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Complications of Ileal Conduits
after Radical Cystectomy: Interven-
tional Radiologic Management
Katsuhiro Kobayashi, MD
Atin Goel, MBBS
Marlon P. Coelho, MD
Mariangeles Medina Perez, MD
Matthew Klumpp, MD
Sanjit O. Tewari, MD
Tomas Appleton-Figueira, MD
David J. Pinter, MD
Oleg Shapiro, MD
Mohammed Jawed, MD
Abbreviations: MIBC = muscle-invasive
bladder cancer, PCNL = percutaneous
nephrolithotomy
RadioGraphics 2021; 41:249–267
https://doi.org/10.1148/rg.2021200067
Content Codes:
From the Departments of Radiology (K.K.,
A.G., M.P.C., M.M.P., M.K., S.O.T., T.A.F.,
D.J.P., M.J.), and Urology (O.S.), SUNY Up-
state Medical University, 750 E Adams St,
Syracuse, NY 13210. Presented as an educa-
tion exhibit at the 2019 RSNA Annual Meeting.
Received April 6, 2020; revision requested June
16 and received July 5; accepted July 6. For this
journal-based SA-CME activity, the authors, ed-
itor, and reviewers have disclosed no relevant re-
lationships. Address correspondence to K.K.
(e-mail: kobayask@upstate.edu).
©
RSNA, 2020
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
„ Describe the surgical technique and
anatomy involved in creating an ileal
conduit for urinary diversion after radical
cystectomy.
„ Recognize early and late complications
of ileal conduits as well as the underlying
pathophysiology and diagnostic workup.
„ Discuss interventional radiologic pro-
cedures and their role in management of
complications of ileal conduits.
See rsna.org/learning-center-rg.
249
VASCULAR AND INTERVENTIONAL RADIOLOGY
Since their introduction into clinical practice in the 1950s, ileal
conduits have been the most common type of urinary diversion
used after radical cystectomy worldwide. Although ileal conduits
are technically simpler to construct than other forms of urinary
diversion, a variety of complications can occur in the early and late
postoperative periods. Early complications include urine leakage,
urinary obstruction, postoperative fluid collection (eg, urinoma, he-
matoma, lymphocele, or abscess), and fistula formation. Late com-
plications include ureteroileal anastomotic stricture, stomal steno-
sis, conduit stenosis, and urolithiasis. Although not directly related
to ileal conduits, ureteroarterial fistula can occur in patients with
an ileal conduit. Interventional radiologists can play a pivotal role
in diagnosis and management of these complications by performing
image-guided minimally invasive procedures. In this article, the au-
thors review the surgical anatomy of an ileal conduit and the under-
lying pathophysiology of and diagnostic workup for complications
related to ileal conduits. The authors also discuss and illustrate cur-
rent approaches to interventional radiologic management of these
complications, with emphasis on a collaborative approach with
urologists or endourologists to best preserve patients’ renal function
and maintain their quality of life.
©
RSNA, 2020 • radiographics.rsna.org
Introduction
Bladder cancer is one of the most common malignancies and a
significant cause of cancer-related death worldwide. According to the
National Center for Health Statistics, 80 470 new cases of bladder
cancer and 17 670 bladder cancer deaths were predicted to have
occurred in 2019 in the United States (1). Tobacco smoking is the
major risk factor for bladder cancer and estimated to contribute to
development of 50% of bladder tumors. Three-fourths of bladder
cancer cases occur in males. Approximately one-fourth of patients
with bladder cancer present with muscle-invasive bladder cancer
(MIBC) requiring multidisciplinary oncologic treatment (2).
Radical cystectomy with urinary diversion remains the mainstay
of treatment of nonmetastatic MIBC. This major surgery involves
removal of the prostate and seminal vesicles in males or the uterus, fal-
lopian tubes, ovaries, and anterior vaginal wall in females in addition
to removal of the bladder. Radical cystectomy with pelvic lymph node
dissection provides the best cancer-specific survival for MIBC, with
10-year recurrence-free survival rates of 50%–59% and overall survival
rates of approximately 45% (3,4). Although less frequently used, radi-
cal cystectomy with urinary diversion is also performed to treat benign
conditions such as neurogenic bladder, radiation cystitis, and congeni-
tal bladder anomalies (5).
250 January-February 2021
TEACHING POINTS
„ The ileal conduit is generally used in patients with compro-
mised renal function, elderly patients, those with significant
comorbidities, and those who are unable to undergo inter-
mittent self-catheterization or who have severe functional
impairment.
„ When accessing the ureter or renal collecting system, retro-
grade cannulation (cannulation from the stoma) through a
Bricker-type anastomosis may be more challenging than in a
Wallace-type anastomosis, especially when the contrast mate-
rial filling the conduit does not reflux into the distal ureter.
„ Chronic bacteriuria is quite common in patients with conduit
diversion. Therefore, prophylactic broad-spectrum antibiotic
treatment needs to be initiated before the procedure except
for routine tube changes.
„ Since initial access to the kidney determines which renal cali-
ces can be reached by a rigid nephroscope or the degree of
maneuverability of the ureteroscope, preprocedure discussion
with the endourologist regarding the calix that needs to be
accessed and the needle trajectory to the calix is crucial.
„ Therefore, if patients with an ileal conduit present with mas-
sive hematuria, especially when it is encountered during ure-
teral stent manipulation, conventional angiography needs to
be performed immediately with a high index of suspicion for
ureteroarterial fistula because the mortality rate is high (7%–
38%) when treatment is delayed.
Currently, the following major techniques
are used for urinary diversion after radical
cystectomy: incontinent cutaneous diver-
sion (conduit), continent cutaneous diversion
(catheterizable pouch), and continent diversion
to the intact native urethra (orthotopic neo-
bladder). Since their introduction into clinical
practice in the 1950s, ileal conduits have been
used for standard urinary diversion in patients
undergoing radical cystectomy. Over the past 2
decades, continent diversion, especially with an
orthotopic neobladder, has gained widespread
popularity as the preferred type of urinary diver-
sion in properly selected patients.
Selection of urinary diversion is determined
on the basis of patient and tumor factors, includ-
ing age; physical condition; intestinal, hepatic,
and renal function; tumor stage; and life expec-
tancy (6). The ileal conduit is generally used in
patients with compromised renal function, elderly
patients, those with significant comorbidities, and
those who are unable to undergo intermittent
self-catheterization or who have severe functional
impairment (7). Since creation of an ileal con-
duit is technically less demanding than continent
diversion, and since MIBC occurs predominantly
in elderly people with comorbidities, ileal con-
duits remain the most common form of urinary
diversion worldwide (8).
Although technically simpler to perform,
conduit diversion has not been associated with
radiographics.rsna.org
a lower morbidity rate than continent diversion.
This is partly because of the more unfavorable
oncologic characteristics and more prevalent
comorbidities in patients who undergo conduit
diversion than continent diversion. A variety of
complications can occur during both early and
late postoperative periods (Table). Although
some complications such as conduit necrosis or
intestinal anastomotic leakage require immedi-
ate surgical intervention, complications such as
paralytic ileus or metabolic abnormalities can be
managed conservatively or medically. Most com-
plications related to ileal conduits can be man-
aged with interventional radiologic techniques
alone or in conjunction with endourologic or
surgical intervention. Therefore, interventional
radiologists can play a pivotal role in diagnosis
and management of complications related to
ileal conduits by performing percutaneous uri-
nary intervention, abscess or fluid drainage, and
on rare occasions endovascular treatment. These
minimally invasive approaches can obviate open
surgery in patients with comorbidities or stabi-
lize the patient’s condition before open surgical
reintervention.
In this article, we review the surgical anatomy
of an ileal conduit and the underlying patho-
physiology of and diagnostic workup for early
and late complications after radical cystectomy
with conduit diversion. We also discuss and
illustrate current approaches to interventional
radiologic management of complications as-
sociated with ileal conduits, with emphasis
on a collaborative approach with urologists or
endourologists.
Surgical Anatomy of an Ileal Conduit
Comprehensive knowledge of the surgical tech-
nique used for and the surgical anatomy of ileal
conduits is essential when performing interven-
tional radiologic procedures for management
of complications after conduit diversion. The
first step of ileal conduit creation is isolation of
a 15- to 20-cm ileal segment approximately 20
cm proximal to the ileocecal valve (Fig 1). The
terminal ileum is preserved to avoid malabsorp-
tion of bile salts and vitamin B12.
An appropriate length of the ileal segment is
carefully selected on the basis of the patient’s
body habitus. An ileal segment that is too short
may not easily reach the stoma site, resulting in
unnecessary tension of the ileoureteral anasto-
mosis, which can lead to ischemia of the anasto-
mosis or distal ureter (9). An ileal segment that
is too long may kink, resulting in intermittent
obstruction of the conduit and leading to recur-
rent urinary tract infection (10). The transected
left ureter is brought under the sigmoid colon
RG • Volume 41 Number 1 Kobayashi et al 251

