Role of CT in Postoperative Evaluation of Patients Undergoing Urinary Diversion

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1 Genitourinary Imaging Pictorial Essay Kawamoto and Fishman T in Urinary Diversion Genitourinary Imaging Pictorial Essay Downloaded from by on 04/29/18 from IP address opyright RRS. For personal use only; all rights reserved Satomi Kawamoto 1 Elliot K. Fishman Kawamoto S, Fishman EK Keywords: bladder cancer, complications, MDT, tumor recurrence, urinary diversion DOI: /JR Received June 16, 2009; accepted after revision ugust 25, oth authors: The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, 601 N aroline St., altimore, MD ddress correspondence to S. Kawamoto (skawamo1@jhmi.edu). ME This article is available for ME credit. See for more information. JR 2010; 194: X/10/ merican Roentgen Ray Society Role of T in Postoperative Evaluation of Patients Undergoing Urinary Diversion OJETIVE. The purpose of this article is to discuss and illustrate the MDT findings of potential complications after cystectomy and urinary diversion. ONLUSION. Multiple complications may occur after urinary diversion. Tumor recurrence is a major concern in patients with bladder cancer. T has an important role in postoperative evaluation of patients with urinary diversion to identify correctable causes early to prevent deterioration in renal function and detect tumor recurrence in patients who had bladder cancer. U rinary diversion is a well-established urologic procedure. The main indication for urinary diversion is to improve or replace the function of the urinary bladder in patients with bladder cancer, neurogenic bladder dysfunction, detrusor overactivity, and chronic inflammatory diseases of the bladder. For treatment of muscle-invasive and refractory superficial bladder cancer, radical cystectomy with a urinary diversion is considered the reference standard. The three most common types of urinary diversions are the incontinent, cutaneous diversion (conduit); continent, cutaneous catheterizable reservoir (pouch); and continent, urinary diversion to the intact native urethra (orthotopic neobladder) [1]. During the past decade, there has been increasingly frequent use of orthotopic reconstruction [2]. Multiple complications may occur after urinary diversion. They may be classified as early and late complications and may also be classified as directly or not directly related to the conduit or neobladder itself. Early complications (< 30 days after surgery) include bowel complications (ileus, obstruction, anastomotic leak, ischemia), infections (urinary tract infection pyelonephritis, abscess), postoperative fluid collections (urinomas, hematomas, lymphoceles), and urinary tract complications (anastomotic leak, obstruction, ischemia) [3]. hang et al. [4] reported that the overall early complication rate after radical cystectomy was 30.9%, with postoperative ileus being the most common minor complication, affecting 54 (18%) of 304 patients. Late complications include stone formation, infection, transmission of high bladder pressure to the upper urinary tract (reflux or functional obstruction), and physical obstruction at any site, most commonly at ureteroenteric anastomosis. These complications may cause deterioration in renal function [3]. orrectable causes should be identified early to prevent deterioration in renal function. T has an important role in detection of postoperative complications and recurrent tumor in patients with urinary diversion. The objective of this article is to discuss and illustrate the normal and abnormal findings after urinary diversion on MDT. T Technique T was performed with 16-MDT or 64- MDT scanners. For patients referred for routine follow-up, T was performed with oral and IV contrast administration at the venous and excretory phases. When complications or recurrence of tumor of the urinary tract were suspected after urinary diversion, T was performed using a T urography protocol, which typically included unenhanced, corticomedullary, venous nephrographic, and excretory phases. Multiplanar reformation images were created routinely, and 3D images were created when requested by the referring physician. Normal Postoperative ppearance fter Urinary Diversion The anatomy of the urinary diversion may vary depending on the types of urinary diversions. In ileal conduit urinary diversion, ureters extend to the ureteroileal anastomosis, 690 JR:194, March 2010

