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CT Findings in Uri- Nary Diversion After Radical Cystectomy: Postsurgical Anatomy and Complications1

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CT Findings in Uri- Nary Diversion After Radical Cystectomy: Postsurgical Anatomy and Complications1 Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights. EDUCATION EXHIBIT 461 CT Findings in Uri- nary Diversion after Radical Cystectomy: Postsurgical Anatomy and Complications1 Violeta Catalá, MD • Marta Solà, MD • Jaime Samaniego, MD • Teresa OnLine-OnLY CME Martí, MD • Jorge Huguet, MD • Juan Palou, MD • Pablo De La Torre, MD See www.rsna .org/education /rg_cme.html Numerous surgical procedures have been developed for urinary diver- sion in patients who have undergone a radical cystectomy for bladder cancer or, less frequently, a benign condition. Because urinary diver- LEARNING sion procedures are complex, early and late postsurgical complications OBJECTIVES frequently occur. Possible complications include alterations in bowel After reading this article and taking motility, anastomotic leaks, fluid collections (abscess, urinoma, lym- the test, the reader phocele, and hematoma), fistulas, peristomal herniation, ureteral stric- will be able to: ■■Describe the main tures, calculi, and tumor recurrence. Computed tomography (CT) is surgical procedures an accurate method for evaluating such events. Multiplanar reformat- used to create a uri- nary diversion after ting and three-dimensional volume rendering of multidetector CT im- radical cystectomy. age data are particularly useful for achieving an accurate and prompt ■■Discuss optimal diagnosis of complications and obtaining information that is essential multidetector CT technique for post- for adequate surgical management. In addition, knowledge of urinary surgical evaluation. diversion procedures, normal postsurgical appearances, and optimal ■■Identify normal CT technique for postsurgical evaluations is essential for detecting anatomy, common and uncommon complications and avoiding misdiagnosis. complications of © urinary diversion, RSNA, 2009 • radiographics.rsnajnls.org and potential diag- nostic pitfalls. TEACHING POINTS See last page Abbreviation: 3D = three-dimensional RadioGraphics 2009; 29:461–476 • Published online 10.1148/rg.292085146 • Content Codes: 1From the Departments of Radiology (V.C., M.S., J.S., T.M., P.D.L.T.) and Urology (J.H., J.P.), Fundació Puigvert, Cartagena 340-350, Barcelona 08025, Spain. Recipient of a Certificate of Merit award for an education exhibit at the 2007 RSNA Annual Meeting. Received May 19, 2008; revi- sion requested July 2 and final revision received September 6; accepted September 9. All authors have no financial relationships to disclose. Address correspondence to V.C. (e-mail: [email protected]). ©RSNA, 2009 462 March-April 2009 radiographics.rsnajnls.org Introduction Table 1 The most frequent indication for radical cystec- Description of Surgical Procedures Most tomy is a muscle-invasive (stage T2 or higher) Commonly Used for Urinary Diversion bladder tumor or high-risk high-grade noninvasive Incontinent cutaneous diversion muscle disease with no evidence of distant me- Cutaneous ureterostomy: Both ureters are anas- tastasis. Less frequently, radical cystectomy may tomosed directly to the anterior abdominal be performed to treat benign conditions such as wall. bladder neuropathy, damage from irradiation, or Ileal conduit creation: An ileal segment of interstitial cystitis. Numerous surgical procedures 15–20 cm is isolated, and both ureters are have been developed for urinary diversion after anastomosed to its proximal end. The distal radical cystectomy. The type of surgical procedure end provides urinary drainage to a cutaneous to be used is decided after the patient is informed stoma (Fig 1). about the possible advantages and disadvantages Continent diversion of each surgical technique. Relevant criteria for Cutaneous diversion with Kock technique (1): A 70–80-cm length of ileum is used. With the selecting the most appropriate technique include central 50-cm segment, a reservoir is created. the patient’s age, overall physical condition, and The remaining proximal and distal segments intestinal, hepatic, and renal function; the tumor are used to create two valves in an antireflux stage; and whether the patient previously under- system: One valve provides cutaneous egress, went abdominal radiation therapy. and the other is anastomosed to the ureters. More than 50 surgical procedures for urinary This procedure is technically more difficult diversion have been described. Because these than others, and complications often occur in procedures are complex, early and late post- relation to the antireflux mechanism. surgical complications are frequent. Computed Cutaneous diversion with colonic reservoir tomography (CT) is an