Daniel Rodríguez B, et al. GÉNITOURINARIO Usefulness of multidetector computed tomography in the postoperative evaluation of urinary diversion surgery

Daniel Rodríguez B(1), Richard Mast V(1), Albert Pons E(1), Eugenia de Lama S(1), Francesc Vigués J(2), Oscar Natoli V(1).

1. Radiology Department, Hospital Universitaria de Bellvitge, L´Hospitalet de Llobregat. Barcelona - España. 2. Urology Department, Hospital Universitaria de Bellvitge, L´Hospitalet de Llobregat. Barcelona - España.

Abstract: Urinary diversion surgeries are procedures that are becoming more frequent, as their indications are not only neoplastic, being useful also in managing other diseases. Due to this increase, it is not uncommon to observe secondary complications, whether in the early postoperative period (less than 30 days after surgery) or later (more than 30 days). Within these are alterations in intestinal motility (paralytic ileus, blockage), anastomotic leaks, fluid collections (lymphocele, urinoma, abscess), fistulas, parastomal herniation, ureteral obstruction, urolithiasis and tumor recurrence. Given the large number of surgical techniques used in these procedures, it is important to know the resulting anatomical changes, occasionally difficult to evaluate. Multidetector computed tomography (MDCT) is of great use in the study of these patients, especially with multiplanar reconstruction techniques, adequately representing the affected urinary and extra-urinary structures, and their relationship to adjacent structures, enabling their accurate and quick identification. Keywords: , Multidetector computed tomography, Postoperative complications, Urinary diversion.

Resumen: Las cirugías de derivación urinaria son procedimientos que cada vez son más frecuentes, ya que sus indicaciones no son sólo neoplásicas, siendo también útiles en el manejo de otras patologías. Debido a este incremento, no es infrecuente observar complicaciones secundarias, ya sean en el postoperatorio temprano (menos de 30 días después de la cirugía) o tardío (más de 30 días). Dentro de éstas tenemos alteraciones de la motilidad intestinal (íleo paralítico, obstrucción), fugas anastomóticas, colecciones líquidas (linfocele, urinoma, absceso), fístulas, herniación paraestomal, estenosis ureterales, litiasis y recurrencia tumoral. Dada la gran cantidad de técnicas quirúrgicas usadas en estos procedimientos, es importante conocer los cambios anatómicos resultantes, ocasionalmente de difícil valoración. La tomografía computarizada multidetector (TCMD) tiene gran utilidad en el estudio de estos pacientes, especialmente mediante las técnicas de reconstrucción multiplanar, representando adecuadamente las estructuras urinarias y extraurinarias afectadas, y sus relaciones con estructuras adyacentes, permitiendo identificarlas acertada y rápidamente. Palabras clave: Cistectomía, Complicaciones postquirúrgicas, Derivación urinaria, Tomografía computarizada multidetector.

Rodríguez D, et al. Utilidad de la tomografía computarizada multidetector en la evaluación postoperatoria de cirugías de derivación urinaria. Rev Chil Radiol 2014; 20(2): 68-74. Correspondence: Daniel Rodríguez Bejarano / [email protected] Paper received 03 March 2014. Accepted for publication 22 May 2014.

Introduction Criteria for choosing a technique are: patients age, The main indication for radical cystectomy is a general condition, curative vs. palliative character of bladder tumor which invades muscle (T2 or greater) the surgery, renal function, tumor stage, intestinal or at high risk of invasion, without metastasis. Less pathology, previous RT, among others(1). common indications include neurogenic bladder, in- Due to the large number of existing techniques, terstitial cystitis (IC) or lesions from radiation therapy the correct interpretation of postoperative radiological (RT). At present there are various surgical techniques findings is complicated. In order to achieve a correct for urinary diversion, which are usually complex. diagnosis, the knowledge of surgical techniques and

68 Revista Chilena de Radiología. Vol. 20 Nº 2, año 2014; 68-74. GÉNITOURINARIO postoperative anatomy, is essential. This article illus- uroexcretory system we will place the patient in the trates the surgical techniques most used for performing prone or lateral position depending on the affected urinary diversion, describing the normal postsurgical system; this change in the position of the patient is changes and complications derived thereof. performed if their baseline conditions permit.