2 T in Urinary Diversion Downloaded from by on 04/29/18 from IP address opyright RRS. For personal use only; all rights reserved with ileal conduit extending to the urostomy (Figs. 1 and 2). In orthotopic neobladder urinary diversion, neobladder is seen extending to the midline lower pelvis and anastomosed to the urethra (Figs. 3 and 4). The ureters may be anastomosed to a segment of the bowel in a separate (ricker procedure) or conjoined (Wallace procedure) fashion (Figs. 1 and 3). In the classic ricker procedure, each ureter is sutured to the lateral aspect of the ileal conduit. In the Wallace procedure, both ureters are conjoined and sutured to the ileum. In right colonic urinary diversion, the colonic pouch is seen in the right lower quadrant. Intrarenal collecting systems are typically slightly wide after urinary diversion, either due to prior obstruction or to reflux. Urinary Leakage and Rupture Urinary leakage from anastomosis is an uncommon early complication and previous studies reported incidence of up to 1.1% [5]. On T, intraperitoneal urinary leak from ileal conduit or neobladder may be detected as extravasation of contrast material into the peritoneal space. scites may contain radiodense fluid, reflecting extravasated contrast material (Fig. 5). ssociated ileus may also be seen. If excretory images are not obtained, extravasation may not be seen. The leakage may also emanate from the anterior portion of the conduit that may not be entirely distended with contrast material. Postsurgical Fluid ollection/ Hematoma Postsurgical fluid collections such as urinoma, abscess, hematoma, and lymphocele can be seen as early postoperative complications. On T, hematoma is seen as a dense fluid collection (Fig. 6) that typically decreases in attenuation over time. The use of IV contrast enhancement helps to differentiate fluid collection, such as hematoma, from vascular complications, such as pseudoaneurysm (Fig. 6). Obstruction/Stricture at nastomosis or Reservoir The incidence of ureteral stricture after radical cystectomy with urinary diversion is reported with rates varying from 3% to 10% in the literature [6]. Ureteral ischemia is the most common cause of ureteroenteric anastomotic stricture. Ureteroenteric obstruction often is silent clinically and is detected by increased serum creatinine or on follow-up imaging studies [7]. Most cases of ureteroenteric anastomotic strictures occur within the first 1 2 years postoperatively but can occur several years after surgery [7]. On T, ureteral stricture is usually associated with hydronephrosis and delayed contrast excretion (Figs. 7 and 8). The involved ureteral wall may be thickened, and it may be difficult to differentiate a stricture with fibrosis from recurrent tumor. Urinary diversion enteric fistula is an uncommon complication after radical cystectomy and urinary diversion (Fig. 9) and reportedly occurred in 12 (2.2%) of 553 patients with a mean follow-up of 28.4 months [6]. Stone Formation Patients who undergo urinary tract diversion procedures have an increased risk of developing urolithiasis, particularly patients with an ileal conduit. In patients after urinary diversion, the underlying cause of urinary stone formation is multifactorial and includes metabolic, structural, infectious, and idiopathic factors. Most stones are primarily of struvite and are thus thought to be secondary to infection by urea-splitting organisms [8]. Stones may be seen within the kidney, ureter, or ileal conduit or in multiple locations (Fig. 10). The incidence of upper tract stones after ileal conduit diversion as reported in the literature varies from 2.6% to 13.4% [8]. Urinary Tract Infection Normal urothelium has several defense mechanisms against bacteria, such as voiding function to wash out bacteria and inhibitory action against bacterial adherence [7]. fter urinary diversion, some of the normal defense mechanisms are impaired and patients are susceptible to bacterial infection [7]. Madersbacher et al. [9] reported that clinically evident urinary tract infection occurred in 30 (23%) of 131 patients with ileal conduit who were followed for more than 5 years, and urosepsis occurred in five patients (3.8%). T findings of upper urinary tract infection include pyelonephritis and renal or perirenal abscess (Fig. 11). Deterioration of renal function may occur because of recurrent urinary tract infection, stone formation, and obstruction or reflux. Madersbacher et al. [9] found that radiographic (shrunken kidney or hydronephrosis) or functional (increased serum creatinine greater than 150 μmol/l [1.7 mg/dl]) deterioration was observed in 27% of patients at minimum follow-up of 5 years after ileal conduit urinary diversion. Local or Distant Tumor Recurrence ancer recurrence remains a major concern after cystectomy and urinary diversion in patients with bladder cancer. Tumor recurrence may present as local recurrence in the pelvis or as distant metastasis manifested as lymphatic or remote organ spread (Fig. 12). Transitional cell carcinoma (T) of the urothelium is often multifocal. Subsequent tumors may occur anywhere in the urinary tract after treatment of the initial carcinoma. Upper tract T after cystectomy for muscle invasive or refractory non-muscle-invasive bladder cancer are reported to occur in 2 8% of patients [10]. Possible risk factors include the presence of T in the distal ureter at cystectomy [11], multifocality, association with bladder carcinoma in situ [12], locally advanced stage at surgery (stage pt3a or greater) [13], and involvement of the prostatic urethra by T [10]. Upper tract T after cystectomy is usually high grade and the prognosis is poor [10]. lthough the role of routine imaging of the upper urinary tract in patients with bladder cancer is controversial, particularly for lowrisk patients [10], T urography can be useful in the detection and assessment of upper urinary tract tumors in patients who are suspected to have upper tract T after urinary diversion for bladder cancer. To detect upper urinary tract T, excretory phase T should be included [14]. Using high-resolution images obtained with thin-section MDT, detection of upper tract T may be improved. On T, T of the upper urinary tract is often seen as a focal intraluminal mass (Fig. 13), urothelial wall thickening with luminal narrowing (Fig. 14), and infiltrating mass. However, flat or early-stage tumors may be difficult or impossible to detect at T [15]. To evaluate T in the renal collecting system and ureter on excretory phase imaging in patients with bladder cancer, optimal opacification and distention are essential [14]. Late omplications Not Directly Related to Urinary Diversion The most common late complications unrelated to neobladder reconstruction leading to open surgery were incisional hernia (1.5%) and small-bowel obstruction (1.6%) [16] (Fig. 15). onclusion MDT can detect potential early and late complications of the urinary tract, recurrent tumors, and complications not directly related to urinary diversion. T has an important JR:194, March