Complications of an Ileal Conduit after Radical Cystectomy

Type Early (<30 days) Late (>30 days)

Bowel-related Paralytic ileus Obstruction
Mechanical obstruction
Enteric fistula*
Anastomotic bowel leak
Ureter or ureteroileal anastomosis–related Urine leakage* Stricture or obstruction*
Obstruction*
Conduit-related Necrosis Stenosis*
Stoma-related Retraction Stenosis*
Necrosis Prolapse or retraction
Parastomal hernia*
Others Urinary tract infection Urinary tract infection
Fluid collection* Urolithiasis*
Cutaneous or genital Upper urinary tract tumor recurrence*
fistula* Ureteroarterial fistula*
Metabolic disturbance
Renal function decline

*These complications may be managed with interventional radiologic procedures with or without an endouro-
logic procedure.

Figure 1. Surgical technique used for ileal conduit creation. (a) Drawing shows isolation of an ileal
segment (*) approximately 20 cm proximal to the ileocecal valve. The mesentery of the isolated ileal seg-
ment is dissected along with the vascular pedicles (dashed black lines). (b) Drawing shows the isolated
ileal segment placed below the ileal anastomosis (*). The mesenteric window of the ileal anastomosis is
sutured (white arrow). The left ureter is brought under the sigmoid colon through the sigmoid mesentery
(black arrow). Both ureters are anastomosed to the proximal ileal segment (Bricker type) (arrowheads).
The proximal ileal segment is pulled through the tunnel created within the abdominal wall, and a cutane-
ous stoma is formed in the right lower quadrant.

