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Postoperative State, Bladder
Benjamin Wildman-Tobriner, MD; Amir A. Borhani, MD
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KEY FACTS

  • Terminology

    • Clinical Issues

      TERMINOLOGY

      • Definitions

        • Anatomic alterations resulting from bladder resection or modification
        • Transurethral resection of bladder tumor (TURBT)
          • Standard for resection of nonmuscle invasive bladder cancer (NMIBC, stage ≤ T1) from inner bladder wall
          • May see no or minimal changes on imaging following this operation
        • Segmental cystectomy
          • a.k.a. partial cystectomy
          • Used for benign and malignant lesions of bladder
          • Removing full-thickness portion of bladder wall
          • Benign indications
            • Colovesical or vesicovaginal fistula (e.g., from diverticulitis)
            • Bladder diverticulum
            • Ulcerative interstitial cystitis
            • Cavernous hemangioma of bladder wall
            • Localized endometriosis of bladder
            • Poor surgical risk for more aggressive procedures
          • Malignant indications
            • High-grade cancer that invades bladder wall but does not involve trigone, neck, or posterior urethra
            • Tumors not amenable to TURBT
          • Bladder contour defects are most evident immediately after surgery
            • Bladder regains its normal capacity and contour over time
        • Simple cystectomy
          • Total resection of bladder
          • Indications
            • Radiation cystitis
            • Interstitial cystitis
            • Pyocystitis
            • Noncorrectable fistula to bowel or other structure
            • Intractable bleeding from bladder
        • Radical cystectomy
          • Resection of bladder with its peritoneal covering, perivesical fat, lower ureters, urachal remnant, regional lymph nodes, and adjacent structures
            • Men: Prostate, seminal vesicles, distal vas deferens
            • Women: Uterus, anterior vaginal wall, ovaries, fallopian tubes, urethra, and external meatus
            • Empty bladder fossa is filled with bowel loops
          • Some form of urinary diversion and reservoir must be provided
          • Indications
            • Muscle invasive bladder cancer (stage ≥ T2) without evidence of metastasis or with low-volume resectable locoregional metastases
            • Superficial bladder tumors refractory to TURBT
            • Stage T1, grade III tumors unresponsive to intravesical BCG vaccine therapy
            • Rare histology: Adenocarcinoma, squamous cell carcinoma, or sarcoma
            • Palliation for pain, bleeding, or urinary frequency
        • Urinary diversion techniques
          • Can be divided into incontinent and continent techniques
            • Incontinent diversion techniques
              • Cutaneous ureterostomy
              • Ileal conduit creation
              • Usually performed in patients with poor prognosis
            • Continent diversion techniques
              • Cutaneous diversion (Kock, colonic reservoir)
              • Orthotopic neobladder reconstruction (Studer, Hautmann, Padovan, Mainz, or Mayo techniques)
              • More complicated techniques; method of choice in patients with better prognosis
              • Based on creation of low-pressure reservoir using segment of bowel to maintain continence
          • Cutaneous ureterostomy
            • Ureters are directly anastomosed to anterior abdominal wall
            • Rarely performed due to high chance of ureteral stenosis at stoma
          • Ileal conduit diversion (Bricker procedure)
            • 15- to 20-cm ileal segment is isolated, and both ureters are anastomosed to its proximal end
            • Easiest procedure to perform
              • Continence and voluntary voiding are lost (plus altered body image)
              • Usually performed in patients with poor prognosis
            • Distal end provides urinary drainage to cutaneous stoma (usually in right side of abdomen)
            • Preserves 15- to 20-cm segment of distal/terminal ileum to maintain absorption of bile salts and vitamins
            • Trace ileal conduit back from stoma to identify it on imaging studies
              • Will appear as small bowel segment with water density contents, except on delayed-phase imaging (when urine is opacified)
          • Cutaneous diversion with Kock technique
            • 70-cm segment of ileum is isolated
            • Reservoir is created by detubularization of central 50-cm segment
            • Remaining proximal and distal segments are then used to create 2 valves to prevent reflux
              • One valve provides cutaneous egress
              • Other valve is anastomosed to ureters
          • Continent cutaneous diversion
            • Continence is provided by catheterizable tunnel and stoma created by appendix with cuff of cecum (appendicovesicostomy, Mitrofanoff technique)
            • Segment of cecum is used to create reservoir and terminal ileum brought out to skin with ileocecal valve providing continence (Indiana pouch)
          • Orthotopic bladder replacement (neobladder)
            • 40- to 60-cm segment of ileum (Studer technique), segment of cecum and ileum (Mainz technique), or entire right colon (Mayo technique) is used to construct neobladder
              • CT will show stapled anastomosis (bowel to bowel) and reservoir
            • Neobladder will be anastomosed to remaining part of bladder or directly to urethra
        • Bladder augmentation
          • a.k.a. augmentation cystoplasty
          • Procedure to increase bladder capacity
          • Utilized for patients who lack adequate bladder capacity or detrusor compliance
            • Decreased bladder capacity or abnormal compliance may manifest as debilitating urgency, frequency, incontinence, recurrent urinary tract infections, or progressive renal insufficiency
            • Indications
              • Interstitial cystitis, radiation cystitis, chronic cystitis
              • Detrusor instability, cloacal extrophy
              • Spinal cord injury, multiple sclerosis, myelodysplasia
          • Isolated loop of ileum &/or segment of colon is used to augment bladder
          • Enteric portion is attached to superior surface of bladder
          • Attached bowel folds may be seen as irregular wall thickening on CT and cystography
          • Asymmetric superior border of bladder on imaging
        • Psoas hitch or Boari flap ureteroneocystostomy
          • Technique used for ureteral reimplantation if ureter is not long enough to be sutured without tension
          • Used after segmental resection of ureter
          • Ipsilateral side of bladder is mobilized superiorly and sutured to psoas muscle to release tension (psoas hitch)
          • Flap of bladder tubularized upon which ureter is sutured (Boari flap)
          • Asymmetric bladder on imaging
            • Ipsilateral side of bladder is tilted superiorly toward psoas and iliacs
            • Contralateral side is displaced inferiorly

