the conduit, which contains a stone

37 Urinary Diversions: Late Complications Tumor recurrence

38 Pelvic recurrence of bladder cancer in patient with Studer pouch

39 Recurrent bladder cancer obstructing neobladder chimney

40 Recurrent bladder cancer obstructing neobladder chimney

41 New TCC Lesions patient with prior radical cystoprostatectomy and Studer pouch

42 Patient with ileal conduit (8/8/16 radical nephroureterectomy and cystoprostatectomy for bladder cancer) CT for RLQ pain 10/2/17:

43 Loopogram

44