through the sigmoid mesentery to the right
lower quadrant of the abdomen (11). The right
and left ureters are then anastomosed to the
proximal part of the ileal segment (Fig 1).
The final step is creation of a stoma in the
right lower quadrant, usually between the umbi-
licus and anterior superior iliac spine. A tunnel
is created underneath the expected stoma site by
bluntly dissecting the abdominal wall. Place-
ment of the stoma through the rectus abdominis
fascia and appropriately sized fascial openings
(usually the width of two fingers) are important
for decreasing the chance of parastomal her-
nia (12). The distal part of the ileal segment is
brought through the tunnel to the skin for stoma
creation.
Ureteroileal Anastomosis
Although various techniques have been devel-
oped for ureteroileal anastomosis, the Bricker and
Wallace techniques are most commonly used. In
the Bricker technique, each ureter is anastomosed
separately to the antimesenteric side of the ileal
segment (end-to-side anastomosis) (Fig 2). In the
252 January-February 2021 radiographics.rsna.org

Figure 2. Techniques used for ureteroileal anastomosis. (a) Drawing depicts

Bricker-type anastomoses, in which the ureteral ends are anastomosed to the an-
timesenteric side of the ileal conduit 1–3 cm apart from each other. (b, c) Draw-
ing shows Wallace-type anastomoses, in which the ureteral ends are conjoined,
oriented in the same (type I) (b) or opposite (type II) (c) directions, and anasto-
mosed to the proximal end of the ileal conduit. (d) Drawing depicts Lahey-type
anastomoses, which represent a combination of the Bricker- and Wallace-type
anastomoses.

Wallace technique, both ureters are anastomosed Cutaneous Stoma

together to the proximal end of the ileal segment
(end-to-end anastomosis) (Fig 2).
Although both techniques create freely reflux-
ing anastomoses, they have different advantages
and disadvantages. Stenosis related to ischemia
or tumor recurrence occurring at the distal end
of one ureter may affect the other ureter in the
Wallace technique, while the other ureter is not
affected with the Bricker technique (9). When
accessing the ureter or renal collecting system,
retrograde cannulation (cannulation from the
stoma) through a Bricker-type anastomosis
may be more challenging than in a Wallace-type
anastomosis, especially when the contrast mate-
rial filling the conduit does not reflux into the
distal ureter.
The Lahey technique combines these two
techniques, using the Bricker technique for the
right ureteroileal anastomosis and the Wallace
technique for the left ureteroileal anastomosis
(Fig 2). Intraoperatively, ureteral stents may
be placed across the ureteroileal anastomosis,
which can help decrease the chance of urine
leakage and improve the return of bowel func-
tion (13). The antirefluxing anastomotic tech-
nique proposed by Le Duc is rarely used be-
cause of its higher risk of anastomotic strictures
than refluxing anastomotic techniques (14).
Two techniques, an end stoma technique and a
loop stoma technique, are currently used to cre-
ate a cutaneous stoma. In the end stoma tech-
nique, the distal end of the ileal segment is left
open and used as an outlet of the ileal conduit.
The distal ileal segment is brought through the
abdominal wall to the skin and circumferentially
sutured to the rectus fascia. A mucosal nipple or
rosebud is then created by everting and suturing
the mucosal surface of the distal end of the ileal
segment to the skin (Fig 3).
Although an end stoma is by far the most
common type, a loop stoma (also called a Turn-
bull stoma) can be created with equivalent func-
tional outcomes to the end stoma (15). In this
technique, the distal end of the ileal segment is
closed to form a blind end, and a loop of the ileal
segment is brought out of the abdominal wall.
The loop is transversely incised, leaving a distal
nonfunctioning limb and a proximal function-
ing limb. The mucosal surface of the proximal
functioning limb is then everted and sutured to
the skin, creating a mucosal nipple in the same
manner as the end stoma (Fig 3). Loop stomas
have a lower incidence of stomal stenosis but a
higher risk of parastomal hernias than end stomas
(16). Loop stomas are preferably used in patients
with obesity, whose abdominal wall is often thick
RG • Volume 41 Number 1 Kobayashi et al 253

Figure 3. Techniques used for the cutaneous stoma. (a) Drawing shows an end stoma. The distal ileal
segment is circumferentially sutured to the rectus fascia (*). The distal margin of the ileal segment is
everted and sutured to the skin. The protruded mucosa of the ileal segment forms a rosebud. (b) Draw-
ing shows a loop stoma. The inverted U-shaped distal ileal segment is brought to the skin and transversely
incised. A rosebud-shaped stoma is created in a similar manner as in an end stoma by everting the incised
ileal loop, exposing the mucosa. The distal end of the ileal segment is closed, forming a blind end (arrow).

