The role of interventional radiology in the management of intra- and extra-peritoneal leakage in patients who have undergone continent urinary diversion

ACR Appropriateness Criteria® Radiologic Management of Urinary Tract Obstruction

Acute obstructive uropathy is a medical emergency, which often is accompanied by acute renal failure or sepsis. Treatment options to resolve the acute obstructive process include conservative medical management, retrograde ureteral stenting, or placement of percutaneous nephrostomy or nephroureteral catheters. It is important to understand the various treatment options in differing clinical scenarios in order to guide appropriate consultation. Prompt attention to the underlying obstructive process is often imperative to avoid further deterioration of the patient's clinical status. A summary of the data and most up-to-date clinical trials regarding treatment options for urinary tract obstruction is outlined in this publication. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

[Uretero-intestinal anastomosis: Achilles heel of urinary diversion using bowel segments]

A well-functioning uretero-intestinal anastomosis is essential for the preservation of kidney function following urinary diversion using bowel segments. In incontinent forms of urinary diversions, such as ileal conduits, the ureters are usually implanted in a refluxive manner, whereas there is still controversy about the ideal implantation technique in continent orthotopic or heterotopic reservoirs (i.e. refluxive versus anti-refluxive). Current techniques of refluxive and antirefluxive uretero-intestinal anastomosis, their indications, typical perioperative and postoperative complications and management are discussed. Irradiated or preoperatively dilated ureters show a higher complication rate in terms of postoperative dilatation and obstruction. Early revision of the implantation site and ureteral reimplantation yield more favorable outcomes and long-term results than a minor invasive endourological treatment. As ureteral stenosis may occur more than 15 years after urinary diversion, regular follow-up including sonographic evaluation of the upper urinary tract to detect hydronephrosis is mandatory. In this setting a diuretic renogram with MAG-III is a helpful tool to determine split renal function and to discriminate urodynamic relevant dilatation of the upper urinary tract from clinical situations requiring only observation, while dimercaptosuccinic acid (DMSA) scans provide valuable information about renal scarring.

Retrograde Ureteric Stents via an Ileal Conduit

Patients having undergone pelvic exenteration with urinary diversion can present with short- and long-term complications such as ureteral strictures, anastomotic leakage, calculi, or fluid collections (abscess, urinoma, lymphocele, or hematoma). A dehiscence resulting in a perineal urinary fistula is an uncommon late complication of urinary diversion surgery; surgical treatment for this complication is less desirable because of postsurgical or radiation-induced pelvic changes that can occur. As a result, nephrostomy or antegrade stenting of the kidneys is more viable. Retrograde ureteric stent insertion is discussed in relation to a patient suffering from ileal conduit dehiscence. The presence of these stents probably helped diminish the potential for complications during subsequent nephrostomy tube insertion.

External-internal nephro-uretero-ileal stents in patients with an ileal conduit: long-term results

OBJECTIVES

To describe an improved technique for upper urinary tract drainage in patients with ureteroileal anastomotic stricture after radical cystectomy and urinary diversion to an ileal conduit, and to review our experience and long-term results.

METHODS

From 1995 to 2002, 16 patients (18 renal units) with ureteroileal anastomotic stricture after radical cystectomy and urinary diversion to an ileal conduit underwent external-internal nephro-uretero-ileal stent placement. The procedure consisted of three stages: insertion of a percutaneous nephrostomy tube; retrograde external-internal stent placement with the help of an antegrade-inserted wire, leaving the stent's port in the stoma bag; and periodic retrograde stent exchange. The median duration of follow-up was 26.6 months.

RESULTS

The overall success rate was 94.7%. No serious complications occurred during the procedure or during follow-up. Patient compliance was fairly good. In 75% of the patients, the stent served as the definitive treatment, avoiding the need for surgical revision.

CONCLUSIONS

External-internal nephro-uretero-ileal stent placement can be used successfully and safely as a definitive treatment for anastomosis-related complications in patients after radical cystectomy and urinary diversion to an ileal conduit.