Kawamoto and Fishman Downloaded from www.ajronline.org by 148.251.232.83 on 04/29/18 from IP address 148.251.232.83. opyright RRS.

T urography of urinary diversions with enhanced T digital radiography: preliminary experience. (editorial) J Urol 2005; 174:1859 2. Hautmann RE. Urinary diversion: ileal conduit to neobladder.

hang SS, ookson MS, aumgartner RG, Wells N, Smith J Jr. nalysis of early complications after radical cystectomy: results of a collaborative care pathway. J Urol 2002; 167:2012 2016 5.

3 Kawamoto and Fishman Downloaded from by on 04/29/18 from IP address opyright RRS. For personal use only; all rights reserved role to identify tumor recurrence and correctable causes of urinary complications early to prevent deterioration in renal function. References 1. Siegel. T urography of urinary diversions with enhanced T digital radiography: preliminary experience. (editorial) J Urol 2005; 174: Hautmann RE. Urinary diversion: ileal conduit to neobladder. J Urol 2003; 169: Sudakoff GS, Guralnick M, Langenstroer P, et al. T urography of urinary diversions with enhanced T digital radiography: preliminary experience. JR 2005; 184: hang SS, ookson MS, aumgartner RG, Wells N, Smith J Jr. nalysis of early complications after radical cystectomy: results of a collaborative care pathway. J Urol 2002; 167: Nieuwenhuijzen J, de Vries RR, ex, et al. Urinary diversions after cystectomy: the association of clinical factors, complications and functional results of four different diversions. Eur Fig. 1 Illustration showing ileal conduit urinary diversion. Ureters are anastomosed to segment of ileum (arrows) in conjoined (Wallace) fashion. Urol 2008; 53: ; discussion, Msezane L, Reynolds WS, Mhapsekar R, Gerber G, Steinberg G. Open surgical repair of ureteral strictures and fistulas following radical cystectomy and urinary diversion. J Urol 2008; 179: Hautmann RE, bol-enein H, Hafez K, et al. Urinary diversion. Urology 2007; 69: Turk TM, Koleski F, lbala DM. Incidence of urolithiasis in cystectomy patients after intestinal conduit or continent urinary diversion. World J Urol 1999; 17: Madersbacher S, Schmidt J, Eberle JM, et al. Long-term outcome of ileal conduit diversion. J Urol 2003; 169: Sved PD, Gomez P, Nieder M, Manoharan M, Kim SS, Soloway MS. Upper tract tumour after radical cystectomy for transitional cell carcinoma of the bladder: incidence and risk factors. JU Int 2004; 94: Kenworthy P, Tanguay S, Dinney P. The risk of upper tract recurrence following cystectomy in patients with transitional cell carcinoma involving Fig. 2 Normal T urography after ileal conduit urinary diversion in patient who underwent cystoprostatectomy and ileal conduit urinary diversion for bladder cancer. nterior volume-rendered image shows normal bilateral renal collecting systems and ureters anastomosed to ileal conduit. the distal ureter. J Urol 1996; 155: Zincke H, Garbeff PJ, eahrs JR. Upper urinary tract transitional cell cancer after radical cystectomy for bladder cancer. J Urol 1984; 131: alaji K, McGuire M, Grotas J, Grimaldi G, Russo P. Upper tract recurrences following radical cystectomy: an analysis of prognostic factors, recurrence pattern and stage at presentation. J Urol 1999; 162: Van Der Molen J, owan N, Mueller-Lisse UG, Nolte-Ernsting, Takahashi S, ohan RH. T urography: definition, indications and techniques a guideline for clinical practice. Eur Radiol 2008; 18: Kawamoto S, Horton KM, Fishman EK. Transitional cell neoplasm of the upper urinary tract: evaluation with MDT. JR 2008; 191: Hautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K, Mattes R, Paiss T. The ileal neobladder: complications and functional results in 363 patients after 11 years of followup. J Urol 1999; 161: , discussion Fig. 3 Illustration shows ileal neobladder urinary diversion. Ureters are anastomosed to segment of ileum (arrows) in conjoined (Wallace) fashion. 692 JR:194, March 2010