and whose ileal mesentery is often short, leading
to easy retraction of the stoma (9).
General Considerations for
Interventional Radiologic
Management
Most of the interventional radiologic proce-
dures used to manage complications related to
ileal conduits require renal access by means of
percutaneous nephrostomy. The basic knowledge
and skills required for this technique are essential
to safely perform the procedures. As percutane-
ous nephrostomy is generally categorized as a
procedure with high bleeding risk, coagulation
abnormalities should be corrected before the
procedure (17). Chronic bacteriuria is quite
common in patients with conduit diversion (18).
Therefore, prophylactic broad-spectrum antibi-
otic treatment needs to be initiated before the
procedure except for routine tube changes. When
performing the procedure in elderly patients with
sedation, an oblique prone position or assistance
of the anesthesiology service may be necessary to
prevent respiratory complications. A urine sample
is obtained on entry to the renal collecting system
and sent for culture and sensitivity testing. Access
of the lower posterior calix by using a subcos-
tal approach is usually best for simple urinary
drainage. When renal access is required for the
purpose of ureteroscopic intervention, access
through a mid- or upper posterior calix offers the
easiest access to the ureteropelvic junction, which
enables smooth ureteral negotiation.
Loopography is a useful diagnostic tool to help
assess complications involving the stoma, con-
duit, ureteroileal anastomosis, and upper urinary
tract. Loopography is performed by injecting wa-
ter-soluble contrast material through a 12–16-F
Foley catheter inserted into the conduit. The
catheter balloon is inflated with diluted contrast
material or water to prevent backflow through
the stoma. Contrast material should reflux into
the ureters and collecting system unless an anti-
refluxing technique is used for ureteroileal anas-
tomosis. Loopography can visualize the course
and contour of the ileal conduit and the type of
ureteroileal anastomosis and help assess the cause
of urinary obstruction as well as urine leakage
(19). Loopography can also provide a map of the
urinary tract when a retrograde approach (ap-
proach from the stoma) is used for any interven-
tional radiologic or endourologic procedures.
Early Complications
Early complications, defined as complications oc-
curring either during hospitalization or within the
first 30 days after surgery, have been reported to
occur in 20%–57% of patients (20). These com-
plications are strongly associated with the surgi-
cal techniques used for urinary diversion (21).
Early complications that can be managed with
interventional radiologic techniques include urine
leakage, ureteral obstruction, postoperative fluid
collection, and fistulas between ileal conduits and
nearby organs.
Urine Leakage
Urine leakage after conduit urinary diversion is
relatively rare, with a reported incidence of ap-
proximately 2% (22). Although it can originate
254 January-February 2021 radiographics.rsna.org

Figure 4. Urine leakage and urinoma in a 66-year-old man who underwent radi-
cal cystectomy with conduit diversion for bladder cancer 3 weeks earlier. The Wal-
lace technique was used for ureteroileal anastomosis. The patient presented with
increased drainage from the surgical wound, fever, and chills. An elevated cre-
atinine level in the fluid from the wound indicated the presence of a urine leak.
(a) Coronal nonenhanced CT image shows a fluid collection with foci of air adjacent to
the ileal conduit (arrow). Bilateral hydronephrosis was also observed (not shown). (b)
Loopogram shows communication between the ileal conduit and the fluid collection (ar-
row), which is compatible with a urine leak. Reflux of contrast material into the left ureter
is also seen (arrowhead). Urine leakage was considered to originate from the ureteroileal
anastomosis. A drainage catheter was then placed within the fluid collection (urinoma)
under CT guidance (not shown). (c) Spot radiograph shows bilateral nephroureteral
stents that were placed percutaneously via the kidneys (antegrade approach) for the pur-
pose of urinary diversion. Note that the distal loops of the stents were placed outside or
near the stoma (arrowheads), facilitating urinary drainage. (d) Loopogram obtained 2
months after stent placement shows resolution of the urine leak. Reflux of contrast mate-
rial into the bilateral ureters was observed (arrowheads).

from any suture or staple line within the ileal
conduit, urine leakage usually occurs at the
ureteroileal anastomosis. Use of ureteral stents
placed across the ureteroileal anastomosis at the
time of surgery has been associated with de-
creased incidence of this complication (23). It is
critical to identify urine leaks because they can
lead to chemical peritonitis, sepsis, periureteral
fibrosis, and scarring, resulting in stricture of the
distal ureter (24).
Patients with urine leaks may present with
abdominal pain, discharge from the wound, or in-
creased output from the abdominal drain placed
at the time of surgery. Loopography (Fig 4) or
CT with excretory phase imaging (CT performed
10–20 minutes after intravenous injection of con-
trast material) is useful for demonstrating urine
leakage. While loopography can delineate the
site of a leak, CT can demonstrate the extent of
urinary ascites or the size and location of urino-
mas (Fig 4). In patients who are not candidates
for imaging with contrast material, scintigraphy
can suggest urine leakage by showing abnormal
uptake around the ileal conduit. A definitive
RG • Volume 41 Number 1 Kobayashi et al 255

Figure 5. Ureteral obstruction in a 57-year-old man who underwent radical cystectomy for bladder cancer 3 weeks earlier. The pa-
tient presented with acute renal failure and sepsis. (a) Axial nonenhanced CT image shows the dilated renal pelvis with mild hydrone-
phrosis bilaterally. A ureteral stent placed during surgery is seen within the left renal pelvis (arrow). (b) Posterior renal scintigram with
technetium-99m diethylenetriaminepentaacetic acid obtained at 30 minutes shows persistent tracer activity in the left renal collecting
system despite intravenous administration of furosemide, which is suggestive of left ureteral obstruction. The patient underwent left
nephrostomy for external urinary drainage. (c) Antegrade nephrostogram obtained after injection of contrast material through the
nephrostomy tube shows obstruction of the mid left ureter (arrow). Loopogram showed obstruction of the midureter at the same
location as seen on the antegrade nephrostogram (not shown). Antegrade ureteroscopy demonstrated no obstructing lesion with a
normal ureteral mucosa. The obstruction was considered to be benign in cause and was likely caused by excessive angulation of the
left ureter while passing through the window created in the sigmoid mesentery.