Surgical techniques The surgical techniques used can be divided into continent and incontinent. The first consists in making reservoirs from intestinal segments (ileum). These circular shaped reservoirs are made using incisions in the antimesenteric edge of the loop, in order to avoid physiological peristalsis that increases the pressure within the reservoir and, hence, leaks can occur. To perform these types of procedures, the patient must have adequate renal function that can compensate for the metabolic acidosis that the urine may cause on the intestinal segment used as a reservoir. In this regard, the ileum has more advantages compared to the colon, since it presents less risk of acidosis, supports higher urinary volumes and allows shorter resections than the colon. Among the continent pro- cedures, the most performed in our institution is the Figure 1. Coronal CT reconstruction that shows in excretory Studer technique. The incontinents, of heterotopic phase both uroexcretory systems and the entero-ureteral character, are used more widely in our environment anastomosis with the Bricker loop more distally (arrowhead). and within them are , , ileal ureterostomy (Bricker), cystostomy, among others(1-4). Early complications (<30 days after surgery) Bowel transit disorders: These are caused by the Radiological evaluation presence of adynamic ileus or bowel obstruction. The Before performing a study, the radiologist specia- use of MDCT with multiplanar reconstructions allows lizing in urological pathology should know the normal identification of the cause of the obstruction, with a postoperative anatomy of the urinary diversion surgeries. sensitivity of 90-96% and a specificity of 96% in the The anatomy changes depend on the type of diversion, diagnosis of complete obstructions(7,8). The ileus is showing, for example, the extension of the usually secondary to small bowel manipulation during at the ureteroileal anastomosis and the ileal conduit surgery. It presents in 20%, and appears as a uniform towards the skin in the Bricker technique (Figure 1), dilatation of bowel loops with air-fluid levels within, the formation of an ileal reservoir and the formation of witn no identifiable obstructive causes (Figure 2)(2). a “chimney” where the ureters anastomose (Studer), In the obstruction, dilation of the loops proximal to the ureters are anastomosed to the abdominal wall the obstruction site occurs. In this case the loops (ureterostomy), among others(4-5). MDCT is a useful in vicinity to the entero-enteric anastomosis and tool that allows a rapid assessment of the urinary tract. usually due to the presence of adhesions, are not It also allows the use of multiplanar and 3D volumetric visible using this technique, being a diagnosis of reconstructions that allow the correct identification of exclusion (Figure 3). When this complication occurs, extra-urinary complications (e.g. paralytic ileus, fluid it is necessary to reoperate the patient(1,8,9). collections) and without interference with intestinal air/gas, which would not be visible using techniques such as intravenous urography(6). 2a 2b In our hospital, where we have two units of MDCT, the study technique commonly used consists of a triple phase after IV administration of iodinated contrast. The first phase is in portal phase (65 seconds), then late phase (180 seconds) and finally an ultra late phase of between 8 and 15 minutes to detect late leaks in the entero-ureteral anastomosis. Very occasionally an arterial phase is added in cases of suspected bleeding or vascular complication. All these image acquisitions Figure 2. Adynamic ileus. MDCT axial (a) and coronal are performed with the patient in supine position, (b) shows generalized dilatation of small bowel loops with except when we find functional delay or ectasia in contrast inside, width unchanged.

69 Dr. Daniel Rodríguez B, et al. Revista Chilena de Radiología. Vol. 20 Nº 2, año 2014; 68-74.

3a 3b 5a 5b

Figure 3. Intestinal occlusion. MDCT axial (a) and coronal Figure 5. Urinoma in the form of a polylobulated fluid (b) showing generalized dilatation of small bowel loops up collection in right hemipelvis (arrow). Volume is located to a certain point, where abrupt change in width can be to the enteroureteral anastomosis and urinoma diagnosis seen (arrows) in the postoperative hernia. was confirmed by fine needle aspiration and secondly on performing evacuation by drainage.

Urinary leakage: A rare complication (1-4%)(10). For a correct diagnosis we must be able to rely on 6a 6b single phase, corticomedullary and excretory. The latter phase is of importance to observe contrast extravasation by the ileal conduit or the neobladder, being more usual at the level of the ureteral-reservoir anastomosis (Figure 4)(1,11).

