Filling Defects in Small Bowel Urinary Conduits

Transcription

1 787 Filling Defects in Small Bowel Urinary Conduits Edward S. Amis, Jr.1 John J. Cnonan Richard C. Pfisten Radiographic evaluation of patients with urinary diversion by small bowel conduit includes excretory urography, loopography, and, if necessary, percutaneous pyelography. Five patients with discrete filling defects in their conduits are discussed. These defects represented stones (two cases), antirefluxing ureteral nipples, metastatic bladder carcinoma, and a turn-in loop construction defect. While the nature of loop filling defects can often be discerned by radiographic studies and a knowledge of the conduit construction technique, endoscopic biopsy may occasionally be necessary for definitive diagnosis. Since the introduction of urinary diversion by ileal conduit in 1950 [1], many thousands of patients have undergone this procedure for either malignant or benign disease. Careful periodic follow-up of these patients is necessary throughout their lifetime. A high percentage (1 1 %-41 %) will develop upper tract detenioration due to neflux, benign or malignant obstruction of the ureteroconduit anatomoses, on problems with the loop itself, such as redundancy, stenosis (segmental on the entire loop), and stomal stnictuning [2, 3]. Discrete filling defects can be seen within the loop during radiographic evaluation. These defects can be structural or related to disease processes. An understanding of the method of surgical construction of the loop explains most defects. Yet in the setting of malignant disease, filling defects can be alarming as they raise the possibility of metastases to the loop. We review the radiography of small bowel urinary conduits, particularly with regard to the diagnosis of loop filling defects. Materials and Methods Received February 20, : accepted after revision June 4, All authors: Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston MA Address reprint requests to Radiology Research Office (RCP), Massachusetts General Hospital. AJR 1 37: , October X/81 I $00.00 American Roentgen Ray Society Small bowel loopograms done at Massachusetts General Hospital during were reviewed after several cases of discrete conduit filling defects of various etiologies were recognized in the course of routine film interpretation. There were 40 examinations performed. When indicated, loopography of small bowel conduits was performed using a 1 4 French Foley catheter with 5 ml balloon inflated in the conduit below the level of the fascia. The catheter is placed on gentle traction to occlude outflow, and then is filled with 1 5% contrast medium by gravity drip under fluoroscopic control. Should free bilateral reflux not be seen, a manometer can be connected and the pressures recorded at which reflux does occur (if at all). Results and Representative Case Reports The overall incidence of filling defects in the 40 loopograms was 20%. The defect most commonly seen was the turn-in construction defect of the proximal loop (five cases). Five patients with well defined defects in their small bowel conduits are presented as representative of the spectrum of this finding.

2 788 AMIS ET AL AJR:137, October 1981 Case 1 A 72-year-old man had a jejunal conduit constructed 1 4 months earlier after radiation therapy for transitional cell carcinoma of the bladder. Excretory unography performed to evaluate renal status demonstrated a 5 x 1 2 mm defect in the proximal loop (fig. 1). Loopography several days later again demonstrated the defect. The patient s condition deteriorated and 6 weeks later he died; autopsy examination showed a prominent turn-in defect resulting from dosure of the proximal end of the loop. Case 2 A 31 -year-old woman with lower thoracic myelodysplasia and paraplegia since birth had an ileal loop constructed 5 years earlier because of multiple urinary tract infections. Loopography was performed because of hematunia, fever, and passage of several tiny struvite stones from the conduit. The loopogram demonstrated stenosis of the midpart of the loop with multiple large stones retained proximal to the stenosis. Case 3 A 62-year-old man had fever, back pain, azotemia, and hematuna. Three months earlier a jejunal conduit had been constructed when recurrent colon carcinoma invaded the distal left ureter and bladder. The night kidney had been nonfunctioning for many years and its ureter was left undisturbed. The loopogram demonstrated no neflux to 35 cm water pressure (fig. 2A). A left percutaneous pyelogram indicated high grade obstruction at the ureterojejunal junction by a nonopaque calculus, probably of uric acid origin (fig. 2B). The 1 2 mm stone produced a discrete filling defect in the proximal conduit. An 8 French Silastic nephrostomy tube was placed percutaneously into the left collecting system. Allopuninol and oral sodium bicarbonate were begun because of a serum uric acid of 20.8 mg/ dl. One week later, urine passed spontaneously via the loop. A nephrostogram demonstrated an unobstructed system indicating stone Case 4 dissolution. A 68-year-old man with a 30 year history of recurrent ureterolithiasis had left flank pain and hematunia. Four years earlier an ileal conduit was constructed in Europe (Italy) because of bladder carcinoma. At loopography, no reflux into the uretens was demonstrated at loop pressures to 55 cm water (fig. 3A). Two round 1 cm defects were seen within the loop. Bilateral percutaneous pyelognaphy revealed dilated ureters terminating in the conduit at the filling defects (fig. 3B) with partial obstruction; in addition a stone was noted in the left mid ureter. Loop endoscopy demonstrated two smooth nipplelike protrusions at the ureteroileal anastomoses. A left uretenolithotomy was performed, and the loop was modified in Wallace-type fashion. Case 5 Fig. 1 -Case 1. Intravenous unognam. Filling defect in proximal loop (arrow). Autopsy 6 weeks later showed this to be surgical plication defect. A 43-year-old man had an ileal loop diversion 6 months earlier for grade III transitional cell carcinoma of the bladder. Excretory urognaphy performed because of hematunia demonstrated obstruction of the lower left ureter and a 4 cm filling defect within the distal ileal loop well away from the ureteroileal anastomoses (fig. 4A). Percutaneous pyelography revealed stnictuning of the left ureter above and at the ureteroileal junction (fig. 4B). Endoscopic biopsy A B Fig. 2.-Case 3. Uric acid stone caused obstruction of left ureter at point of anastomosis with conduit. A, Loopogram. No neflux up solitary left ureter. Nonopaque filling defect (solid arrow) in proximal loop. Foley catheter balloon in distal conduit (open arrow). B, Percutaneous pyelognam. Nonopaque 1 cm calculus (arrow) at uneterojejunal anastomosis.

