Iatrogenic injury to the urinary tract - A pictorial review of imaging appearances and radiological management

Transcription

1 Iatrogenic injury to the urinary tract - A pictorial review of imaging appearances and radiological management Poster No.: C-2044 Congress: ECR 2015 Type: Educational Exhibit Authors: B. Rawal, R. P. Patel, N. Vasdev, U. P. Ratnayake, A. Patel; Stevenage/UK Keywords: Abdomen, Interventional non-vascular, Urinary Tract / Bladder, CT, Fluoroscopy, Catheter arteriography, Embolisation, Stents, Imaging sequences, Fistula, Obstruction / Occlusion DOI: /ecr2015/C-2044 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 75

2 Learning objectives 1. To review iatrogenic injury of the urinary tract during obstetric, abdomino-pelvic surgery and percutaneous urological intervention. 2. To recognise the role of imaging in identifying the extent of injury and guiding subsequent therapeutic management. Page 2 of 75

3 Background The urinary tract contributes to retroperitoneal and pelvic structures, therfore it is particulary vulnerable to iatrogenic injury during obstetric and abdomino-pelvic surgery. Injuries to the urinary tract can be complex and imaging plays a fundamental role in accurate diagnosis and subsequent management. Ureteric laceration, transection and ligation are well-recognised complications following emergency caesarean section. Timely diagnostic imaging is essential to anatomically characterise the extent of injury and guide subsequent urological management. Complications of percutaneous urological intervention, for example life-threatening haemorrhage following nephrostomy placement, also rely on accurate CT imaging to plan appropriate angiographic intervention. Page 3 of 75

4 Findings and procedure details We present a selection of cases that highlight the importance of a multi-disciplinary approach to managing iatrogenic injuries to the urinary tract and the fundamental role of multimodality imaging techniques in managing complex injuries. This pictorial review details the use of multi-modality imaging including CT-urography, cystourethrography and renal angiography in management of these patients. Multi-modality imaging not only helps identify the exact site of the pathology, it also allows radiological and surgical planning of subsequent intervention. Case 1 31 year old lady underwent an emergency Caesarean section complicated by bladder injury and subsequently developed a vesico-vaginal fistula. The diagnosis was confirmed by both cystourethrography and CT-urography (Fig. 1-3). Imaging confirmed the diagnosis, the site and size of the fistula. Page 4 of 75

5 Fig. 1: Cystogram demonstrating vesico-vaginal fistula (arrow) from the post wall of the bladder to the anterior vaginal vault. References: - Stevenage/UK Fig. 2: CT urogram coronal outlining the vesico-vaginal fistula (arrow). References: - Stevenage/UK Page 5 of 75

6 Fig. 3: Sagittal reconstruction of CT urography demonstrating vesico-vaginal fistula secondary to bladder injury during caesarean section. A narrow fistula tract between the vault of the vagina anteriorly and posterior wall of the bladder is depicted (arrow). References: - Stevenage/UK In view of the relative small size of the fistula, the patient was managed conservatively. A long-term urethral catheter was sited and removed once the fistula had healed. Surgical repair was therefore avoided. Case 2 82 year old lady had an inadvertent ureteric transection with a harmonic scalpel during abdomino-perineal (AP) rectal resection. Following the AP resection, she became septic with a distended abdomen. A contrast enhanced CT of the abdomen and pelvis demonstrated a large, multiloculated peripherally enhancing collection and a left hydronephrosis (Fig 4 and 5). Page 6 of 75

7 Fig. 4: Axial contrast enhanced CT abdomen and pelvis; large multi-loculated intra and retroperitoneal fluid collections. References: - Stevenage/UK Page 7 of 75

8 Fig. 5: Sagittal reconstruction contrast enhanced CT abdomen and pelvis demonstrating multi-loculated intra and retroperitoneal fluid collections. References: - Stevenage/UK The collection was drained percutaneously in the radiology department under ultrasound guidance. The size of the collection resolved as did the patient's symptoms, however repeat imaging demonstrated persistent hydronephrosis (Fig 6). Page 8 of 75

9 Fig. 6: Coronal reconstruction contrast enhanced CT following drainage revealing a persistent left hydronephrosis (small arrow) and residual fluid collections (large arrow). References: - Stevenage/UK A retrograde urogram and attempted stent insertion proved unsuccessful and contrast injection revealed extravasation from the distal ureter (Fig 7). Subsequently, a percutaneous left sided nephrostomy was placed and nephrostogram revealed a transition point at the level of the pelvic brim (Fig 8). Page 9 of 75