diagnosis can be made on the basis of the creati-
nine level in the fluid from the wound or in the
peritoneal fluid near the ileal conduit.
Initial management of urine leakage includes
percutaneous urinoma drainage along with diver-
sionary percutaneous nephrostomy. Nephrostomy
catheters can be converted to nephroureteral
stents, which are placed across the anastomosis
(Fig 4). If the laterality of the anastomosis from
which the urine leak originates is known in the
setting of a Bricker-type anastomosis, drainage
of the affected single kidney may be adequate
(25). However, drainage of the bilateral kidneys
is mandatory in the setting of a Wallace-type
anastomosis to achieve adequate external drain-
age. Nephroureteral stents are generally left in
place for 4–8 weeks, permitting ureteral healing
(26). Conservative approaches with these inter-
ventional radiologic techniques can be definitive
treatments. If these interventions are unsuccess-
ful, surgical revision of the ureteroileal anastomo-
sis is required.
Ureteral Obstruction
Ureteral obstruction can occur in up to 10% of
patients in the early postoperative period (20,27).
It is mostly related to surgical errors at the
ureteroileal anastomosis but may occur far from
the anastomosis, as excessive angulation of the
left ureter can occur where it crosses the sigmoid
mesentery (22). Patients may present with flank
pain, pyelonephritis, or worsening of renal func-
tion. Treatment requires relief of obstruction by
placing a nephrostomy tube (Fig 5). If obstruc-
tion is caused by extrinsic compression from a
fluid collection such as in a urinoma, the fluid
collection needs to be drained by percutaneously
placing a drainage catheter (28). The cause of
obstruction requires investigation with antegrade
nephrostography or loopography, which may be
followed by ureteroscopic interrogation (Fig 5).
Postoperative Fluid Collection
Fluid collection is frequently seen in the early
postoperative period after radical cystectomy
with conduit diversion. Patients with fluid col-
lection may present with abdominal pain, fever,
or peritoneal signs. The differential diagnosis
includes urinomas, seromas, hematomas, lym-
phoceles, and abscesses. Among these, urinomas
and abscesses usually require prompt percuta-
neous drainage unless they are small. Seromas,
hematomas, and lymphoceles require percutane-
ous drainage when they become symptomatic or
infected or when they obstruct nearby structures
such as the ureter, bowel, or ileal conduit.
Nonenhanced and contrast-enhanced CT with
delayed phase imaging is the study of choice in
differentiating these types of fluid collection.
Urinomas may be associated with a confined
encapsulated fluid collection or with free fluid
within the peritoneal cavity (urinary ascites) (26).
Excretory phase images show increased attenua-
tion of urinomas by the influx of iodinated urine
(Fig 6). Abscesses may show rim enhancement
and air bubbles within the fluid collection. Any
type of postoperative fluid collection can become
infected, forming an abscess (Fig 6).
256 January-February 2021 radiographics.rsna.org

Figure 6. Urinoma complicated by abscess formation in a 69-year-old man who underwent robot-assisted laparoscopic radical
cystectomy with conduit diversion. On postoperative day 2, the patient was noted to be tachycardic with decreased urine output
through the stoma. (a) Coronal contrast-enhanced CT image obtained in the excretory phase shows excreted high-attenuating urine
(arrow) adjacent to the ileal conduit. Surgically placed drains are noted (arrowheads). The patient underwent bilateral diversionary
nephrostomy. Antegrade nephrostogram obtained during nephrostomy showed ureteroileal anastomotic leakage (not shown). On
postoperative day 18, the patient was discharged from the hospital. Ten days after discharge, the patient presented with fever and
abdominal pain. (b) Axial contrast-enhanced CT image shows a large fluid collection with rim enhancement in the lower abdomen,
which is suggestive of an abscess. The patient underwent percutaneous placement of a drainage catheter. A culture from material that
was aspirated from the fluid collection grew Granulicatella adiacens. Also noted was a high creatinine level, which is compatible with
an infected urinoma. (c) Spot radiograph shows a drainage catheter placed within the abscess. Contrast material injected through
the catheter opacifies the abscess cavity (arrow). The left ureteral stent is in place (arrowhead).

If the diagnosis of a urinoma or abscess is
uncertain, needle aspiration can be performed to
obtain material for laboratory analysis, including
creatinine and culture and susceptibility testing.
Hematomas are usually seen near the surgical
bed as a type of hyperattenuating fluid collection
at nonenhanced CT. Contrast-enhanced CT with
arterial and venous phase imaging may be needed
if vascular complications such as pseudoaneu-
rysms are clinically suspected (29).
Lymphoceles usually manifest as a thin-walled
homogeneous type of fluid collection arising from
the pelvic wall. Surgical clips related to lymph
node dissection may be seen adjacent to the lym-
phocele. Lymphoceles commonly resolve sponta-
neously, but those that are large or symptomatic
require percutaneous drainage with or without
sclerotherapy. Intranodal glue embolization after
Lipiodol (ethiodized oil; Guerbet, Villepinte,
France) lymphangiography has been reported as
a promising treatment of lymphoceles refractory
to sclerotherapy, although this technique is still
under investigation (30,31).
Fistulas
Fistulous communication between an ileal
conduit and the nearby bowel, vagina, or skin is
a rare complication seen in the early postopera-
tive period. Risk factors for developing a fistula
include poor preoperative nutritional status,
diabetes mellitus, chemotherapy, and long-term
corticosteroid use (32). Patients with a urinary-
enteric fistula typically present with feculent
debris in the urine or pneumaturia. CT may
show air within the conduit or contrast material
in the urinary system after administration of oral
contrast material (33). Loopography is useful in
visualizing the site and orientation of the fistula.
Small fistulas can be treated conservatively
with nothing per mouth, parenteral nutrition,
somatostatin analogs, and antibiotics. Diverting
urinary catheter drainage with a Foley catheter
placed within the conduit via the stoma, neph-
rostomy tubes, or nephroureteral stents may be
needed in refractory cases (34). Surgical repair is
required in patients with a large fistula or when
conservative management is unsuccessful.
Late Complications
The risk of complications related to ileal con-
duits persists beyond 30 days after surgery. The
overall complication rate related to ileal conduits
20 years after surgery has been reported to be
as high as 80% (35). However, most complica-
tions can be managed conservatively, and the
reoperation rate is low. Late complications that
can be managed with interventional radiologic
techniques include ureteroileal anastomotic
stricture, stomal or conduit stenosis, and uroli-
thiasis. Percutaneous renal access may be needed
to assess upper urinary tract tumor recurrence
with ureteroscopy. Although not directly related
to ileal conduits, ureteroarterial fistula can occur
in patients with an ileal conduit.
Ureteroileal Anastomotic Stricture
Strictures at the ureteroileal anastomosis have
been reported to occur in approximately 1.3%–
RG • Volume 41 Number 1 Kobayashi et al 257

