Multi-modality Imaging of

Urinary Diversion Complications

Daniel Oppenheimer, M.D.

Daniel_Oppenheimer@urmc.rochester.edu

Brett Talbot, M.D.

Shweta Bhatt, M.D.

Ravinder Sidhu, M.D.

Purpose

This educational exhibit will discuss current options of surgical urinary diversion and detail the imaging findings of frequently encountered post operative complications

Introduction Radical Cystectomy (RC) and Urinary Diversion (UD) is a

technically challenging operation with significant morbidity Accurate and prompt identification of post-operative

complications is essential to preserving renal function, improving quality of life and survival

Complications can occur up to 20 years or more after surgery, emphasizing the need for close long-term follow-up

The radiologist plays a pivotal role in identifying postoperative complications by providing a timely diagnosis for the Urologist and other clinicians to intervene upon

Several other complications including urinary incontinence, sexual dysfunction, metabolic alterations and decreased renal function are common following RC and UD, but not well evaluated radiologically

Types of Urinary Diversion Ureterosigmoidostomy Ileal/colon conduit Continent Cutaneous Reservoir Orthotopic Neobladder

Ureterosigmoidostomy

First developed technique in surgical urinary diversion

Continent, with rectal voiding

Increased risk of colorectal cancer, metabolic acidosis and renal failure

Has now largely been replaced by other techniques

Axial CECT image of a ureterosigmoidostomy (arrows)

Ileal Conduit Urinary Diversion Ileal conduit urinary diversion

was gold standard until introduction of orthotopic neobladder

Ureters anastomosed to a segment of isolated ileum which is brought to the surface of the abdominal wall.

Urine continually drains from the ureters, through the anastomosed loop of bowel and is collected in a bag through the stoma

Advantages of Ileal loop urinary diversion Technically simpler operation, shorter

operative time compared to continent reconstructionsIdeal for patients with medical comorbidities to

decrease perioperative complications Short gut diverting segment limits enteric

absorption of urine waste products, limiting metabolic abnormalitiesRecommended diversion method in renal

insufficiency or hepatic dysfunction

Disadvantages of Ileal loop urinary diversion Requires external appliance and stoma care Altered self image/impact on quality of life Stomal complications including parastomal

hernia, stomal stenosis and bleeding/skin irritation

Continent Cutaneous Diversion

Low pressure reservoir is constructed from detubularized bowel and a catheterizable connection is created between the reservoir and the skin

The reservoir stores urine and is intermittently catheterized

Enables continence with no need for external appliance, but requires patient motivation/education regarding lifelong self catheterization using sterile technique

Indiana Pouch continent cutaneous urinary diversion

Orthotopic Neobladder Reservoir created from

detubularized bowel which is anastomosed to the native urethra

Relies upon natural sphincter muscles to maintain continence

Facilitates restoration of normal voiding mechanism and maintains patient self-image Gaining popularity Requires careful patient selection

○ Contraindicated if urethra is non-functional or involved with tumor

○ Requires active patient training/participation to ensure full return of spontaneous voiding

Complications of Urinary Diversion

*Complications can occur 20+ years after surgery, emphasizing the need for close monitoring and frequent follow up

Early Complications• Fluid collections

• Abscess• Lymphocele• Urinoma• Hematoma

• Bowel obstruction/Ileus

• Hydronephrosis

• Stomal complications

• Pyelonephritis/infection

• Fistula

Late Complications*• Anastomotic stricture/stenosis

• Recurrent UTIs/Pyelonephritis

• Urolithiasis

• Oncologic Recurrence

Post-operative Fluid Collections

UrinomaBest evaluated on delayed excretory phase images

as enhancing fluid due to contrast accumulationUsually treated with percutaneous drainage and

stenting over the site of leak Hematoma

Heterogeneous, non-enhancing collection near surgical site

AbscessAir within a collection with thickened enhancing wall

suggests infection, although air may also be seen if drainage catheters are present

Abscess

Axial CECT image demonstrates a thick walled enhancing collection in the pre-sacral region (dashed oval) with a focus of luminal gas (arrow) and surrounding infiltrative changes, consistent with abscess