T in Urinary Diversion Downloaded from www.ajronline.org by 148.251.232.83 on 04/29/18 from IP address 148.251.232.83. opyright RRS.

4 Normal T urography after ileal orthotopic neobladder reconstruction in patient who underwent cystoprostatectomy and urinary diversion

, Oblique anterior 3D T urography image shows normal appearance of bilateral collecting systems and ureters anastomosed to neobladder.

5 Leak from ileal orthotopic neobladder in patient who underwent recent cystoprostatectomy and ileal orthotopic neobladder reconstruction

, xial contrast-enhanced T image shows amorphous contrast material immediately superior to ileal neobladder (arrowheads).

Small ascites (asterisk) is present, which is radiodense, suggestive of extravasated contrast material.

6 Pelvic hematoma and pseudoaneurysm 4 weeks after radical cystoprostatectomy and ileal conduit reconstruction for bladder cancer.

4 T in Urinary Diversion Downloaded from by on 04/29/18 from IP address opyright RRS. For personal use only; all rights reserved Fig. 4 Normal T urography after ileal orthotopic neobladder reconstruction in patient who underwent cystoprostatectomy and urinary diversion for bladder cancer., nterior volume-rendered T image shows neobladder in pelvis (asterisk)., Oblique anterior 3D T urography image shows normal appearance of bilateral collecting systems and ureters anastomosed to neobladder. There is duplication of left collecting system. Fig. 5 Leak from ileal orthotopic neobladder in patient who underwent recent cystoprostatectomy and ileal orthotopic neobladder reconstruction for bladder cancer. Patient had abdominal pain, distention, and nausea., xial contrast-enhanced T image shows amorphous contrast material immediately superior to ileal neobladder (arrowheads)., xial T image inferior to shows ileal neobladder containing contrast material (arrow). Small ascites (asterisk) is present, which is radiodense, suggestive of extravasated contrast material., Sagittal reformation image shows amorphous contrast material (arrowheads) superior to neobladder (arrow), indicating leak. Fig. 6 Pelvic hematoma and pseudoaneurysm 4 weeks after radical cystoprostatectomy and ileal conduit reconstruction for bladder cancer. There was drop in hemoglobin in early postsurgical period and recurrent fever. T angiography was performed for suspected pseudoaneurysm found by previous T for evaluation of hematoma or abscess., xial unenhanced T image shows hematoma in pelvis., rterial phase sagittal image shows large pseudoaneurysm (arrow) surrounded by large hematoma. ngiography showed pseudoaneurysm with feeding branches from left and right internal pudendal arteries and left obturator artery, and patient was successfully treated with coil embolization. JR:194, March

7 enign ureteral stricture in patient 6 months after cystoprostatectomy and ileal conduit diversion for bladder cancer.