      IMAGING

      • Imaging Recommendations

        CLINICAL ISSUES

        • Natural History & Prognosis

          Selected References

          1. Kobayashi K et al: Complications of ileal conduits after radical cystectomy: interventional radiologic management. Radiographics. 41(1):249-67, 2021
          2. Razik A et al: Urinary diversions: a primer of the surgical techniques and imaging findings. Abdom Radiol (NY). 44(12):3906-18, 2019
          3. Shergill AK et al: Comprehensive imaging and surgical review of urinary diversions: what the radiologist needs to know. Curr Probl Diagn Radiol. 48(2):161-71, 2019
          4. Chang SS et al: Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO guideline. J Urol. 196(4):1021-9, 2016
          5. Moomjian LN et al: Follow the stream: imaging of urinary diversions. Radiographics. 36(3):688-709, 2016
          6. Tonolini M et al: Multidetector CT imaging of post-robot-assisted laparoscopic radical prostatectomy complications. Insights Imaging. 4(5):711-21, 2013
          7. Catalá V et al: CT findings in urinary diversion after radical cystectomy: postsurgical anatomy and complications. Radiographics. 29(2):461-76, 2009
          8. Chiva LM et al: Ileal orthotopic neobladder after pelvic exenteration for cervical cancer. Gynecol Oncol. 113(1):47-51, 2009
          9. Hellenthal NJ et al: Incontinent ileovesicostomy: long-term outcomes and complications. Neurourol Urodyn. 28(6):483-6, 2009
          10. Meyer JP et al: A three-centre experience of orthotopic neobladder reconstruction after radical cystectomy: revisiting the initial experience, and results in 104 patients. BJU Int. 103(5):680-3, 2009
          11. Milhoua PM et al: Primary endoscopic management versus open revision of ureteroenteric anastomotic strictures after urinary diversion--single institution contemporary series. J Endourol. 23(3):551-5, 2009
          12. Taneja SS et al: Creation of urinary stoma before abdominal wall transposition of ileal conduit improves stomal protrusion, eversion, and symmetry. Urology. 73(4):893-5, 2009
          13. Sudakoff GS et al: CT urography of urinary diversions with enhanced CT digital radiography: preliminary experience. AJR Am J Roentgenol. 184(1):131-8, 2005
          14. Dyer RB et al: Complications of ureteral stent placement. Radiographics. 22(5):1005-22, 2002
          Related Anatomy
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          Related Differential Diagnoses
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          References
          Tables