Lymphocele Caused by surgical transection or injury to

lymphatics, often following lymphadenectomy Homogeneous collection with thin wall When large, lymphoceles can compress adjacent

structures including the ureters, blood vessels and bowel, resulting in pain, hydronephrosis, venous thrombosis, abdominal distension and bowel obstruction

Delayed CECT helpful to distinguish from urinoma If large or infected, treatment options include

percutaneous or surgical drainage, simple aspiration, sclerotherapy and peritoneal marsupialization

Lymphocele

Axial CECT and corresponding PETCT images in a patient recently post-op from radical cystectomy and ileal conduit urinary diversion demonstrates a thin walled peripherally enhancing, peripherally hypermetabolic low attenuation collection in the pelvis (arrow), later proven to be a lymphocele

Bowel Obstruction

Most commonly secondary to adhesions near the enteroenteric anastomosis

Radiologic findings:Dilated bowel loops with air-fluid levels

proximal to site of obstructionAbrupt change in intestinal caliber

Acute complete/high grade obstruction requires immediate surgical correction, whereas partial obstruction is usually managed conservatively

Small Bowel Obstruction

Axial CECT images demonstrate stomal stenosis (arrow) resulting in bowel obstruction, evidenced by dilated small bowel loops with multiple air fluid levels

Hydronephrosis

Common with conduit urinary diversion due to reflux

Can also be seen in the setting of urinary obstruction secondary to oncologic recurrence, stomal stenosis, stricture or calculus

Chronic hydronephrosis can result in renal parenchymal scarring, atrophy and deterioration of renal function

Hydronephrosis

Grayscale sonographic image demonstrates moderate right hydronephrosis in a patient with an ileal conduit urinary diversion

Hydronephrosis

Initial axial CECT image demonstrates moderate right and severe left hydronephrosis. Chronic hydronephrosis has resulted in parenchymal volume loss in the left kidney one year later

Initial Exam 1 year later

Stomal Complications Include parastomal hernia, stomal stenosis

and bleeding/skin irritation Majority occur within first 5 years of surgery Stenosis or hernia may be recognized by

difficulty catheterizing or decreased urostomy output

Obesity and old age are risk factors of developing parastomal hernia

Surgical revision is an option for hernias, although they frequently recur

Parastomal Hernia

Axial and sagittal reformatted CECT images demonstrate herniation of small bowel loops (thin arrows) through the stoma defect (thick arrow)

Pyelonephritis/Ureteritis Bacterial colonization occurs in nearly 100% after

continent cutaneous diversion, but clinical symptoms are rare if urine flow remains unobstructed

Stasis of urine secondary to reflux, incomplete voiding or obstruction (caused by oncologic recurrence, stricture, stomal stenosis or urolithiasis) can result in infection

While asymptomatic bacteriuria is seen in the majority of patients, symptomatic infection is less common, and urosepsis is rare.

Chronic suppressive antibiotic therapy is only indicated in patient’s with recurrent UTIs

Ureteritis

Axial CECT images demonstrate enhancement of the left renal pelvis and bilateral ureters (arrows), consistent with inflammation due to infection

Fistula Affects approximately 0.2-2% of patients after

urinary diversion Enterourinary, enterogenital or enterocutaneous Prior pelvic radiation predisposing factor Can be reduced with careful closure of the

anastomosis or pouch, stenting of the ureteroenteric anastomosis

Early treatment with percutaneous drainage often results in spontaneous closure of fistula, although surgical revision may be required

Fistula

Loopogram image demonstrates contrast filling the normal loops of diverting bowel and refluxing up both ureters (arrows), but also extraluminal contrast in the left upper pelvis in an enterocutaneous fistula (dashed oval)

Stricture Affects approximately 3-10% of patients after urinary

diversion Most commonly at ureteroenteric anastomosis, usually

secondary to ischemia of the distal ureter resulting in fibrosis

Left ureter > right ureter due to angulation and longer mobilization

Benign strictures usually smooth and short segment Malignant strictures often irregular and long with enhancing

soft tissue component on CT 4-50% success with endoscopic management, surgical

ureteral re-implantation ~80% successful May be reduced with meticulous surgical technique,

minimal ureteral dissection, assuring well-perfused segment, and careful apical suture placement

Anastomotic Stricture

Fluoroscopic images from a nephrostogram demonstrate a stricture at the ureteroenteric anastomosis (arrow), which was subsequently dilated with a 7 mm x 4 cm balloon

Stricture

Loopogram image (left) demonstrates abrupt non-opacification of the distal left ureter extending proximally secondary to a stricture (arrow). Corresponding coronal reformatted CECT image demonstrates non-opacification of mid-distal ureter secondary to a distal ureteral stricture (arrow).