3 AJR:137, October 1981 FILLING DEFECTS IN URINARY CONDUITS 789 Fig. 3.-Case 4. Unusual ileal loop with antinefluxing nipples. A, Loopogram. No neflux into ureters. Two 1 cm defects within loop. B, Antegnade pyelogram. Filling defects are antinefluxing. nippled distal ureters. Fig. 4.-Case 5. Bladder carcinoma metastatic to loop. A, Excretory urogram. Obstructed left kidney and large filling defect (arrow) in distal loop. B. Percutaneous pyelogram. Stenosis of distal left ureter (arrowhead) and of uretenojejunal anastomosis (open arrow). Filling defect in distal loop (solid arrows) surrounded by contrast. of the loop lesion demonstrated undifferentiated carcinoma consistent with the bladder primary. Subsequently, widespread metastatic disease was demonstrated. Discussion As originally described by Bnicken [1 ], construction of the ileal conduit involved separate end-to-side anastomoses of the uretens to the ileal segment and a layered closure of the proximal end of the loop (fig. 5A). As the proximal end of the loop is closed in layers, tissue is progressively turned in; this can appear as a discrete defect in the region of the closure, analogous to the inverted appendiceal stump (figs. 1 and 6). Closure of the proximal end of the loop has also been accomplished with stainless steel staples. This has been accompanied by formation of stones along the staple line [4] or around extruded staples which may lie free within the loop or be spontaneously passed through the stoma [5]. Stones have also formed on fragments of silk suture used for closure of the end of the loop and on foreign bodies inadvertantly introduced into the loop [6]. Stone formation without a preexisting foreign body nidus has also been reported [6, 7], particularly in the presence of loop stenosis (case 2). A ureteral calculus impacted at the ureteroconduit anastomosis can also present as a loop filling defect (fig. 2). In the Pyrah procedure [8], reported in 1 957, one ureter is anastomosed to the loop end-to-side as advocated by Bnicker [1 1 with the remaining ureter spatulated and anastomosed to the proximal open end of the loop (fig. 5B). In