Figure 7. Ureteroileal anastomotic stricture in a 69-year-old man who underwent radical cystoprostatectomy for bladder
cancer 5 months earlier. He was found to have left hydroureteronephrosis at surveillance CT (not shown). (a) Coronal
contrast-enhanced CT image in the excretory phase shows a dilated left ureter and renal collecting system. A contrast
material–filled nondilated right ureter is seen (arrowhead). (b) Loopogram shows lack of reflux into the left ureter, which
is suspicious for left ureteroileal anastomotic stricture. Reflux of contrast material into the right ureter is seen. (c) Ante-
grade nephrostogram shows severe narrowing of the distal left ureter (arrow), which is compatible with left ureteroileal
anastomotic stricture. A nephrostomy tube was then placed in the left kidney (not shown). (d) Magnified spot radiograph
obtained during balloon dilation of the anastomotic stricture shows a waist (arrow) at the anastomotic stricture. After full
expansion of the balloon, an antegrade nephroureteral stent was left in place. (e) Spot radiograph shows an antegrade
nephroureteral stent left in place after balloon dilation. The stent was removed after three sessions of repeat balloon dila-
tion over 3 months. The patient was subsequently lost to follow-up.

10% of patients with an ileal conduit, most of
whom are diagnosed within 2 years after surgery
(36). The strictures can be benign or malignant,
with the majority being benign. Tumor recurrence
at the anastomosis is rare, with reported rates of
less than 1% (37). Brush biopsy of the anasto-
mosis or distal ureter can be performed whenever
there is a concern that the stricture may be malig-
nant (38). The exact cause of benign ureteroileal
anastomotic strictures is unclear, but it is thought
to be periureteral fibrosis and scarring secondary
to ischemia or urine leakage at the anastomotic
site (35,39). Anastomotic strictures more com-
monly occur in the left ureter, presumably because
of its extensive mobilization and tension caused by
passing through the sigmoid mesentery, predispos-
ing the distal left ureter to ischemia (14).
Patients with ureteroileal anastomotic stricture
may present with flank pain, recurrent urinary
tract infection, or sepsis. Those with signs of infec-
tion need prompt decompression with percuta-
neous nephrostomy, which can be followed by
antegrade nephrostography to define the degree
and site of obstruction. Ureteroileal anastomotic
stricture can be clinically silent and may be found
by progressive deterioration of renal function or
hydronephrosis at surveillance imaging. In asymp-
tomatic patients, the initial workup includes renal
US (to confirm hydronephrosis) or contrast-
enhanced CT with excretory phase imaging (Fig
7). CT may demonstrate a cause of obstruction
other than ureteroileal anastomotic stricture, such
as recurrent tumor involving the ureter or vascular
structures compressing the ureter (19).
258 January-February 2021
Loopography is useful for assessing the pa-
tency of the ureteroileal anastomosis (Fig 7). Re-
flux of contrast material from the conduit to the
ureter can rule out obstruction. Absence of reflux
is highly suspicious for anastomotic stricture but
is not diagnostic for this condition because it may
occur secondary to a benign process such as a
mucosal flap or edema (40). Renal scintigraphy
is useful in quantifying the degree of obstruction
and establishing split renal function. A poorly
functioning kidney may require nephrectomy.
Antegrade nephrostography is effective in diag-
nosing ureteroileal anastomotic strictures (Fig 7).
It not only depicts the site and nature of the ob-
struction but also can provide access for urinary
drainage, permitting recovery of renal function,
which helps confirm the diagnosis.
Ureteroileal anastomotic strictures pose a
particular challenge for interventional radiologists
and urologists. Surgical repair with excision of the
strictured distal ureter and reimplantation of the
ureter to another site of the ileal conduit remain
the standard treatment of this condition, and high
success rates (approximately 80%–90%) in the
short and long terms have been reported (41).
However, surgical repair is often difficult because
of dense adhesions from previous major surgeries
or because of fibrosis related to radiation treat-
ment. Advances in interventional radiologic and
endourologic techniques have provided alternative
options for treatment, including balloon dilation,
ureteral stent placement, and endoureterotomy.
Although none of these techniques have achieved
long-term patency rates similar to those of surgi-
cal repair, they offer reduced morbidity, a shorter
hospital stay, and decreased costs (42).
Interventional radiologic procedures with or
without subsequent endourologic intervention can
be performed by using an antegrade approach,
a retrograde approach, or a combination of the
two. Since a nephrostomy tube is usually placed
for decompression at the initial intervention, an
antegrade approach is frequently used. External
drainage for several days before an attempt at
ureteral negotiation often improves the prospects
for ureteral transit and decreases the chance of in-
fectious complications (43). However, a retrograde
approach, which can obviate the risk of bleeding
from percutaneous nephrostomy, may be used
subsequent to loopography.
At the authors’ institution, the strictured seg-
ment is negotiated with a hydrophilic guidewire
inserted through a 5-F angled catheter. A 5- or 6-F
vascular sheath long enough to reach the anas-
tomosis may be used for better maneuverability of
the guidewire and catheter. Once the strictured
segment is negotiated, the wire is usually exchanged
for a stiff guidewire for subsequent intervention.
radiographics.rsna.org
Balloon dilation for ureteroileal anastomotic
strictures is typically performed with a 4–8-mm
high-pressure balloon catheter. The balloon
remains inflated with a pressure of 12–15 atm
for approximately 3–5 minutes. Balloon dilation
is repeated or the balloon size is increased until
no waist is visualized fluoroscopically (Fig 7). A
nephroureteral stent is then placed to maintain
patency of the strictured segment and to repeat di-
lation if follow-up nephrostography shows residual
stricture. The stent is eventually removed when
clinically appropriate, usually in 6–12 weeks, and a
nephrostomy tube is reinserted into the renal col-
lecting system. This catheter can be clamped and
antegrade pyeloureterography can be performed at
a later date to help determine adequacy of ante-
grade flow.
The overall reported success rates of balloon
dilation combined with stent placement vary,
ranging from 0% to 70% at a median follow-up
of 12–48 months (44–46). Strictures larger than
1 cm are usually associated with poorer outcomes
(44). Repeated dilation followed by sequential
upsizing of the stent (usually from 8 F to 10–12
F) is often required to maintain long-term pa-
tency because balloon dilation only stretches the
stricture instead of removing the surrounding scar
tissue (47). The complications associated with this
approach are generally minor, with infection and
hematuria being the most common. Perforation
of the ureter after balloon dilation can generally
be avoided by selection of properly sized balloon
catheters. Even if it occurs, it is usually of no
consequence as long as access is maintained and
the system is adequately drained at the end of the
procedure (47).
Endoureterotomy, an endoscopic incision of
the strictured ureteral segment, has been devel-
oped with various cutting modalities, including
cold-knife, electrocautery, Acucise cutting bal-
loon catheters (Applied Medical, Rancho Santa
Margarita, Calif) (which are used in combina-
tion with an electrocautery cutting wire), and
holmium:YAG lasers. Regardless of the type of
cutting modality, the overall patency rates for en-
doureterotomy with stent placement are reported
to range from 30% to 100% at a mean follow-up
of 10–60 months (48). Because of the better pa-
tency rates compared with those of balloon dila-
tion, endoureterotomy is now the endourologic
procedure of choice for ureteroileal anastomotic
strictures.
Several researchers have reported their experi-
ence with use of metallic stents for ureteroileal
anastomotic strictures. These include a metallic
double-pigtail stent, a self-expandable stent, and
a balloon-expandable stent (49–51). Although
the reported patency rates are promising (mean
RG • Volume 41 Number 1 Kobayashi et al 259