10 Fig. 7: Retrograde urogram displaying distal ureteric contrast extravasation (arrow). References: - Stevenage/UK Page 10 of 75

11 Fig. 8: Subsequent percutaneous nephrostomy in theatre following unsuccessful retrograde stent insertion. References: - Stevenage/UK Seven months later, a repeat CT scan showed an adequately decompresed kidney and residual small intra-abdominal collections (Fig 9). Page 11 of 75

12 Fig. 9: Coronal reconstruction contrast enhanced CT shows a decompressed left kidney (arrow) and small residual collections in the abdomen. References: - Stevenage/UK A 'rendez-vous' procedure was performed. This was unsuccessful in view of an approximately 16cm defect between the proximal ureteric transition point (level of the pelvic brim) and downstream ureteric stump (Fig 10-12). It was presumed the ureter suffered ischaemic injury, therefore involving a large length. Page 12 of 75

13 Fig. 10: Rendezvous procedure. Nephrostogram demonstrates an abrupt 'cut off' of the mid ureter at the pelvic brim. References: - Stevenage/UK Page 13 of 75

14 Fig. 11: Rendezvous procedure. A wire/catheter combination is advanced into the mid ureter but cannot be negotiated into the distal ureteric segment (arrow) References: - Stevenage/UK Page 14 of 75

15 Fig. 12: Rendezvous procedure. Retrograde ureteric access with a wire and contrast injection reveals a blind ending ureteric stump (arrow). References: - Stevenage/UK Patient continued to represent with urosepsis. A DMSA was performed revealing a scarred left kidney functioning at 29% and right at 71% (Fig 13). Page 15 of 75

16 Fig. 13: DMSA study reveals a scarred left kidney functioning at 29%. References: - Stevenage/UK Imaging and uro-intervention played a fundamental role in the management of this iatrogenic complication and the patient eventually underwent a nephrectureterectomy as the ureter could not be salvaged. Case 3 33 year old lady sustained a distal ureteric laceration during an emergency C section in which she failed to progress during labour. She sustained a lower uterine segment and Page 16 of 75

17 broad ligament tear. A CT urogram was requested because of the suspected right sided ureteric injury which demonstrated a tortuous right hydroureter and delayed downstream drainage (Fig 14). Fig. 14: Coronal MIP CT urogram. Tortuous right sided hydroureter, delayed downstream drainage and transition point at the pelvic brim (arrow). References: - Stevenage/UK A retrograde urogram demonstrated distal ureteric contrast extravasation and a ureteric stent was sited retrogradely (Fig 15 and 16). Page 17 of 75

18 Fig. 15: Retrograde urogram demonstrates a distal ureteric laceration and contrast extravasation (arrows). References: - Stevenage/UK Page 18 of 75

19 Fig. 16: Retrograde ureteric stent is deployed across the ureteric injury. References: - Stevenage/UK A repeat CT urogram was performed following stent insertion to further characterise the anatomical relationship between the ureteric injury and other nearby structures (Fig 17-20). Page 19 of 75

20 Fig. 17: Axial MIP CT urogram. Ureteric stent in situ, Contrast extravasation from the distal ureter dispersing irregularly into the pelvis, channeling through an apparent defect within the right lower uterine segment filling the endometrial cavity and vagina (arrows). References: - Stevenage/UK Page 20 of 75

21 Fig. 18: Coronal MIP CT urogram. Ureteric stent in situ. Distal uretero-uterine fistula. Pelvic contrast extravasation and fistula with the uterine cavity (arrow). References: - Stevenage/UK Page 21 of 75

22 Fig. 19: Sagittal MIP CT urogram. Contrast filled endometrial cavity (large arrow) copiously filling the vagina (small arrow). References: - Stevenage/UK Page 22 of 75

23 Fig. 20: Sagittal MIP CT urogram. Distal ureteric contrast extravasation (arrow). Ureteric stent in situ. References: - Stevenage/UK In view of the persistent contrast extravasation from the distal ureter and the ureterouteric fistula, a diverting nephrostomy was placed (Fig 21). Page 23 of 75