          Tables

          KEY FACTS

          • Terminology

            • Clinical Issues

              TERMINOLOGY

              • Definitions

                • Anatomic alterations resulting from bladder resection or modification
                • Transurethral resection of bladder tumor (TURBT)
                  • Standard for resection of nonmuscle invasive bladder cancer (NMIBC, stage ≤ T1) from inner bladder wall
                  • May see no or minimal changes on imaging following this operation
                • Segmental cystectomy
                  • a.k.a. partial cystectomy
                  • Used for benign and malignant lesions of bladder
                  • Removing full-thickness portion of bladder wall
                  • Benign indications
                    • Colovesical or vesicovaginal fistula (e.g., from diverticulitis)
                    • Bladder diverticulum
                    • Ulcerative interstitial cystitis
                    • Cavernous hemangioma of bladder wall
                    • Localized endometriosis of bladder
                    • Poor surgical risk for more aggressive procedures
                  • Malignant indications
                    • High-grade cancer that invades bladder wall but does not involve trigone, neck, or posterior urethra
                    • Tumors not amenable to TURBT
                  • Bladder contour defects are most evident immediately after surgery
                    • Bladder regains its normal capacity and contour over time
                • Simple cystectomy
                  • Total resection of bladder
                  • Indications
                    • Radiation cystitis
                    • Interstitial cystitis
                    • Pyocystitis
                    • Noncorrectable fistula to bowel or other structure
                    • Intractable bleeding from bladder
                • Radical cystectomy
                  • Resection of bladder with its peritoneal covering, perivesical fat, lower ureters, urachal remnant, regional lymph nodes, and adjacent structures
                    • Men: Prostate, seminal vesicles, distal vas deferens
                    • Women: Uterus, anterior vaginal wall, ovaries, fallopian tubes, urethra, and external meatus
                    • Empty bladder fossa is filled with bowel loops
                  • Some form of urinary diversion and reservoir must be provided
                  • Indications
                    • Muscle invasive bladder cancer (stage ≥ T2) without evidence of metastasis or with low-volume resectable locoregional metastases
                    • Superficial bladder tumors refractory to TURBT
                    • Stage T1, grade III tumors unresponsive to intravesical BCG vaccine therapy
                    • Rare histology: Adenocarcinoma, squamous cell carcinoma, or sarcoma
                    • Palliation for pain, bleeding, or urinary frequency
                • Urinary diversion techniques
                  • Can be divided into incontinent and continent techniques
                    • Incontinent diversion techniques
                      • Cutaneous ureterostomy
                      • Ileal conduit creation
                      • Usually performed in patients with poor prognosis
                    • Continent diversion techniques
                      • Cutaneous diversion (Kock, colonic reservoir)
                      • Orthotopic neobladder reconstruction (Studer, Hautmann, Padovan, Mainz, or Mayo techniques)
                      • More complicated techniques; method of choice in patients with better prognosis
                      • Based on creation of low-pressure reservoir using segment of bowel to maintain continence
                  • Cutaneous ureterostomy
                    • Ureters are directly anastomosed to anterior abdominal wall
                    • Rarely performed due to high chance of ureteral stenosis at stoma
                  • Ileal conduit diversion (Bricker procedure)
                    • 15- to 20-cm ileal segment is isolated, and both ureters are anastomosed to its proximal end
                    • Easiest procedure to perform
                      • Continence and voluntary voiding are lost (plus altered body image)
                      • Usually performed in patients with poor prognosis
                    • Distal end provides urinary drainage to cutaneous stoma (usually in right side of abdomen)
                    • Preserves 15- to 20-cm segment of distal/terminal ileum to maintain absorption of bile salts and vitamins
                    • Trace ileal conduit back from stoma to identify it on imaging studies
                      • Will appear as small bowel segment with water density contents, except on delayed-phase imaging (when urine is opacified)
                  • Cutaneous diversion with Kock technique
                    • 70-cm segment of ileum is isolated
                    • Reservoir is created by detubularization of central 50-cm segment
                    • Remaining proximal and distal segments are then used to create 2 valves to prevent reflux
                      • One valve provides cutaneous egress
                      • Other valve is anastomosed to ureters
                  • Continent cutaneous diversion
                    • Continence is provided by catheterizable tunnel and stoma created by appendix with cuff of cecum (appendicovesicostomy, Mitrofanoff technique)
                    • Segment of cecum is used to create reservoir and terminal ileum brought out to skin with ileocecal valve providing continence (Indiana pouch)
                  • Orthotopic bladder replacement (neobladder)
                    • 40- to 60-cm segment of ileum (Studer technique), segment of cecum and ileum (Mainz technique), or entire right colon (Mayo technique) is used to construct neobladder
                      • CT will show stapled anastomosis (bowel to bowel) and reservoir
                    • Neobladder will be anastomosed to remaining part of bladder or directly to urethra
                • Bladder augmentation
                  • a.k.a. augmentation cystoplasty
                  • Procedure to increase bladder capacity
                  • Utilized for patients who lack adequate bladder capacity or detrusor compliance
                    • Decreased bladder capacity or abnormal compliance may manifest as debilitating urgency, frequency, incontinence, recurrent urinary tract infections, or progressive renal insufficiency
                    • Indications
                      • Interstitial cystitis, radiation cystitis, chronic cystitis
                      • Detrusor instability, cloacal extrophy
                      • Spinal cord injury, multiple sclerosis, myelodysplasia
                  • Isolated loop of ileum &/or segment of colon is used to augment bladder
                  • Enteric portion is attached to superior surface of bladder
                  • Attached bowel folds may be seen as irregular wall thickening on CT and cystography
                  • Asymmetric superior border of bladder on imaging
                • Psoas hitch or Boari flap ureteroneocystostomy
                  • Technique used for ureteral reimplantation if ureter is not long enough to be sutured without tension
                  • Used after segmental resection of ureter
                  • Ipsilateral side of bladder is mobilized superiorly and sutured to psoas muscle to release tension (psoas hitch)
                  • Flap of bladder tubularized upon which ureter is sutured (Boari flap)
                  • Asymmetric bladder on imaging
                    • Ipsilateral side of bladder is tilted superiorly toward psoas and iliacs
                    • Contralateral side is displaced inferiorly