Stricture

Nephrostogram/loopogram image demonstrates an irregular stricture in the mid right ureter (arrow), later biopsy proven urothelial carcinoma

Urolithiasis

Late complication – rare within first 2 years of surgery

Best evaluated on NECT More common in continent reconstructions Multifactorial etiology

Incomplete emptying/residual urineExposed surgical material/staplesChronic bacteriuriaMetabolic alteration of urine contentObstruction

Urolithiasis

Axial CECT demonstrates a large calculus (arrow) layering dependently in the Indiana pouch

Oncologic Recurrence Local recurrence rate ~5-15% within 5 years, often

within 2 years of surgery Higher stage and malignant nodal disease associated

with greater risk of recurrence and poor survival Up to 70% with local recurrence also have distant

metastasis May manifest as an obstructing stricture, pelvic soft

tissue mass or lymphadenopathy Symptoms include macrohematuria and pain Symptomatic recurrence has worse prognosis compared

to incidentally discovered recurrence because symptoms are often due to locally advanced disease

Oncologic Recurrence

Loopogram (left) and coronal reformatted CECT images (right) demonstrate a lobulated filling defect in the distal left ureter (dashed oval, arrow), later biopsy proven urothelial carcinoma recurrence

References Burger M, et al. ICUD-EAU International Consultation on Bladder Cancer 2012: Non-muscle-invasive

urothelial carcinoma of the bladder. Eur Urol. 2013;63(1):36-44. Catalá V, Solà M, Samaniego J, Martí T, Huguet J, Palou J, De La Torre P. CT findings in urinary diversion

after radical cystectomy: postsurgical anatomy and complications. Radiographics. 2009 Mar-Apr;29(2):461-76. doi: 10.1148/rg.292085146.

Hautmann RE. Urinary diversion: ileal conduit to neobladder. J Urol 2003;169:834–42. Hautmann R, Volkmer B, Abol-Enein H, et al. 2nd International Consultation on Bladder Cancer: urinary

diversion. ed. 2. Paris, France: International Consultation on Urological Diseases– European Association of Urology; 2012.

Hautmann RE, Hautmann SH, Hautmann O. Complications associated with urinary diversion. Nat Rev Urol 2011;8:667–77.

Kim JK, Jeong YY, Kim YH, Kim YC, Kang HK, Choi HS. Postoperative pelvic lymphocele: treatment with simple percutaneous catheter drainage.Radiology. 1999;212:390-4.

Madersbacher S, Schmidt J, Eberle JM, Thoeny HC, Burkhard F, Hochreiter W, Studer UE. Long-term outcome of ileal conduit diversion. J Urol. 2003 Mar;169(3):985-90.

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 Apr;179(4):1428-31.

Soukup V, Babjuk M, Bellmunt J, Dalbagni G, Giannarini G, Hakenberg OW, Herr H, Lechevallier E, Ribal MJ. Follow-up after surgical treatment of bladder cancer: a critical analysis of the literature. Eur Urol. 2012 Aug;62(2):290-302.

Stenzl A, Sherif H, Kuczyk M. Radical cystectomy with orthotopic neobladder for invasive bladder cancer: a critical analysis of long term oncological, functional and quality of life results. Int Braz J Urol. 2010 Sep-Oct;36(5):537-47.

Sung DJ, Cho SB, Kim YH, Oh YW, Lee NJ, Kim JH, Chung KB, Cheon J. Imaging of the various continent urinary diversions after cystectomy. J Comput Assist Tomogr. 2004 May-Jun;28(3):299-310.