4a 4c

Figure 6. Recently postoperative (Bricker) patients who presented pelvic hematoma (arrow) in image a) and subcutaneous fluid collection compatible with seroma (arrowhead) in image b). 4b

Lymphoceles are usually present in patients who undergo lymphadenectomy plus cystectomy. They present a uniform appearance (homogeneous), located in relation with surgical clips (Figure 7). Usually these lymphoceles are treated conservatively. All collec- tions mentioned above are susceptible to infection Figure 4. MDCT images (a, b) and coronal reconstruction (c) and abscess formation, observed as a thick-walled showing contrast leakage in the entero-ureteral anastomosis collection which enhance after contrast (Figure 8)(1). (arrows) and multiple collections surrounding (arrowhead). The patient underwent surgery after 24 hours. 7a 7b

Fluid collections: They are located at the bottom of the cystectomy and can mimic the morphology of the bladder. These include urinoma, lymphocele, abscesses or hematomas. In the diagnosis of urino- ma it is important to carry out the excretory phase, in order to visualize the accumulation of contrast in the collection (Figure 5)(11); if the diagnosis remains unclear, the collected fluid can be analyzed (elevated Figure 7. Recently postoperative (Bricker) patient who levels of creatinine and decreased glucose levels will (1 presents a fluid collection in left hemipelvis (arrows) confirm diagnosis) ). These urinomas can be handled adjacent to lymphadenectomy clips (arrow); lymphocele (11) by drainage placement . Regarding hematomas, a extends medial and adjacent to the iliac vessels (arrow). dense heterogeneous collection is observed, that The diagnosis was confirmed by puncture and CT-guided typically reduces attenuation over time (Figure 6)(12). percutaneous drainage.

70 Revista Chilena de Radiología. Vol. 20 Nº 2, año 2014; 68-74. GÉNITOURINARIO

(2) 8a 8b low intravesical pressure of said reservoirs . The presence of recurrent infections, as well as lithiasis and/or reflux can cause significant deterioration of the renal function (Figure 11)(12). It can also present as an early complication.

Figure 8. Recently postoperative (Bricker) patient presenting pneumoperitoneum. (image a -arrowheads). In the coronal reconstruction (image b) generalized dilatation of small bowel loops (arrows) and small adjacent collection to wall continuity solution in ileal loop in relation to perforation (arrows), is observed.

Fistulas: These can be entero-urinary, entero- genital or entero-cutaneous, more commonly situated Figure 10. Inhomogeneous renal parenchyma with alternation toward the intestinal anastomosis. The latter are usually of edematous areas and kidneys with globular appearance managed with an indwelling ; in the case of (arrows). entero-genital fistulas is required in order to drain the urine and in some cases it may even require temporary or permanent 11a 11b ureteral occlusion(2,13). Pelvic radiation serves as a predisposing factor(1,12). Urinary obstruction: It is not frequently seen early, but if it occurs, is due to failures in the development of the surgical technique or edema in the anastomosis (Figure 9), which in severe cases can even make necessary the reconstruction of the anastomosis(1).

9a 9b Figure 11. Patient who went to the emergency department for fever and worsening renal function. History of Bricker diversion surgery 3 years ago. MDCT axial (a) and coronal (b) shows left renal abscesses (arrowhead) with posterior pararenal loculated fluid of linflammatory appearance (arrow) and multiple lithiasis in lower left calyceal group, ipsilateral middle and pelvis (arrows).

Lithiasis: The incidence of lithiasis in these pa- tients is similar to that of the general population and Figure 9. Stenosis in the enteroureteral anastomosis the prevalence varies according to the series and type (arrows), of irregular morphology, hypercaptant with prominent of intervention (3-43% according to series and type surrounding vessels. of surgery)(15). The etiology is multifactorial(12) and as risk factors we have bacterial colonization, metabolic Late complications (> 1 month after surgery) disorders as a result of the procedure, urinary stasis Urinary tract infection: This is as a result of alte- and exposure of nonabsorbable surgical material with rations of the defense mechanisms by the surgery, the urine(15). Most of these calculus are made of struvite resulting in increased susceptibility to the development and can be located in the reservoir, in the ileal conduit or of these infections (Figure 10)(14). In approximately upper urinary tract. For correct diagnosis it is important 80% of the patients with ileal conduits or cutaneous to perform a non-contrast phase (Figure 12), since the diversions, bacteriuria2) appears. delay in identification would imply the development of In continent reservoirs performing catheterization an obstructive uropathy and a possible impairment of implies the development of bacteriuria, although renal function(1,12). Management of the lithiasis varies with less development of pyelonephritis, given the according to location and the type of diversion(15).