, xial image shows thickening and contrast enhancement of distal left ureter (arrow) near anastomosis to ileal conduit.

Excreted contrast seen in normal caliber right ureter (arrowhead).

Renal ultrasound showed left hydronephrosis and left perinephric fluid collection.

and, Excretory phase axial () and anterior volume-rendered () images show mild left hydronephrosis and contrast extravasation into perinephric and

, Patient had left percutaneous nephrostomy placement.

Patient underwent ureteral reimplantation. Fig.

5 Kawamoto and Fishman Downloaded from by on 04/29/18 from IP address opyright RRS. For personal use only; all rights reserved Fig. 7 enign ureteral stricture in patient 6 months after cystoprostatectomy and ileal conduit diversion for bladder cancer., oronal multiplanar reformation (MPR) image shows moderate hydronephrosis of left kidney., xial image shows thickening and contrast enhancement of distal left ureter (arrow) near anastomosis to ileal conduit., Excretory phase coronal MPR image shows dilated left ureter (arrows) and thickening of distal left ureter near anastomosis to ileal conduit. Excreted contrast seen in normal caliber right ureter (arrowhead). Ureteroscopy showed left distal ureteral stricture, and biopsy was negative for malignancy. Fig. 8 Worsening left pelvic pain and fever. Renal ultrasound showed left hydronephrosis and left perinephric fluid collection. Patient underwent cystoprostatectomy and ileal conduit urinary diversion for bladder cancer 7 days previously. and, Excretory phase axial () and anterior volume-rendered () images show mild left hydronephrosis and contrast extravasation into perinephric and periureteral regions. Left distal ureter is not opacified due to filling defect, which was thought to be clot., Patient had left percutaneous nephrostomy placement. Nephrostogram in prone position several months after surgery shows stricture of distal left ureter at anastomosis (arrow). Patient underwent ureteral reimplantation. Fig. 9 Ureteroenteral fistula in patient 4 months after radical cystectomy and ileal orthotopic neobladder reconstruction for bladder cancer. Patient had recurrent abdominal pain and fever and recurrent urinary tract infections on right side. Nephrostomy was placed for right hydronephrosis., oronal reformation image shows mild right hydroureter extending to right lower quadrant (arrowheads) and is closely related to adjacent distal small bowel (arrow). Ileal neobladder (asterisk) is seen in pelvis., Percutaneous right nephrostomy is in place. Nephrostogram in pone position shows fistula from distal right ureter to terminal ileum (arrows) and contrast material fills colon. t surgery, right ureteral stricture was found. Patient was treated with repair of ureteroenteric fistula. Pathologically, distal right ureter had fibrosis and chronic inflammation, but there was no evidence of tumor. 694 JR:194, March 2010

T in Urinary Diversion Downloaded from www.ajronline.org by 148.251.232.83 on 04/29/18 from IP address 148.251.232.83. opyright RRS. For personal use only; all rights reserved Fig.

rterial phase anterior volume-rendered image shows 7-mm calculus in lower pole of left kidney (arrow) with adjacent renal cortical scarring.

11 Recurrent urinary tract infection with urinary conduit stomal stenosis and bilateral hydronephrosis in patient who underwent radical cystoprostatectomy and ileal conduit urinary diversion for

, Excretory phase axial image shows bilateral hydronephrosis. Subtle filling defects (arrows) are seen within right renal pelvis.

Fluoroscopic gravity loopogram and ultrasound before and after surgery showed resolution of filling defects within left renal pelvis, and they were thought to represent clot, inflammatory debris, or

12 Liver and bone metastases in patient who underwent radical cystectomy with ileal conduit urinary diversion and left nephrectomy for upper and lower tract transitional cell carcinoma with