24 Fig. 21: Diverting nephrostomy and ureteric stent. References: - Stevenage/UK Two months later, through robot assisted right ureteric recontruction, the ureter was reimplantated into the anterior dome of the bladder. A subsequent cystogram revealed a small leak from the right dome of the bladder (Fig 22), a large bore urinary catheter was left in situ for another two weeks and a repeat cystogram did not identify a leak (Fig 23). Page 24 of 75

25 Fig. 22: Cystogram. Contrast leak from the bladder dome (arrow). References: - Stevenage/UK Page 25 of 75

26 Fig. 23: Cystogram two weeks later. No leak identified. References: - Stevenage/UK She the returned two weeks later with fevers and lower abdominal pain. A CT urogram was performed confirming a persistent small leak at the dome of the bladder on the right adjacent to the surgically re-implanted ureter (Fig 24 and 25). Page 26 of 75

27 Fig. 24: Coronal MIP CT urogram. Small residual area of contrast extravasation from the right lateral bladder dome adjacent to the surgically re-implanted ureter (arrows). References: - Stevenage/UK Page 27 of 75

28 Fig. 25: Sagittal MIP CT urogram. Ureteric stent in situ across the surgically reimplnted ureter. Small bladder dome leak antero-lateral to re-implantated ureter (arrow). References: - Stevenage/UK This was treated conservatively with antibiotics and the patient made a full recovery. Case 4 68 year old patient with known transitional cell carcinoma of the urinary bladder presented with a chronically hydronephrotic right kidney. He subsequently developed renal failure Page 28 of 75

29 and a non contrast CT of the urinary tract revealed a new left sided hydronephrosis. A left sided nephrostomy was inserted radiologically. He developed acute left loin pain and haematuria via the urinary catheter and nephrostomy drainage bag as well as a substantial haemoglobin drop. A non contrast CT revealed a large subcapsular and retroperitoneal haematoma (Fig 26). Fig. 26: Coronal MIP non contrast CT. Large left subcapsular (small arrow) and retroperitoneal hematoma. Haemorrhagic clot in the bladder (large arrow). References: - Stevenage/UK Page 29 of 75

30 The patient was haemo-dialysed for a CT angiogram which demonstrated a left upper pole renal artery branch pseudoaneurysm (Fig 27-29). Fig. 27: Axial MIP CT angiogram. Contrast extravasation/pseudoaneurysm left upper pole renal artery branch (arrow). References: - Stevenage/UK The patient underwent successful coil angio-embolisation of the pseudoaneurym (Fig 30 and 31). Page 30 of 75

31 Fig. 30: Selective micro-catherisation of left upper pole renal artery. Subsequent angiogram displaying a small pseudoaneurysm (arrow). References: - Stevenage/UK Page 31 of 75

32 Fig. 31: No demonstrable filling of the pseudoaneurysm following coil embolisation. References: - Stevenage/UK This case demonstrates how multimodality imaging and subsequent treatment prevented further complications and allowed therapetic control via coil embolisation. Case 5 75 year old man with a known horseshoe kidney and a history of bladder cancer was admitted secondary to sepsis of unknown cause. A non-contrast CT was performed in view of acute renal failure. This demonstrated bilateral hydronephrosis and hydroureter Page 32 of 75

33 down to the bladder which was obscured due to beam hardening artefact from bilateral hip replacements. There was also new retroperitoneal adenopathy (Fig 32-34). Fig. 32: Coronal MIP non contrast CT. Horseshoe kidney and bilateral hydronephrosis and hydroureter (arrow) References: - Stevenage/UK Page 33 of 75

34 Fig. 34: Coronal MIP non contrast CT. Retroperitoneal lymphadenopathy (arrows). References: - Stevenage/UK A right sided nephrostomy was performed under concious sedation and purulent urine aspirated. Subsequently, a left antegrade ureteric stent was sited, however when attempting to tackle the right side, an initial nephrostogram revealed filling of the subcapsular space rather than free drainage into the pelvicalcyeal system and downstream into the ureter. It was concluded that the nephrostomy was displaced and attempts to re-site the catheter were unsucessful now due to the presence of large subcapsular collection. A right antegrade stent could therefore not be sited. Page 34 of 75

35 A subsequent non contrast CT study revealed a displaced nephrostomy catheter and a large contrast filled subcapsular collection due to previous contrast injection (Fig 35 and 36). Fig. 35: Coronal MIP non contrast CT. Left ureteric stent in situ. Displaced right nephrostomy catheter and contrast filled subcapsular collection (arrow). References: - Stevenage/UK Page 35 of 75

