Radical cystectomy and urinary diversion: Normal anatomy and complications

Transcription

1 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 ; Leganés Madrid, Ma/ES, Leganes, sp/es, Leganes/Madrid/ES, 4 Madrid/ES Keywords: Diagnostic procedure, CT, Urinary Tract / Bladder, Abdomen, Outcomes DOI: /ecr2014/C-0648 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 16

2 Aims and objectives BACKGROUND: Throughout the evolution of urinary diversion surgery, multiple surgical techniques have been developed in the search for a safer method to achieve adequate control of the underlying condition of the patient, which is one that meets the patient's needs and involve minimal risk of complications both short and long term. The objectives that arise when urinary diversion is indicated have evolved over the years; in the past only the protection of the upper urinary tract was intended, while currently the primary objective is the restoration of the pre- surgery natural state, in the pursuit of better quality of life for the patient. The evolution of the urinary diversion surgery has gone through three pathways where multiple surgical procedures have been developed: - Incontinent cutaneous diversion - Continent cutaneous diversion - Continent diversion to the native urethra (orthotropic neobladder ) At present, the realization of a orthotopic neobladder is the ideal technique for any patient. Radical cystectomy (RC) with urinary diversion (UD) is a complex procedure, in wich several early and late complications may occur such as: Alterations in intestinal motility, anastomotic leaks, fluid collections (abscess, urinoma, lymphocele, hematoma), fistulas, peristomal herniation, calculi formation and tumor recurrence. CT is the ideal technique to assess both the postsurgical anatomy and complications. Multiplanar reformating and 3D volume rendering images are very useful for anatomic assessment and reach a diagnosis. With this poster we pretend to: -Illustrate the normal anatomy after the procedures performed in our Hospital for radical cystectomy (RC) and urinary diversion (UD). - Discuss the most appropriate CT urography protocol - Review early and late complications after these procedures. Page 2 of 16

3 Methods and materials A longitudinal study that included all patients who underwent surgical procedures for RC and UD from 2000 to present day was performed in our Hospital. Data were obtained from surgical and radiology reports as well as from an administrative database. The sample includes 113 individuals (98 males and 15 females) with mean age of 66.5 years, with muscle-invasive bladder cancer (98%) and other bladder diseases (2%), bladder neuropathy, post radiation cystitis. Surgical procedures for RC and UD performed in our Hospital were: Continent (15%): Orthotopic bladder replacement with Studer technique. Incontinent (85%): Cutaneous ureterostomy, Ileal conduit creation with Bricker procedure and ureterosigmoidostomy with Goodwin technique. We found that alterations of bowel transit and postsurgical fluid collections were the most frequent early complications whereas urinary obstruction and calculi formation were the most common late complications. MDCT PROTOCOL In our Hospital, studies are performed with a multidetector 32-channel CT scanner. We follow this protocol: - After fasting for at least 6 hours, the patient ingests 1 Lt of water over 30 minutes before the exam. - Abdominopelvic unenhanced images are acquired. - After intravenous administration of 120 ml contrast material, images in two phases are aquired: nephrographic study (90 seconds after the injection) and excretory phase study (approximately 10 minutes after the contrast injection). -At the workstation we use both two-dimen-sional and 3D postprocessing techniques, including MPR, MIP and volume rendering. Page 3 of 16

4 Results The surgical procedures performed in our Hospital for urinary diversion were: INCONTINENT TECHINIQUES: Cutaneous ureterostomy: One of the technically easiest and fastest procedures performed only when the use of intestinal segments is not posible, for example in patients with bowel disease or serious medical conditions. Both ureters are anastomosed to the anterior abdominal wall. Figure 1. Ileal conduit creation (Bricker procedure): In this procedure both ureters are anastomosed to a reservoir made with a segment of ileum, then the ileal stoma is anastomosed to the abdominal wall, usually in the right flank. Figure 2. CONTINENT TECHNIQUES: Ureterosigmoidostomy: Although this procedure resolves the problem of external drainage, it is associated with the number of complications, which include hipercholoremic acidosis, ureteral reflux, pyelonephritis, calculi formation, and development of colonic tumors. Now it is a procedure into desuse in our Hospital. Figure 3. Orthotopic bladder replacement: In the literatury orthotopic neobladder construction is now the most frequent technique performed for urinary diversion, specially for young patients. In this procedure the reservoir (made with an ileal segment) is anastomosed to the native urethra, therefore preserving the voluntary voiding and improving the quality of life of the patient. Figure 4. Postsurgical complications were: Page 4 of 16