6 T in Urinary Diversion Downloaded from by on 04/29/18 from IP address opyright RRS. For personal use only; all rights reserved Fig. 10 alculi in ileal conduit and in left kidney in patient who underwent ileal conduit urinary diversion for neurogenic bladder in childhood. Patient has recurrent urinary tract infections and stones. rterial phase anterior volume-rendered image shows 7-mm calculus in lower pole of left kidney (arrow) with adjacent renal cortical scarring. There are also multiple calculi (arrowheads) within ileal conduit in right lower quadrant. Fig. 11 Recurrent urinary tract infection with urinary conduit stomal stenosis and bilateral hydronephrosis in patient who underwent radical cystoprostatectomy and ileal conduit urinary diversion for bladder cancer more than 20 years previously. Patient had abdominal pain and positive urine cultures for Escherichia coli. Urine cytology showed acute inflammatory cells and candida species., Excretory phase axial image shows bilateral hydronephrosis. Subtle filling defects (arrows) are seen within right renal pelvis., Excretory phase coronal image with wide window setting shows filling defects (arrows) in left renal pelvis. Patient underwent stomal revision. Fluoroscopic gravity loopogram and ultrasound before and after surgery showed resolution of filling defects within left renal pelvis, and they were thought to represent clot, inflammatory debris, or fungus ball. Fig. 12 Liver and bone metastases in patient who underwent radical cystectomy with ileal conduit urinary diversion and left nephrectomy for upper and lower tract transitional cell carcinoma with adenocarcinoma differentiation., xial T image shows multiple hypodense masses in liver that developed during follow-up, compatible with metastases., nterior volume-rendered image shows interval development of mixed sclerotic and lytic lesion involving L3 vertebral body, representing bone metastasis. Fig. 13 Multiple transitional cell carcinoma (T) in renal pelvis on both sides in patient 2 years after undergoing cystectomy and left ureterectomy with ileal interconnection with continent diversion for refractory bladder carcinoma in situ with distal left ureteral involvement. and, rterial () and excretory phase oblique axial () T images show multiple masses (arrows) in bilateral renal pelvis. Excretory phase oblique axial T image () shows multiple masses (arrows) in bilateral renal pelvis, seen as filling defect in left renal pelvis. There is delayed excretion of contrast material from right kidney due to hydronephrosis. Masses were high-grade papillary T with widespread involvement of ureter and renal pelvis on both sides. There was invasion through muscularis propria of ureter and into renal parenchyma bilaterally (stage pt3). JR:194, March

14 Infiltrating high-grade transitional cell carcinoma (T) in renal pelvis in patient 4 months after undergoing radical cystoprostatectomy and segmental

, rterial phase axial () and coronal () images and excretory phase coronal () image show diffuse thickening and stranding of left renal pelvis and proximal

Pathologically, there was infiltrating high-grade T in renal pelvis invading renal parenchyma. Fig.

carcinoma of urethra. Patient has undergone neoadjuvant chemoradiation therapy.

7 Kawamoto and Fishman Downloaded from by on 04/29/18 from IP address opyright RRS. For personal use only; all rights reserved Fig. 14 Infiltrating high-grade transitional cell carcinoma (T) in renal pelvis in patient 4 months after undergoing radical cystoprostatectomy and segmental ureterectomy for bladder cancer and left distal ureteral involvement. Patient developed hematuria and positive urine cytologies with high-grade T., rterial phase axial () and coronal () images and excretory phase coronal () image show diffuse thickening and stranding of left renal pelvis and proximal ureter (arrows) extending to calyces. Left kidney is atrophic, and there is mild left hydronephrosis. Pathologically, there was infiltrating high-grade T in renal pelvis invading renal parenchyma. Fig. 15 Small-bowel obstruction with scrotal hernia in patient 3 years after undergoing cystoprostatectomy and urethrectomy with ileal conduit for squamous cell carcinoma of urethra. Patient has undergone neoadjuvant chemoradiation therapy. and, xial images of pelvis () and scrotum () show multiple dilated small-bowel loops in abdomen and pelvis extending into scrotum. There are multiple areas of adhesions and nondistended bowel loops (arrowheads, ) near ileal conduit. Urostomy is seen in right lower quadrant (arrow, ). t surgery, there were multiple adhesions but no evidence of tumor recurrence. FOR YOUR INFORMTION This article is available for ME credit. See for more information. 696 JR:194, March 2010

Radical cystectomy and urinary diversion: Normal anatomy and complications

Radical cystectomy and urinary diversion: Normal anatomy and complications Poster No.: C-0648 Congress: ECR 2014 Type: Scientific Exhibit Authors: J. M. Marin, N. alegre, P. Perez Martin, A. Velarde Pedraza