              IMAGING

              • Imaging Recommendations

                CLINICAL ISSUES

                • Natural History & Prognosis

                  Selected References

                  1. Kobayashi K et al: Complications of ileal conduits after radical cystectomy: interventional radiologic management. Radiographics. 41(1):249-67, 2021
                  2. Razik A et al: Urinary diversions: a primer of the surgical techniques and imaging findings. Abdom Radiol (NY). 44(12):3906-18, 2019
                  3. Shergill AK et al: Comprehensive imaging and surgical review of urinary diversions: what the radiologist needs to know. Curr Probl Diagn Radiol. 48(2):161-71, 2019
                  4. Chang SS et al: Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO guideline. J Urol. 196(4):1021-9, 2016
                  5. Moomjian LN et al: Follow the stream: imaging of urinary diversions. Radiographics. 36(3):688-709, 2016
                  6. Tonolini M et al: Multidetector CT imaging of post-robot-assisted laparoscopic radical prostatectomy complications. Insights Imaging. 4(5):711-21, 2013
                  7. Catalá V et al: CT findings in urinary diversion after radical cystectomy: postsurgical anatomy and complications. Radiographics. 29(2):461-76, 2009
                  8. Chiva LM et al: Ileal orthotopic neobladder after pelvic exenteration for cervical cancer. Gynecol Oncol. 113(1):47-51, 2009
                  9. Hellenthal NJ et al: Incontinent ileovesicostomy: long-term outcomes and complications. Neurourol Urodyn. 28(6):483-6, 2009
                  10. Meyer JP et al: A three-centre experience of orthotopic neobladder reconstruction after radical cystectomy: revisiting the initial experience, and results in 104 patients. BJU Int. 103(5):680-3, 2009
                  11. Milhoua PM et al: Primary endoscopic management versus open revision of ureteroenteric anastomotic strictures after urinary diversion--single institution contemporary series. J Endourol. 23(3):551-5, 2009
                  12. Taneja SS et al: Creation of urinary stoma before abdominal wall transposition of ileal conduit improves stomal protrusion, eversion, and symmetry. Urology. 73(4):893-5, 2009
                  13. Sudakoff GS et al: CT urography of urinary diversions with enhanced CT digital radiography: preliminary experience. AJR Am J Roentgenol. 184(1):131-8, 2005
                  14. Dyer RB et al: Complications of ureteral stent placement. Radiographics. 22(5):1005-22, 2002