5 Urinary leakage and rupture This uncommon complication is suspected when extravasation of contrast material into the peritoneal space is seen. The excretory is the most useful phase for detecting this complication. Figure 5. Postsurgical fluid collection/ hematoma This complication is common in the early postoperative period. Hematoma typically appears as a dense collection that decreases in attenuation over the time. Figure 6. Obstruction/stricture at the anastomosis or reservoir site Ureteroenteric obstruction is usually silent clinically and is detected by increased serum creatinine or on follow-up exams.imaging studies. It can occur several years after the surgery. Fig 9. Stone formation Patients who undergo urinary tract diversion procedures have an increased risk of developing urolithiasis, particularly patients with an ileal conduit. The calculi formation is multifactorial. Figure 7 and 8. Urinary tract infection Patients with urinary diversion are susceptible to urinary infections because of the loss of the normal defense mechanisms. Local or distant tumor recurrence Tumor recurrence is a major concern in patients with urinary diversion because of its frequent multifocal nature. It may present as local recurrence or distant lymphatic / remote organ metastasis. The excretory phase is important for the detection of upper urinary tract recurrence. Fig 10. Images for this section: Page 5 of 16

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7 Fig. 1: CT performed 6 days after cutaneous ureterostomy in a patient that underwent radical cystectomy for bladder cancer. Anterior volume-rendered image shows double J stents placed in both ureters. The white arrow shows a pig-tail stent for drainage of a pelvic postsurgical collection. Page 7 of 16

8 Fig. 2: Volume-rendered CT image shows postoperative changes in a patient after radical cystectomy and ileal conduit construction. The long black arrow shows the uretero-ileal anastomosis, the short black arrow shows the ileal conduit and the white arrow shows the mechanical suture of the ileo-ileal anastomosis. Fig. 3: Volume rendered image shows both ureters anastomosed to the sigma (asterisk). Page 8 of 16

9 Fig. 4: Volume rendered CT image in a 50 year-old patient that underwent radical cystectomy and orthotopic bladder replacement. The asterisk shows the reservoir (orthotopic neobladder). Page 9 of 16

10 Fig. 5: Urinary leak. Volume rendered image (a), coronal (b) and sagital (c) reformated images obtained in a patient a week after urinary diversion with the Bricker procedure. White arrow in a and black arrows in b and c show urinary extravasation near one of the uretero-ileal anastomosis. Page 10 of 16

11 Fig. 6: Postsurgical fluid collection. Axial CT image in excretory phase (a) and oblique reformatted image (b) obtained in a patient 6 days after radical cystectomy and urinary diversion with Bricker procedure, show a small fluid collection with an air bubble (white arrows) that doesn't enhances after the contrast administration. The thin white arrow in a, shows the ileal reservoir, the black arrows show the ureteral stents. Fig. 7: Axial CT image of a patient that underwent radical cystectomy and neobladder construction for bladder cancer, shows a calculus in the reservoir. Page 11 of 16

12 Fig. 8: Coronal reformated CT image in the same patient as figure 3. The arrow shows a calculus in the distal ureter near the uretero-sigma anastomosis. The asterisk shows the sigma. Page 12 of 16

13 Fig. 9: Intestinal obstruction. Axial CT image in excretory phase obtained in a patient that underwent radical cystectomy and urinary diversion with Bricker procedure. The asterisk shows dilated fluid-filled small-bowel loop near the ileo-ileal mechanical suture (arrow). Adhesions were found at surgery. Page 13 of 16

14 Fig. 10: Axial CT image in early excretory phase in a patient that underwent radical cystectomy and neobladder construction. The arrow shows a filling defect suspected to be a recurrent tumor. This finding is not confirmed in a later phase with the patient prone. Page 14 of 16

15 Conclusion - Radical cystectomy with urinary diversion surgeries are complex procedures that frequently lead to complications, therefore it is important for the radiologist to be familiar with the postoperative anatomy and to be aware of the possible complications (related or not to the surgery). - MDCT is the best method to assess postsurgical anatomy and detect early and late complications; the urography protocol must be optimized for better detection of complications. - In our Hospital are performed more often incontinent urinary diversion procedures. - Complications that occur most often after RC and UD are similar to those described in the literature. Personal information References 1. Hautmann Richard E., Abol-Enein Hassan et al. Urinary diversion. Journal Urology 2006; 05: Catalá Violeta, Solà Marta et al. CT Findings in Urinary Diversion after Radical Cystectomy: Postsurgical Anatomy and Complications. RadioGraphics 2009; 29: Kawamoto Satomi, Fishman Elliot K. Role of CT in Postoperative Evaluation of Patients Undergoing Urinary Diversion. American Journal of Roentgenology 2010; 194: Pnincenthal Robert A., Lowman Robert. Ureterosigmoidostomy: The Development of Tumors, Diagnosis, and Pitfalls. American Journal of Roentgenology : Page 15 of 16

16 5. Heaney Michael 0., Francis Isaac A, et al. Orthotopic Neobladder Reconstruction: Findings on Excretory Urography and CT. American Journal of Roentgenology 1999;172: Page 16 of 16