accurate method for de- creation: A segment of colon is detubularized tecting these complications. The diversity of the and folded to form the reservoir (Fig 2). Con- tinence is provided by a catheterizable tunnel surgical procedures and of the resultant postop- and stoma created from the appendix with a erative anatomic changes makes image interpreta- cuff of cecum. The mesentery is preserved. tion difficult. Familiarity with the normal postop- Orthotopic bladder replacement (neobladder erative anatomy and with optimal CT technique construction) with Studer (2) (Fig 3), Haut- is essential to achieve correct diagnosis. mann (3), and Padovan (4) techniques: In all In this article, we review various surgical tech- three procedures, a 40–60-cm ileal segment is niques used for urinary diversion after radical used to construct a neobladder. The techniques cystectomy, discuss optimal CT technique for differ in the configuration of the neobladder postsurgical evaluation, and describe the imaging and ureteral anastomoses. All three are widely appearances of normal postoperative anatomic performed with very good functional results. Orthotopic bladder replacement with Mainz changes as well as early and late complications. technique (5): A 15-cm length of cecum and ascendant colon and 30-cm segment of the Surgical Techniques distal ileum are detubularized to construct the The principal methods of urinary diversion entail reservoir. Disadvantages of using the ileocecal fashioning a segment of intestine into a conduit valve and distal ileum include diarrhea and or reservoir to which the ureters are anastomo- decreased intestinal absorption of bile acid and sed. Methods of urinary diversion are commonly vitamin B12. differentiated according to whether the functional Orthotopic bladder replacement with Mayo result is urinary incontinence or continence: technique (6): The entire right colon is opened Either incontinent cutaneous diversion or con- lengthwise to the cecum, folded over on itself, tinent diversion may be performed, with the lat- and anastomosed to the urethra. This proce- dure is not performed in Europe. ter method involving either orthotopic bladder replacement with attachment to the intact native urethra or creation of a reservoir with cutaneous diversion. The procedures most frequently per- Incontinent Cutaneous Diversion formed are described in Table 1 (1–6). Cutaneous Ureterostomy.—Cutaneous ure- terostomy is performed only in patients who un- dergo total cystectomy and only when the use of RG ■ Volume 29 • Number 2 Catalá et al 463 Figure 1. Incontinent cutaneous diversion (Bricker procedure). (a–c) Schematics show the surgical technique (a, b) and the resultant anatomic configuration (c). First, an ileal segment approximately 15–20 cm long, proximal to the ileocecal valve, is isolated for construction of the ileal conduit (a). Next, the ileal segment with its mesentery is positioned below the ileo- ileal anastomosis (b). Both ureters are anastomosed together to the proximal end of the ileal conduit (refluxing Wallace-type anastomosis), and two stents are placed through the uretero- intestinal anastomosis. (d) Volume-rendered CT image shows normal postoperative changes in a patient after radical cystectomy and ileal conduit construction. The ureters (short black arrows), uretero-ileal anastomosis (curved arrow), ileal conduit (long black arrows), and surgi- cal clips from lymphadenectomy (white arrow) are clearly depicted. intestinal segments is not possible (commonly, in Ileal Conduit Creation (Bricker procedure).— patients with bowel disease or a serious coexisting In this commonly performed procedure, a 15- to medical condition). The procedure is performed 20-cm-long ileal segment is isolated, and the by anastomosing the ureters directly to the ante- ureters are implanted at its proximal end. A rior abdominal wall. Stomal stenosis, subsequent 10- to 15-cm-long ileal segment proximal to the urinary tract infection, and compromise of renal ileocecal junction is preserved to maintain ad- function are the most frequent complications and equate absorption of bile salts, vitamin B12, and limit the use of this technique (7). fat-soluble vitamins. The ileal stoma is usually Multidetector CT allows the accurate and located in the right flank (Fig 1). This procedure complete depiction of both ureters and their sur- gical anastomoses to the anterior abdominal wall. 464 March-April 2009 radiographics.rsnajnls.org RG ■ Volume 29 • Number 2 Catalá et al 465 Figures 2, 3. (2) Continent cutaneous diversion. (a) Schematic shows the construction of a pouch from a seg- ment of the left colon by using the Mitrofanoff technique. Continence is provided by a narrow catheter port constructed from the excised and repositioned appendix and a generous cuff of cecal tissue, which serves as the
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