Imaging of the Various Continent Urinary Diversions After Cystectomy

Continent urinary diversions have recently become the preferred procedures rather than performing an ileal conduit. Intravenous urography, pouchography, and computed tomography scans are frequently used for postoperative evaluation of patients with bladder carcinoma. During postoperative follow-up imaging studies, the radiologist must keep these 4 facets in mind as his primary focus: 1) the detection of newly developed urothelial tumors, 2) the detection of metastasis, 3) the detection of postoperative complications, and 4) the monitoring of upper urinary tract distention. Various surgical techniques that are used in continent diversions alter the normal anatomy and make the imaging interpretation difficult. An accurate interpretation can be made only if radiologists become familiar with the various surgical procedures and the appearances of various postoperative anatomic changes.

Routine pouchograms are not necessary after continent urinary diversion

OBJECTIVES

Pouchograms are routinely performed before catheter removal after continent urinary diversion at our institution. Our aim was to determine the necessity of pouchograms based on a review of our experience.

METHODS

A retrospective review of patient records and radiographic studies was done for patients undergoing radical cystectomy and continent urinary diversions between 1991 and 2001.

RESULTS

Seventy-two patients underwent continent urinary diversion (orthotopic, n = 59; cutaneous, n = 13) during the study period. All underwent pouchogram postoperatively (median 22 days; range 20 to 27). Six patients (8.3%) had a demonstrable radiographic leak; in 5 of the 6 patients, the urine leak was suspected on clinical grounds. Three patients (4.7%) developed urosepsis after pouchogram.

CONCLUSIONS

Our findings indicate that routine pouchograms before pouch activation after continent urinary diversion may not be necessary.

Continent urinary diversion and low-rectal anastomosis in patients undergoing exenterative procedures for recurrent gynecologic malignancies

OBJECTIVE

The aim of this study was to review the complications associated with continent urinary diversion and associated procedures in patients with gynecologic malignancies.

METHODS

We retrospectively reviewed the medical records of all patients who underwent construction of a continent urinary conduit between October 1991 and October 1998 on the Gynecology Service at Memorial Sloan-Kettering Cancer Center.

RESULTS

Thirty-three patients were identified, of whom 22 underwent total pelvic exenteration, 8 underwent anterior exenteration, and 3 underwent urinary diversion procedures only. Complications associated with the urinary diversion procedure included ureteral strictures (2), pouch leakage (2), mild hydronephrosis, (6), pyelopnephritis (2), nocturnal incontinence (5), and difficulty with self-catheterization (2). Additional procedures performed concomitantly with continent urinary diversion and exenteration included pelvic reconstruction (18), low-rectal anastomosis (13), and intraoperative radiation therapy (9). The most significant morbidity was seen in patients undergoing concomitant low-rectal anastomosis, in whom the rate of anastomotic leaks was 54% (7 of 13 patients).

CONCLUSIONS

Continent urinary diversion can successfully be accomplished at the time of exenteration in patients with recurrent gynecologic malignancies. The rate of major complications related to the urinary diversion is small and most complications can be managed nonsurgically. The greater than 50% rate of anastomotic leaks in patients undergoing concomitant low-rectal anastamosis suggests that such anastomosis should not be undertaken in this group of patients.

Radiology of urinary diversions

Radiologic evaluation of urinary diversion has three objectives: to monitor upper tract distention, to detect new urothelial tumors and to detect metastasis. The type of imaging procedure and the frequency of imaging is dictated by the urologist preference. As many surgical procedures are available for noncontinent and continent diversion, interpretation of radiographic studies requires a detailed knowledge of the type of surgical procedure that has been performed.

Urological problems and the treatment of gynaecological cancer

This article reviews the recent literature on urological complications in gynaecological oncology. In particular it focuses on the current controversies in the management of urinary fistulae and reconstruction or urinary diversion after pelvic exenteration.