Role of static fluid MR urography in detecting post urinary diversion complications

Peer review under responsibility of Alexandria University Faculty of Medicine.

Available online 16 June 2017

Figures & data

Fig. 1 A 54 years old male with urinary bladder cancer (Invasive TCC, grade III), underwent radical cystectomy and urinary diversion (ileal conduit). Follow up MRU 2 years postoperative was done. (1A) Coronal maximum intensity-projection MR urography images obtained from three-dimensional (3D) T2 turbo spin echo, (1B) coronal T2 WI & (1C) axial T2 WI sequences show a left intra-ureteric defect elicited in conventional MR sequences as soft tissue lesion (arrows) likely meta-synchronous Lesion (proved pathologically to be TCC grade III) with subsequent hydroureter & hydronephrosis .A pelvic cystic fluid collection is also noted.

Table 1 Demographic, primary pathology, type of urinary diversion, laboratory features and MRI findings of the patients.

Age	Sex	Primary pathology	Operation	MRU following operation	Cr. Mg/dl	e GFR mL/min/1.73 m^2	Complications
73 years	Male	Cancer bladder (TCC, grade II)	Failed partial cystectomy followed by Radical cystectomy & ileal conduit	3 weeks	1.5	49	Urinary leakage
55 years	Male	Cancer bladder (Invasive TCC, grade III)	Radical cystectomy & ileal conduit	2 years	1.18	68	Left ureteric recurrence (proved pathologically to be TCC grade III)
							Left hydroureteronephrosis
48 years	Male	Cancer bladder (Invasive TCC, grade II)	Robotic radical cystectomy & ileocecal neobladder (continent orthotopic urinary diversion)	2 years	0.7	128	Lymphocele
58 years	Male	Cancer bladder (TCC) (Urothelial with squamous differentiation)	Radical cystectomy & ileocecal neobladder	5 years	3.6	18	Urethral & neo-bladder recurrence infiltrating the right distal ureter with right hydroureteronephrosis.
52 years	Male	Cancer bladder (TCC, grade III)	Robotic radical cystectomy with nerve preservation, bilateral pelvic lymphadenectomy, Ileocecal neobladder	I year	1.26	64	Bilateral ureteric stricture & hydroureteronephrosis
63 years	Male	Cancer bladder (SCC, grade II, Bilharziasis)	Radical cystectomy rectal bladder followed by right nephrectomy & uretero-cutaneous diversion	10 years	2.4	29	No complications detected
							Non urological findings(Hepatosplenomegaly, Ascites)
61 years	Male	Cancer bladder (Verrucoid SCC, grade I)	Radical cystectomy, pelvic lymphadenectomy, rectal bladder & colostomy	I year	0.95	86	Bilateral hydroureteronephrosis
							Bilateral lower ureteric stricture
66 years	Male	Cancer bladder (SCC, Bilharziasis)	Radical cystectomy including bladder, prostate, seminal vesicles & lower ureters (uretero-cutaneous diversion)	1 year	1.17	66	Bilateral hydroureteronephrosis, Bilateral lower ureteric stricture
							Left ureteric non obstructing stone
							Parastomal hernia
58 years	Male	Cancer bladder (SCC, grade II, Bilharziasis)	Radical cystectomy ileocecal neobladder & bilateral pelvic lymphadenectomy	1 year	0.86	97	Left uretero-neobladder stricture with subsequent left hydroureteronephrosis
59 years	Male	Cancer bladder (Infiltrating high grade TCC)	Radical cystectomy, bilateral lymphadenectomy & Ileal conduit	6 months	1.6	47	Lymphocele
51 years	Male	Cancer bladder (Poorly differentiated TCC, high grade)	Radical cystectomy, bilateral pelvic lymphadenectomy & reconstructed ileocecal bladder	6 month	0.98	86	Left lower ureteric stricture with mild left hydroureteronephrosis
34 years	Female	Cancer bladder (Invasive adenocarcinoma, old bilharziasis)	Anterior pelvic exentration (uterus, bladder, right, left ureter lower parts & bilateral lymphadenectomy) & urinary diversion (continent ileocecal neobladder)	5 month	0.9	76	No complications detected
51 years	Male	Cancer bladder (Adenocarcinoma Grade III)	Radical cystectomy, lymphadenectomy, continent ileocecal neobladder	2 years	1.4	57	No complications detected
79 years	Female	Cancer bladder (TCC grade II)	Anterior pelvic exentration, Ileal conduit	6 years	1.5	36	Bilateral hydroureteronephrosis
							Urethral recurrence with vaginal invasion
67 years	Male	Cancer bladder (SCC grade III)	Radical cystectomy, bilateral lymphadenectomy, rectal neobladder, bilateral ureteric stents & colostomy	2 years	2.6	26	Bilateral ureteric strictures
64 years	Female	Cancer bladder (SCC grade II)	Anterior pelvic exentration & urinary diversion (Ileal conduit)	1 year	1.8	30	Recurrent pelvic mass with rectal invasion
65 years	Male	Cancer bladder Multicentric urothelial carcinoma (70% TCC) with squamous metaplasia	Right nephroureterocystectomy & urinary diversion	1 month	2.5	28	No complications detected
							Non urological findings: Multiple hepatic metastatic focal lesions
58 years	Male	High grade malignant hemangiopericytoma, Grade III	Pelvic mass excision, Radical cystectomy, bilateral lymphadenectomy, Ileal conduit	3 years	1.5	51	No complications detected. (Right sided pleural effusion)
64 years	Male	Cancer bladder (SCC grade II)	Radical cystectomy, bilateral lymphadenectomy & urinary diversion (Ileal conduit)	8 years	1.7	43	No complications detected
57 years	Male	Cancer bladder(TCC grade II)	Radical cystectomy, bilateral lymphadenectomy & urinary diversion (Ileal conduit)	6 months	1.4	56	Bilateral mild hydronephrosis (no stricture)
60 years	Male	Cancer bladder(TCC grade II, bilharziasis)	Radical cystectomy (including seminal vesicles, prostate, ureters), bilateral lymphadenectomy & ileocecal neobladder (continent)	6 years	CRF	CRF	Left renal chronic obstructive uropathy, Right renal atrophy
							Hepatic Metastatic focal lesions, Ascites

