Multi-modality Imaging of Urinary Diversion Complications

1. Daniel Oppenheimer, M.D. Daniel_Oppenheimer@urmc.rochester.edu Brett Talbot, M.D. Shweta Bhatt, M.D. RavinderSidhu, M.D. Multi-modality Imaging of Urinary Diversion Complications

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

3. 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

4. Types of Urinary Diversion • Ureterosigmoidostomy • Ileal/colon conduit • Continent Cutaneous Reservoir • OrthotopicNeobladder

5. 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with rectal voiding • Increased risk of colorectal cancer, metabolic acidosis and renal failure • Has now largely been replaced by other techniques Axial CECT image of a ureterosigmoidostomy (arrows)

6. Ileal Conduit Urinary Diversion • Ileal conduit urinary diversion was gold standard until introduction of orthotopicneobladder • 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

7. Advantages of Ileal loop urinary diversion • Technically simpler operation, shorter operative time compared to continent reconstructions • Ideal for patients with medical comorbidities to decrease perioperative complications • Short gut diverting segment limits enteric absorption of urine waste products, limiting metabolic abnormalities • Recommended diversion method in renal insufficiency or hepatic dysfunction

8. Disadvantages of Ileal loop urinary diversion • Requires external appliance and stoma care • Altered self image/impact on quality of life • Stomal complications including parastomalhernia, stomal stenosis and bleeding/skin irritation

9. 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

10. OrthotopicNeobladder • 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

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

12. Post-operative Fluid Collections • Urinoma • Best evaluated on delayed excretory phase images as enhancing fluid due to contrast accumulation • Usually treated with percutaneous drainage and stenting over the site of leak • Hematoma • Heterogeneous, non-enhancing collection near surgical site • Abscess • Air within a collection with thickened enhancing wall suggests infection, although air may also be seen if drainage catheters are present

13. 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

14. 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

15. 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

16. Bowel Obstruction • Most commonly secondary to adhesions near the enteroenteric anastomosis • Radiologic findings: • Dilated bowel loops with air-fluid levels proximal to site of obstruction • Abrupt change in intestinal caliber • Acute complete/high grade obstruction requires immediate surgical correction, whereas partial obstruction is usually managed conservatively

17. 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

18. 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

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

20. Hydronephrosis Initial Exam 1 year later 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

21. 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

22. Parastomal Hernia Axial and sagittal reformatted CECT images demonstrate herniation of small bowel loops (thinarrows) through the stoma defect (thick arrow)

23. 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

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

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

26. 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)

27. 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

28. 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

29. 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).

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

31. Urolithiasis • Late complication – rare within first 2 years of surgery • Best evaluated on NECT • More common in continent reconstructions • Multifactorial etiology • Incomplete emptying/residual urine • Exposed surgical material/staples • Chronic bacteriuria • Metabolic alteration of urine content • Obstruction

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

33. 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

34. 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

35. 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. • HautmannRE. 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, RibalMJ. Follow-up after surgical treatment of bladder cancer: a critical analysis of the literature. EurUrol. 2012 Aug;62(2):290-302. • Stenzl A, Sherif H, Kuczyk M. Radical cystectomy with orthotopicneobladder for invasive bladder cancer: a critical analysis of long term oncological, functional and quality of life results. IntBraz J Urol. 2010 Sep-Oct;36(5):537-47. • Sung DJ, Cho SB, Kim YH, Oh YW, Lee NJ, Kim JH, Chung KB, CheonJ. Imaging of the various continent urinary diversions after cystectomy. J Comput Assist Tomogr. 2004 May-Jun;28(3):299-310.