36 Fig. 36: Axial MIP non contrast CT. Displaced right nephrostomy catheter and contrast filled subcapsular collection. References: - Stevenage/UK This was treated conservatively and the drain removed. The patient went on to improve with conservative management and no further interventions were performed. Page 36 of 75

37 Images for this section: Fig. 1: Cystogram demonstrating vesico-vaginal fistula (arrow) from the post wall of the bladder to the anterior vaginal vault. - Stevenage/UK Page 37 of 75

38 Fig. 2: CT urogram coronal outlining the vesico-vaginal fistula (arrow). - Stevenage/UK Page 38 of 75

39 Fig. 3: Sagittal reconstruction of CT urography demonstrating vesico-vaginal fistula secondary to bladder injury during caesarean section. A narrow fistula tract between the vault of the vagina anteriorly and posterior wall of the bladder is depicted (arrow). - Stevenage/UK Page 39 of 75

40 Fig. 4: Axial contrast enhanced CT abdomen and pelvis; large multi-loculated intra and retroperitoneal fluid collections. - Stevenage/UK Page 40 of 75

41 Fig. 5: Sagittal reconstruction contrast enhanced CT abdomen and pelvis demonstrating multi-loculated intra and retroperitoneal fluid collections. - Stevenage/UK Page 41 of 75

42 Fig. 6: Coronal reconstruction contrast enhanced CT following drainage revealing a persistent left hydronephrosis (small arrow) and residual fluid collections (large arrow). - Stevenage/UK Page 42 of 75

43 Fig. 7: Retrograde urogram displaying distal ureteric contrast extravasation (arrow). - Stevenage/UK Page 43 of 75

44 Fig. 8: Subsequent percutaneous nephrostomy in theatre following unsuccessful retrograde stent insertion. - Stevenage/UK Page 44 of 75

45 Fig. 9: Coronal reconstruction contrast enhanced CT shows a decompressed left kidney (arrow) and small residual collections in the abdomen. - Stevenage/UK Page 45 of 75

46 Fig. 10: Rendezvous procedure. Nephrostogram demonstrates an abrupt 'cut off' of the mid ureter at the pelvic brim. - Stevenage/UK Page 46 of 75

47 Fig. 11: Rendezvous procedure. A wire/catheter combination is advanced into the mid ureter but cannot be negotiated into the distal ureteric segment (arrow) - Stevenage/UK Page 47 of 75

48 Fig. 12: Rendezvous procedure. Retrograde ureteric access with a wire and contrast injection reveals a blind ending ureteric stump (arrow). - Stevenage/UK Page 48 of 75

49 Fig. 13: DMSA study reveals a scarred left kidney functioning at 29%. - Stevenage/UK Page 49 of 75

50 Fig. 14: Coronal MIP CT urogram. Tortuous right sided hydroureter, delayed downstream drainage and transition point at the pelvic brim (arrow). - Stevenage/UK Page 50 of 75

51 Fig. 15: Retrograde urogram demonstrates a distal ureteric laceration and contrast extravasation (arrows). - Stevenage/UK Page 51 of 75

52 Fig. 16: Retrograde ureteric stent is deployed across the ureteric injury. - Stevenage/UK Page 52 of 75

53 Fig. 17: Axial MIP CT urogram. Ureteric stent in situ, Contrast extravasation from the distal ureter dispersing irregularly into the pelvis, channeling through an apparent defect within the right lower uterine segment filling the endometrial cavity and vagina (arrows). - Stevenage/UK Page 53 of 75

54 Fig. 18: Coronal MIP CT urogram. Ureteric stent in situ. Distal uretero-uterine fistula. Pelvic contrast extravasation and fistula with the uterine cavity (arrow). - Stevenage/UK Page 54 of 75

55 Fig. 19: Sagittal MIP CT urogram. Contrast filled endometrial cavity (large arrow) copiously filling the vagina (small arrow). - Stevenage/UK Page 55 of 75

56 Fig. 20: Sagittal MIP CT urogram. Distal ureteric contrast extravasation (arrow). Ureteric stent in situ. - Stevenage/UK Page 56 of 75