eGFR, estimated glomerular filtration rate; Cr Creatinine; SCC squamous cell carcinoma; TCC transitional cell carcinoma.

Table 2 MR urography sequences used in Philips Acheiva MR scanner.

Sequence	TR/TE (ms)	Slice thickness (mm)	Flip angle	Acquisition time (s)
Axial T2 TSE	532/100	10	90	47
Axial T1 dual FFE	175/2.3–4.6	10	80	15
Coronal T1 FFE	10/4.6	7.5	15	120
Coronal T2 TSE	478/100	7.5	90	120
^a3D T2 TSE	1435/650	1	90	327
^bSingle shot TSE	10,000/800	40–60	90	10

TSE: Turbo Spin Echo, FFE: Fast Field Echo, 3D: three dimensional, TR: Repetition time, TE: Echo time.

a Multi-slice T2-weighted MR urography sequence.

b Single slice T2-weighted MR urography sequence.

Fig. 2 A 61 years old male patient with urinary bladder cancer (Verrucoid SCC, grade I) underwent radical cystectomy, pelvic lymphadenectomy, rectal bladder & colostomy. MRU 1 year postoperative. (2A) Coronal maximum intensity-projection MR urography images obtained from three-dimensional (3D) T2 turbo spin echo & (2B) single shot MR urography image show right uretero-rectal bladder stricture with subsequent hydroureteronephrosis.

Fig. 3 A 59 years old male patient with cancer bladder (Infiltrating high grade TCC) underwent radical cystectomy, bilateral lymphadenectomy & ileal conduit. MRU is done 6 months postoperative. (3A) Coronal maximum intensity-projection MR urography images obtained from three-dimensional (3D) T2 turbo spin echo, & (3B) Coronal T2 WI show a cystic abdominal fluid collection (lymphocele).

Fig. 4 A 58 years old male patient with cancer bladder (TCC) (Urothelial with squamous differentiation) underwent radical cystectomy, left radical nephrectomy & ileocecal neobladder. MRU 5 years postoperative. (4A) Coronal maximum intensity-projection MR urography images obtained from three-dimensional (3D) T2 turbo spin echo, & (4B) Coronal T2 WI show neobladder mass lesion (recurrence), right upper ureteric stenotic segment and ureteroneobladder stricture.

Fig. 5 A 64 years old female with urinary bladder cancer (SCC grade II) underwent anterior pelvic exentration & urinary diversion (Ileal conduit) MRU 1 year postoperative. (5A) Axial T2 WI, (5B) sagittal T1 WI, (5C) Coronal maximum intensity-projection MR urography images obtained from three-dimensional (3D) T2 turbo spin echo & (5D) single shot MR urography image show recurrent pelvic mass with rectal invasion and rectal fistula. Left ureteric complete duplication is noted in the MRU sequences.