Figure 8. Conversion of an antegrade nephroureteral stent to a retrograde nephroureteral stent in a 73-year-old man who un-
derwent radical cystectomy for bladder cancer 3 years earlier. He had an antegrade left nephroureteral stent placed for ureteroileal
anastomotic stricture 1 year earlier. (a, b) Fluoroscopic images with the patient in a right-sided decubitus position show an antegrade
nephroureteral stent in place that was removed over a guidewire. A vascular sheath was used to maintain access to the renal col-
lecting system (arrowhead). An inferior vena cava (IVC) filter is in place. (c) Fluoroscopic image shows a retrograde nephroureteral
stent placed via the stoma. The hub of the stent was placed out of the stoma for urinary drainage within the ostomy bag (not seen).

89.6%), the sample sizes have been small with
short follow-up durations (mean 12 months)
(48). These metallic stents may have utility in
selected patients, although complications of
obstruction related to tissue ingrowth and stent
migration remain problematic (47).
In patients who experience failure from bal-
loon dilation or endoureterotomy, or those with
limited life expectancy due to their primary dis-
ease, long-term indwelling nephroureteral stent
placement may be appropriate. In this setting,
retrograde nephroureteral stents are better toler-
ated than antegrade stents because of the lack of
externalized flank catheters, enhancing patient
comfort and quality of life and reducing the com-
plications associated with antegrade catheters.
If the patient has an antegrade nephroureteral
stent in place, it can be converted to a retrograde
stent under fluoroscopic guidance (Fig 8). In this
technique, the patient is usually placed in a lat-
eral decubitus position. A guidewire is advanced
through the indwelling antegrade nephroureteral
stent and manipulated out of the stoma, provid-
ing through-and-through access. An angled cath-
eter may need to be used to direct the guidewire
to the stoma. A retrograde nephroureteral stent
is then inserted over the guidewire with the distal
end forming a loop within the renal pelvis (Fig
8). Care needs to be taken to place a retrograde
nephroureteral stent with an appropriate length
so that the distal part of the stent has a suffi-
cient length within the ostomy bag. A retrograde
nephroureteral stent can also be placed via the
stoma in a retrograde fashion. After loopography,
the strictured ureteroileal anastomosis is negoti-
ated with a guidewire and an angled catheter.
Once access to the renal pelvis is obtained, a
stent is advanced into the renal pelvis over the
guidewire. This technique may be difficult if the
affected ureter is not opacified with contrast
material by reflux or if the Bricker technique is
used for the anastomosis. The success rates of
this technique have been reported to range from
14% to 86% (52).
Stoma-related Complications
Stoma-related complications are the most com-
mon late complications to occur after conduit di-
version. The incidence has been reported to be as
high as 60% (53). Management of stoma-related
complications is of great importance because
stoma malfunction significantly degrades quality
of life. These complications include parastomal
hernia, stomal stenosis, retraction, and prolapse.
A multidisciplinary approach involving enterosto-
mal therapists, urologists, and interventional ra-
diologists is essential for managing stoma-related
complications.
Parastomal hernia is an incisional hernia sec-
ondary to fascial defects next to the stoma. Para-
stomal hernia is the most common stoma-related
complication, with a reported incidence of ap-
proximately 15% (53). The true incidence remains
undetermined because most patients with this
condition are asymptomatic. Risk factors include
female sex, obesity, advanced age, and low preoper-
ative albumin levels (54). The hernia sac may con-
tain the ileal loop forming the stoma, abdominal fat
or omentum, or bowel loops other than the stoma
(55). Parastomal hernia can cause gastrointestinal
or urinary obstruction, pain, or bleeding. Although
approximately one-third of patients with parasto-
mal hernia require surgical repair, recurrence is
frequent, with reported incidences ranging from
30% to 75% (9). Urinary obstruction caused by
parastomal hernia may be treated with placement
260 January-February 2021 radiographics.rsna.org