57 Fig. 21: Diverting nephrostomy and ureteric stent. - Stevenage/UK Page 57 of 75

58 Fig. 22: Cystogram. Contrast leak from the bladder dome (arrow). - Stevenage/UK Page 58 of 75

59 Fig. 23: Cystogram two weeks later. No leak identified. - Stevenage/UK Page 59 of 75

60 Fig. 24: Coronal MIP CT urogram. Small residual area of contrast extravasation from the right lateral bladder dome adjacent to the surgically re-implanted ureter (arrows). - Stevenage/UK Page 60 of 75

61 Fig. 25: Sagittal MIP CT urogram. Ureteric stent in situ across the surgically re-implnted ureter. Small bladder dome leak antero-lateral to re-implantated ureter (arrow). - Stevenage/UK Page 61 of 75

62 Fig. 26: Coronal MIP non contrast CT. Large left subcapsular (small arrow) and retroperitoneal hematoma. Haemorrhagic clot in the bladder (large arrow). - Stevenage/UK Page 62 of 75

63 Fig. 27: Axial MIP CT angiogram. Contrast extravasation/pseudoaneurysm left upper pole renal artery branch (arrow). - Stevenage/UK Page 63 of 75

64 Fig. 28: Coronal MIP CT angiogram. Contrast extravasation/pseudoaneurysm left upper pole renal artery branch (arrow). - Stevenage/UK Page 64 of 75

65 Fig. 29: Coronal MIP CT angiogram. Left upper pole renal artery branch contrast extravasation/pseudoaneurysm (arrow). Large left subcapsular haematoma. - Stevenage/UK Page 65 of 75

66 Fig. 30: Selective micro-catherisation of left upper pole renal artery. Subsequent angiogram displaying a small pseudoaneurysm (arrow). - Stevenage/UK Page 66 of 75

67 Fig. 31: No demonstrable filling of the pseudoaneurysm following coil embolisation. - Stevenage/UK Page 67 of 75

68 Fig. 32: Coronal MIP non contrast CT. Horseshoe kidney and bilateral hydronephrosis and hydroureter (arrow) - Stevenage/UK Page 68 of 75

69 Fig. 33: Coronal MIP non contrast CT. Bilateral hydroureter (arrows). Pelvic images degraded by beam hardening artefact from bilateral hip replacements. - Stevenage/UK Page 69 of 75

70 Fig. 34: Coronal MIP non contrast CT. Retroperitoneal lymphadenopathy (arrows). - Stevenage/UK Page 70 of 75

71 Fig. 35: Coronal MIP non contrast CT. Left ureteric stent in situ. Displaced right nephrostomy catheter and contrast filled subcapsular collection (arrow). - Stevenage/UK Page 71 of 75

72 Fig. 36: Axial MIP non contrast CT. Displaced right nephrostomy catheter and contrast filled subcapsular collection. - Stevenage/UK Page 72 of 75

73 Conclusion Urinary tract injuries are a well recognised complication of various bowel and gynaecological procedures. They certainly result in significant morbidity and the implications can have dramatic outcomes, for example the need for life-saving embolotherapy and salvage nephroureterectomy. We have shown that early radiology input and multi-modality imaging allows accurate characterisation of the extent of urinary tract injury, therefore appropriately guiding urological management. A strong relationship between radiologists and urological surgeons is key in practically managing such complex iatrogenic injury. Page 73 of 75

74 Personal information Dr Amit Patel Consultant Interventional and Uro-radiologist Lister Hospital, Stevenage, United Kingdom. Page 74 of 75

75 References 1. Meirow D, Moriel EZ, Zilberman M, Farkas A. Evaluation and treatment of iatrogenic ureteral injuries during obstetric and gynecologic operations for nonmalignant conditions. J Amer Col Surg 178:144, Williams RD. Urologic complications of pelvic surgery. In: Jewett MAS (ed.). Urologic Complications of Pelvic Surgery and Radiotherapy. Isis Medical Media, Oxford ;1-22, Higgins CC. Ureteral injuries during surgery: A Review of 87 cases. JAMA 199:118, Neuman M, Eidelman A, Langer R, Golan A, BukovskyI, Caspi E. Iatrogenic injuries to the ureter during gynecologic and obstetric operations. Surg Gynecol Obstet 173:268, Selzman AA, Spirnak JP. Iatrogenic ureteral injuries: A 20-year experience in treating 165 injuries. J Urol 155: , Page 75 of 75