90% of bladder tumours are transitional cell carcinoma (TCC), the remaining 10% of cases are squamous cell carcinoma, adenocarcinoma and sarcoma.

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1 The Role of the Interventional Radiologist in Management of Post-Radical Cystectomy Ureteral Obstruction : A Case Review of Retrograde Transileal Conduit Ureteric Stents. Poster No.: C-2288 Congress: ECR 2014 Type: Authors: Keywords: DOI: Educational Exhibit J. P. Das, B. Hutchinson, P. Navin, P. McCarthy; Galway/IE Outcomes, Education and training, Cancer, Stents, Instrumentation, Complications, Percutaneous, Fluoroscopy, CT, Urinary Tract / Bladder, Pelvis, Interventional non-vascular /ecr2014/C-2288 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 8

2 Learning objectives The objective of this review is to describe the technique employed and the potential complications encountered by the interventional radiologist in the management of ureteral obstruction in patients with ileal conduits following radical cystectomy for the management of bladder cancer. Background Bladder cancer in the developed world accounts for the majority (60%) of cases worldwide. The incidence is increasing, by over one third from the early 90s, and continues to rise (5) 90% of bladder tumours are transitional cell carcinoma (TCC), the remaining 10% of cases are squamous cell carcinoma, adenocarcinoma and sarcoma. Indications for radical cystectomy and ileal conduit urinary diversion include superficial or infiltrating/locally invasive TCC with resectable loco-regional metastases (Stage T2-3b) and primary adenocarcinoma, SCC, or sarcoma. Complications can occur in almost one third of patients post radical cystectomy with ureteroileal anastomotic obstruction occuring in up to 15% of cases (1,2) Minimally invasive percutaneous stenting of uretero-ileal strictures by an interventional radiologist is often preferred to open surgical revision given the potentially hazardous post-radiotherapy surgical environment and limiting associated comorbid factors associated and present in bladder cancer patients (1) Successful outcomes following percutaneous retrograde transileal conduit ureteric stent insertion range from 76% to 92% over 1-3 years (6) (identical to that of open surgery) further endearing this minimally invasive technique to the referring urologist. Findings and procedure details Findings Page 2 of 8

3 9 patients post-radical cystectomy were referred for image-guided placement of retrograde transileal ureteric stents between March 2011 and October Patient population consisted of 7 males and 2 females. The mean age was 67 years ( range years) 27 retrograde stents (6 unilateral, 21 bilateral) were placed. Indications for stent placement were ureteric-conduit anastamotic stricture formation with associated complications of acute renal failure and hydronephrosis, and routine exchange of previosly placed nephroureteral stents. Procedure details The placement of retrograde transileal ureteric stents is performed in four stages: 1. Antegrade nephrostomy insertion Antegrade nephrostomy inertion acts as a urinary diversion from the anastomosis. This is performed with the patient prone and under conscious sedation. Initial puncture of the lower pole renal calyx is performed using a 21G needle under ultrasound. Exchange of this using an and subsequently a inch stiff guidewire is then performed. Dilation up to 10F for placement of a single pigtail nephrostomy drain within the renal pelvis is then performed. 2. Retrograde nephroureteroconduit stent insertion Using the antegrade nephrostomy tube a inch j-tipped guidewire is passed into the renal pelvis and proximal ureter and the initial nephrostomy catheter is removed. A 5F catheter is placed over this guidewire which are then advanced into the ileal conduit. The guidewire and catheter are then manipulated out through the ileal conduit orifice (Figure 2) The guidewire is then exchanged for a super-stiff guidewire and the 5F catheter is then removed. A single pigtail catheter is then placed retrogradely and a drainage bag is placed over the ileal conduit. 3. Removal of antegrade nephrostomy following nephrostogram. Page 3 of 8

4 10 days post- nephroureteroconduit stent placement a nephrostogrm is performed. Contrast is introduced antegradely with the patient in the supine or prone position to demonstrate satisfactory flow of contrast from the renal pelvis into the ileal conduit. The antegrade nephrostomy is then removed (Figure 3) 4. Routine interval retrograde transileal exchange of nephroureteric stent. Under conscious sedation and the patient lying in the supine position, a guidewire is passed through the existing nephrouretertioconduit stent which is then exchanged over the guidewire (Figure 4) In our patient population, routine exchange of nephroureteric stent was performed at three monthly intervals. No significant complications were recorded in our patient group. Potential complications encountered by the interventional radiologist include inability to cross strictures using a guidewire which can result in the need for surgical revision (3), and dislodgement of the nephrostomy catheter. Delayed complications include urosepsis secondary to catheter encrustation and occlusion, dislodgement of the retrograde catheter and bleeding from an antegrade nephrostomy catheter (3) Images for this section: Page 4 of 8

5 Fig. 1: Left nephrostomy tube with guidewire through the nephrostomy site exiting out the ileal conduit orifice Page 5 of 8

6 Fig. 2: Bilateral transileal ureteric stents. Left nephrostogram post exchange of left retrograde nephroureteral stent following removal of temporary antegrade nephrostomy. Page 6 of 8

7 Fig. 3: Left single pigtail nephroureteroconduit stent in situ. Page 7 of 8

8 Conclusion Placement of transileal conduit retrograde ureteric stents over existing antegrade nephrostomies is both safe and effective in manageing post-radical cystectomy ureteral obstruction. Personal information References 1. Tal R, Bachar GN, Baniel J, Belenky A. External-internal nephro-uretero-ileal stents in patients with an ileal conduit: long-term results. Urology 2004; 63: Di Marco DS, LeRoy AJ, Thieling S, Bergstralh EJ, Segura JW. Long-term results of treatment for ureteroenteric strictures. Urology 2001; 58: Zaleski GX et al.placement of retrograde nephroureteral stents through ileal conduits AJR 1998; 170: Alago Jr. W et al. Placement of transileal conduit retrograde nephroureteral stents in patients with ureteral obstruction after cystectomy: technique and outcome. AJR 2008; 191: Bladder-estimated incidence, all ages, both sexes GLOBOCAN 2008: Estimated cancer Incidence, Mortality, Prevalence and Disability-adjusted life years (DALYs) Worldwide in International Agency for Research on Cancer (IARC), World Health Organization 6.Tal R, Sivan B, Kedar D, Baniel J. Management of benign ureteral strictures following radical cystectomy and urinary diversion for bladder cancer. J Urol 2007; 178: Page 8 of 8