71 Dr. Daniel Rodríguez B, et al. Revista Chilena de Radiología. Vol. 20 Nº 2, año 2014; 68-74.

12a 12b Ureteral stenosis: Presents an incidence ranging from 3-10% in the literature(1). Usually observed 1-2 years after surgery, but it can be seen years later(14). The most common etiology of this com- plication is distal ureteral ischemia, followed by failures in the development of the technique and tumor recurrence(1). Clinically insidious, detected by the increase in serum creatinine and in MDCT by hydronephrosis and delayed elimination of the contrast (Figure 15). It is important to take into Figure 12. MDCT study of Bricker control patient intervened account the difficulty of differentiating between two years ago. Axial image (a) showing acute pelvicalyceal a ureteral stenosis with associated fibrosis and ectasia (arrowhead). In the coronal reconstruction (b) lithiasis tumor recurrence(12). Regarding the management in the entero-ureteral anastomosis (arrow) can be seen. of this complication, surgical revision continues to be the definitive long term treatment(17). Parastomal herniation: Of frequent appearance, predominantly in Bricker type diversions (Figure 13). Obesity, plays a major role, for developing this condition, as does advanced age. Regarding the management of these hernias, surgical repairs are moderately suc- cessful(16). Another complication not directly related to the urinary diversion and usually observed are the incisional hernias (Figure 14)(12).

Figure 13. Patient who in CT control for Bricker secondary to Figure 15. Beaded ectasia of left uroexcretor system to the high-grade bladder tumor presented parastomal herniation anastomosis where a long stenosis, regular without lesion adjacent to Bricker loop under the skin (arrows). that suggests recurrence, can be seen (arrow).

Tumor recurrence: Presents an incidence of 2-8%(18). As risk factors to present this complica- tion are found the tumor stage (pT3a or greater), transitional cell carcinoma in the distal during cystectomy, multifocal tumor or that affects the prostatic urethra(1,12,18). One study suggests that the compromise of the juxtavesical ureteral segment or intramural during cystectomy has an increased risk of anastomotic recurrence and poor prognosis(19). In the CT it can be seen as a focal intralumi- nal mass, ureteral wall thickening, infiltrating soft Figure 14. Postsurgical simple eventration through anterior tissue mass, hydronephrosis or lymphadenopathy abdominal wall (arrows) with no signs of complication. (Figures 16, 17 and 18)(1,12). 72 Revista Chilena de Radiología. Vol. 20 Nº 2, año 2014; 68-74. GÉNITOURINARIO

