Imaging of Urinary Diversions

Targeted CE per ARRT’s Discipline, Category, and Subcategory classification for enrollments starting after February 17, 2023:

Computed Tomography: 3.00
Procedures: 3.00
Abdomen and Pelvis: 3.00

Magnetic Resonance Imaging: 3.00
Procedures: 3.00
Body: 3.00

Radiography: 3.00
Procedures: 3.00
Thorax and Abdomen Procedures: 3.00

Registered Radiologist Assistant: 3.00
Procedures: 3.00
Abdominal Section: 3.00

Sonography: 3.00
Procedures: 3.00
Abdomen: 3.00

Vascular-Interventional Radiography: 3.00
Procedures: 3.00
Nonvascular Procedures: 3.00

Outline

1. Introduction
2. Incontinent Diversions
   1. Ileal Conduit
      1. Surgical Anatomy
      2. Expected Imaging Findings
         1. IVP Imaging
         2. Abdominopelvic MR Imaging and MR Urography
         3. Loopography
         4. Ultrasonography
      3. Complications
      4. Early Complications
         1. Urine Leak
         2. Bowel Leak (Leakage of Bowel Contents
         3. Alterations in Bowel Function
         4. Fluid Collections
         5. Conduit Necrosis
      5. Late Complications
         1. Stomal Complications: Parastomal Hernia
         2. Stomal Complications: Stomal Stenosis
         3. Strictures
         4. Urolithiasis
         5. Small-Bowel Obstruction
   2. Sigmoid Conduit
      1. Surgical Anatomy
      2. Expected Imaging Findings
      3. Early Complications
      4. Late Complications
         1. Uretero-Bowel Anastomotic Stenosis
         2. Upper Tract Complications
3. Continent Diversions
   1. Continent Diversion with Catheterizable Cutaneous Stoma: The Indiana Pouch
      1. Surgical Technique
      2. Expected Imaging Findings
         1. Abdominal and Pelvic CT and CT Urography
         2. US Imaging
         3. Pouchography
      3. Complications
      4. Early Complications
      5. Late Complications
         1. Urolithiasis
         2. Stomal Complications
         3. Stricture
   2. Continent Diversion with Anastomosis to Native Urethra: Orthotopic Neobladder
      1. Surgical Anatomy
         1. Studer Pouch
         2. Hautmann Pouch
      2. Expected Imaging Findings
         1. Abdominal and Pelvic CT and CT Urography
         2. Pouchography
      3. Early Complications
      4. Late Complications
         1. Fistula
         2. Ureteral Stricture
         3. Subneovesical Obstruction
         4. Rupture
4. Recurrent Tumor
   1. Local Tumor Recurrence
   2. Upper Tract Recurrence
   3. Distant Metastases
5. Conclusion

Objectives

Upon completion of this course, students will:

1. know the main reason for radical cystectomy and urinary diversion
2. determine the risk factors for developing bladder cancer
3. identify organs that may be removed during radical cystectomy surgery
4. select the appropriate urinary diversion category for the Bricker procedure
5. identify the patient criteria for the ileal conduit urinary diversion procedure
6. discuss why preservation of the terminal ileum is important in urinary diversion
7. discuss CT contrast bolus techniques to reduce radiation exposure when imaging patients with urinary diversions
8. discuss the importance of identification of the ileal segment on CT for patients with ileal conduit urinary diversion
9. discuss the IVP procedure for patients with urinary diversion
10. identify the most appropriate use of MR imaging for patients with urinary diversion
11. discuss alternate MR imaging techniques if contrast cannot be administered
12. identify the contrast material used for loopography
13. describe the normal findings of the ileal conduit and urinary system on loopgraphy
14. discuss the indications for loopography
15. identify the indications for postoperative surveillance of the kidneys with ultrasound
16. discuss the long-term complication rate of patients with ileal conduit and urinary diversion
17. discuss the consequences of bowel leak after ileal conduit and urinary diversion surgery
18. identify the CT imaging features of different postoperative fluid collections
19. know the most appropriate imaging modality to evaluate for stomal stenosis of the ileal conduit
20. discuss the late features of strictures as a late complication of ileal conduit creation
21. describe the factors which contribute to stone formation in patients with ileal conduits
22. discuss patient conditions which may necessitate sigmoid conduit over ileal conduit creation
23. be familiar with the imaging features of a sigmoid conduit
24. describe the techniques patients use to void after continent urinary diversion procedures
25. describe the features of the optimum continent pouch
26. know the possible locations of the stoma in patients with the Indiana pouch urinary diversion
27. describe the phases of CT scans to differentiate the gastrointestinal tract from the urinary tract in patients with Indiana pouch urinary diversions
28. discuss the mimics of the haustra of the Indiana pouch as seen on imaging
29. identify surgical modifications which has helped reduce the overall incidence of postoperative urine leak after Indiana pouch creation
30. discuss the cause of urolithiasis in patients with cutaneous continent urinary diversions
31. know the clinical signs of ureteroenteric anastomotic stricture formation in patients with cutaneous continent urinary diversions
32. describe the advantages of using the ileum in neobladder creation
33. describe the mucosal pattern of the afferent limb of the Studer pouch as imaged on CT
34. discuss the amount of contrast used in the early postoperative evaluation of neobladder on fluoroscopy
35. be familiar with the most common site for fistula formation in patients with a neobladder
36. identify the symptoms of fistula formation in patients with neobladder surgery
37. discuss the causes of spontaneous neobladder rupture
38. identify structures in which tumor involvement at cystectomy increases the risk of local recurrence
39. discuss factors which increase the incidence of upper tract tumor recurrence
40. know the site for common distant metastasis in patients with urinary diversion