4 790 AMIS ET AL AJR:137, October 1981,A D Fig. 7.-Antirefluxing small bowel urinary conduit diversions. A, Nippled ureters end-to-side. B, Nippled unetens end-to-end. C, Intussuscepted conduit. Fig. 5.-Refluxing small bowel urinary conduit diversions. A, Bricker. B, Pyrah. C, Wallace (1966). 0, Wallace (1970). E, Clank (V type). Fig. 6.-Layered closure results in tissue being progressively inverted which, in some cases, results in proximal loop defect , Wallace [9] spatulated the ureters and sutured their medial bonders together before anastomosing them to the proximal end of the conduit (fig. 5C). Because uretenic obstruction sometimes followed this method, in [10] Wallace advocated suturing the ureters head-to-tail before their anastomosis to the conduit (fig. 5D). In 1 978, Clark [1 1 ] described the V anastomosis in which both ureters are spatulated and joined together to form a single tube which is anastomosed to the proximal end of the conduit (fig. 5E). Recognizing the detrimental effects of free reflux of urine, particularly when infected, from the conduit into the upper tracts, several antireflux techniques of loop constructive have been described. These rarely performed procedures result in distinct radiographic appearances. Nippling of the ureters at the ureteroileal anastomoses (with or without submucosal tunneling) after the methods described by Turner-Warwick and Ashken [1 2] and Mathisen [1 3] has met with varying degrees of success. This procedure results in well defined, round filling defects at the uretenoconduit anastomoses (figs. 3A, 3B, and 7A). Also advocated has been a nippled side-by-side anastomosis of the ureters into the open end of the conduit (fig. 7B) [1 4, 15]. Another antinefluxing construction method has been the intussusception of the conduit at its midpoint [1 6] (fig. 7C). The intussusception is easily seen on loopography, with the proximal segment of the loop emptying easily through the intussusception on drainage films. If the technique of loop construction is known and a filling defect in the loop remains unexplained, other entities must be considered. Reported causes include blood clot [1 7], mucus cast [1 8], calculi [4-7], short areas of stenosis [19], air [20], and, most importantly, recurrent tumor at the uneteroconduit anastomoses or metastatic to other parts of the loop [21-26]. A case of conduit volvulus has been reported [27]; the radiographic appearance was typical, however, including the classic beak sign at the point of twist. Hematunia from an ileal conduit has been ascribed to vanices developing secondary to portal hypertension. These vanices seem to always occur at the mucocutaneous junction [1 7, 28]. There is not mention of vanicoid filling defects involving the loop itself in any of the reported cases. Primary small bowel tumors are rare, constituting about 1 % of all gastrointestinal tumors. No reports could be found of occurrence in small bowel segments used for urinary diversion.

5 AJR:137, October 1981 FILLING DEFECTS IN URINARY CONDUITS 791 Transitional cell carcinoma and cervical carcinoma involving the conduit have been reported, although the incidence is very low. Recurrent transitional cell carcinoma can involve the ureteroconduit anastomoses, but can also occur in the loop away from transitional epithelium or even at the stoma. These recurrences in sites remote from transitional epithehum probably represent metastases (case 5), although the possibility of tumor implanation at the time of original surgery cannot be excluded. In the reported cases, the time between the initial formation of the conduit and the development of recurrent tumor varied from 1 to 6 years. Gross hematunia prompted evaluation in most cases, but others were undergoing routine follow-up study when the lesions were discovered. Cytology is useful if positive [29], but if negative does not exclude the presence of tumor. High jejunal conduits are occasionally used in place of ileal segments, mainly in patients previously receiving pelvic irradiation. Construction techniques and their radiographic appearance and evaluation are virtually identical to the more common ileal conduits. Radiographic evaluation of the patient with a small bowel conduit usually involves only excretory urography. This establishes stability of the upper tracts. Progressive dilatation, inflammatory scanning, and stone formation in the upper tracts are indications for loopography. Since most uretenoconduit anastomoses are constructed to allow free reflux, the absence of neflux at loopognaphy suggests obstruction at the uretenoconduit anastomoses. Loopography also defines the length, position, lumen, and integrity of the conduit, and its ability to empty can be assessed by a drainage film or fluoroscopy. Other indications for loopography include stomal stenosis, hematunia, and positive urine cytology. Generally, when loopography is necessary to explain upper tract changes seen on the unogram, rescheduling will be necessary to allow contrast material to clear from the upper tracts. Failure to perform loopognaphy as a separate examination may cause reflux to be missed. When both unography and loopognaphy are dictated by such symptoms or findings, loopography should be performed first, again so that reflux will not be missed. Drainage of contrast material from nefluxing upper tracts must be complete before excretory urography. This can be determined by a plain film of the abdomen before injection of contrast material. When there is absence of reflux at loopognaphy in a system without antirefluxing mechanisms, obstruction is likely. Unography may inadequately visualize the obstructed upper tracts. In this situation, percutaneous antegrade pyelography may be necessary to further delineate the obstructed system. In summary, filling defects in a urinary conduit are uncommon but can usually be explained if one is aware of the surgical technique used in constructing the loop. Viewing the excretory urogram or percutaneous pyelogram in conjunction with the loopogram is helpful in evaluating defects at the ureteroconduit anastomoses such as antinefluxing nipples, stones, or recurrent tumor. If a lesion cannot be diagnosed with certainty, further studies are necessary. These include uninanalysis, exfoliative cytology of the conduit urine, and possibly endoscopic visualization of the lesion with biopsy. REFERENCES 1. Bnicker EM. Bladder substitution after pelvic evisceration. Surg Clin North Am 1950;30: Pitts WA Jr, Muecke EC. A 20-year experience with ileal conduits: the fate of the kidneys. J Urol 1979;1 22: Middleton AW Jr, Hendren WH. Ileal conduits in children at the Massachusetts General Hospital from to J Urol 1976;1 15: , Bergman SM, Sears NF, Javadpour N. 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