16a 16b Bibliography 1. Catalá V, Solá M, Samaniego J, Martí T, Huguet J, Palou J, et al. CT Findings in Urinary Diversion after Radical Cystectomy: Postsurgical anatomy and com- plications. Radiographics 2009; 29: 461-476. 2. Tejerizo JC, Schiappapietra J, Quijada Folgar E. Derivaciones urológicas bajas. Módulo: cirugía re- constructiva urológica. Programa de actualización continua y a distancia en urología. Sociedad Argentina de Urología. Módulo 2: 2002. 3. Amis ES, Newhouse JH, Olsson CA. Continent Urinary Figure 16. Patient with deteriorating general condition and Diversions: Review of Current Surgical Procedures and appearance of hematuria through Bricker loop. Solid mass in Radiologic Imaging. Radiology 1988; 168: 395-401. the distal ureter adjacent to the anastomosis (short arrows) 4. Keogan MT, Carr L, McDermott VG, Leder RA, Webster that conditions retrograde ureteral dilatation predominantly GE. Continent Urinary Diversion Procedures: Radio- left (long arrow). graphic Appearances and Potential Complications. AJR 1997; 169: 173-178. 17a 17b 5. Sung DJ, Cho SB, Kim YH, Oh YW, Lee NJ, Kim JH, et al. Imaging of the Various Continent Urinary Diversions After Cystectomy. J Comput Assist Tomogr 2004; 28: 299-310. 6. Mattei A, Birkhaeuser FD, Baermann C, Warncke SH, Studer UE. To Stent or not to Stent Perioperatively the Ureteroileal Anastomosis of Ileal Orthotopic Bladder Substitutes and Ileal Conduits? Results of a Prospective Randomized Trial. J Urol 2008; 179(2): 582-586. 7. Furukawa A, Yamasaki M, Furuichi K, Yokoyama Figure 17. Patient who went to emergency room for K, Nagata T, Takahashi M, et al. Helical CT in the deteriorating general condition. a) solid mass compatible Diagnosis of Small Bowel Obstruction. RadioGraphics with local recurrence in the distal ureter adjacent to the 2001; 21(2): 341-355. anastomosis (arrowhead). b) left retroperitoneal para-aortic 8. Silva AC, Pimenta M, Guimaraes LS. Small Bowel adenopathies (arrow). Obstruction: What to Look For. Radiographics 2009; 29: 423-439. 9. Mullan CP, Siewert B, Eisenberg RL. Small Bowel 18a 18b Obstruction. AJR 2012; 198: W105-W117. 10. Nieuwenhuijzen JA, De Vries RR, Bex A, Van der Poel HG, Meinhardt W, Antonini N, et al. Urinary Diversions After Cystectomy: The Association of Clinical Factors, Complications and Functional Re- sults of Four Different Diversions. Eur Urol 2008; 53: 834-842. 11. Titton RL, Gervais DA, Hahn PF, Harisinghani MG, Arellano RS, Mueller PR. Urine Leaks and Urino- Figure 18. Patient who went to emergency room for signs mas: Diagnosis and Imaging-guided Intervention. of intestinal occlusion. Bricker type diversion intervention Radiographics 2003; 23: 1133-1147. performed two years previously. CT was performed on 12. Kawamoto S, Fishman EK. Role of CT in Postope- admission showing carcinomatosis (arrowhead) signs with rative Evaluation of Patients Undergoing Urinary occlusive signs in small bowel loops (*) and local recurrence Diversion. AJR 2010; 194: 690-696. in the distal ureter adjacent to the anastomosis (arrow). 13. Yu NC, Raman SS, Patel M, Barbaric Z. Fistulas of the Genitourinary Tract: A Radiologic Review. Radiographics 2004; 24: 1331-1352. Conclusion 14. Hautmann RE, Abol-Enein H, Hafez K, Haro I, Mansson Given the complexity and increase in the per- W, Mills RD, et al. Urinary diversion. Urology 2007; formance of urinary diversion surgery, it is crucial to 69: 17-49. establish close cooperation between the urologist 15. Okhunov Z, Duty B, Smith AD, Okeke Z. Management and radiologist. of Urolithiasis in Patients After Urinary Diversions. So it is essential that the radiologist knows the BJU Int 2011; 108: 330-336. type of procedure performed, postoperative MDCT 16. Kouba E, Sands M, Lentz A, Wallen E, Pruthi RS. findings and its possible complications, always using Incidence and Risk Factors of Stomal Complications in Patients Undergoing Cystectomy with Ileal Conduit a common language to provide the necessary sup- Urinary Diversion for . J Urol 2007; port. This will allow a timely and efficient detection of 178: 950-954. these complications and in this way be able to treat 17. Tal R, Sivan B, Kedar D, Baniel J. Management of them properly. Benign Ureteral Strictures Following Radical Cys- 73 Daniel Rodríguez B, et al. Revista Chilena de Radiología. Vol. 20 Nº 2, año 2014; 68-74.

tectomy and Urinary Diversion for Bladder Cancer. 94: 785-789. J Urol 2007; 178: 538-542. 19. Yossepowitch O, Dalbagni G, Golijanin D, Donat 18. Sved PD, Gomez P, Nieder AM, Manoharan M, Kim SM, Bochner BH, Herr HW, et al. Orthotopic Urinary SS, Soloway MS. Upper Tract Tumour After Radical Diversion after Cystectomy for Bladder Cancer: Cystectomy for Transitional Cell Carcinoma of the Implications for Cancer Control and Patterns of Bladder: Incidence and Risk Factors. BJU Int 2004; Disease Recurrence. J Urol 2003; 169: 177-181.