Figure 9. Urinary obstruction related to parastomal hernia in a 54-year-old woman who underwent radical cystectomy with conduit
diversion for bladder cancer. The patient presented with acute renal failure and hydronephrosis of her solitary right kidney. (a) Sagittal
CT image of the abdomen shows parastomal hernia with a prolapsed ileal loop (arrow). A large fascial defect is noted (arrowhead).
Loopogram demonstrated obstruction of the ileal conduit (not shown). Retrograde access to the ileal conduit with cystoscopy was
unsuccessful. (b) Antegrade nephrostogram of the right kidney shows hydronephrosis and near complete obstruction of the ileal con-
duit (arrow). (c) Spot radiograph shows an antegrade nephroureteral stent placed across the obstruction for decompression of the re-
nal collecting system. (d) Retrograde nephrostogram shows a retrograde nephroureteral stent that was converted from an antegrade
stent. Since the patient was not a surgical candidate, the ileal conduit obstruction was managed with a long-term retrograde stent.

Figure 10. Severe stomal stenosis in a 63-year-old woman who underwent radical cystectomy with conduit diversion for bladder
cancer 5 months earlier. The patient presented with poor urine output through the stoma with a pinhole opening in the skin. At-
tempts to place a Foley catheter via the stoma were unsuccessful because of severe stenosis. (a) Sagittal abdominal CT image shows
the distended ileal conduit (arrow). Bilateral hydronephrosis was also observed (not shown). Loopogram demonstrated severe stomal
stenosis with minimal contrast material opacification of the ileal conduit (not shown). (b) US image during percutaneous placement
of a drainage catheter shows an 18-gauge needle (arrow) advanced into the distended conduit. (c) Spot radiograph shows a drainage
catheter placed within the conduit for decompression. The ileal conduit is opacified with contrast material (*). The patient underwent
surgical revision of the stoma 2 months later.

of an antegrade or retrograde nephroureteral stent
in patients who are not surgical candidates (Fig 9).
Stomal stenosis, narrowing of the conduit
lumen at the level of the skin or fascia, has been
reported to occur in approximately 2.8%–8.5%
of ileal conduits (56). This late complication is
thought to occur secondary to ischemia (and re-
sultant fibrosis), which may be related to a tight
fascial opening or hyperkeratosis of the peristo-
mal skin characterized by progressive hardening
and proliferation of the skin. Hyperkeratosis is a
consequence of ongoing irritation to the peri-
stomal skin that is typically caused by a poorly
fitting stoma appliance (57).
Stomal stenosis, if not addressed, can lead to
urinary stasis, infection, deterioration of renal
function, and perforation of the conduit. The
degree and extent of this condition may be best
assessed with loopography performed with a
lateral projection (19). Stenosis may be treated
with digital or balloon dilation with or without
drainage catheter (usually a Foley catheter)
placement via the dilated stoma. If the stenosis is
severe and retrograde access to the conduit is not
RG • Volume 41 Number 1 Kobayashi et al 261

Figure 11. Conduit stenosis in an 83-year-old man who underwent radical cystectomy with
conduit diversion for bladder cancer 35 years earlier. The patient was found to have bilateral
hydronephrosis at surveillance CT. Renal scintigraphy showed persistent tracer activity within
the bilateral renal collecting systems and ureters, which is suggestive of urinary stasis (not
shown). (a) Loopogram shows bilateral hydronephrosis (black arrows) with diffuse narrowing
of the ileal conduit (white arrow). A significantly dilated distal right ureter is noted (arrow-
head). (b) Spot radiograph shows bilateral retrograde nephroureteral stents placed via the
stoma to facilitate urinary drainage.

possible, percutaneous drainage of the conduit is
needed as a temporary measure for decompres-
sion before surgical revision (Fig 10).
Stomal retraction, which can result from per-
sistent tension to the stoma due to a short mes-
entery, inadequate bowel mobilization, or a thick
abdominal wall, significantly degrades patients’
quality of life (53). A nonprotruding stoma seen
in this condition can easily cause urinary contact
with the adhesive tape of the stoma appliance,
leading to poor fitting and resultant continuous
urine leakage. Management is usually conservative
with use of a convex pouching system, but placing
a catheter such as a Foley catheter into the stoma
may be needed if urine leakage persists (53,57).
Stomal prolapse occurs when the distal con-
duit loop telescopes out through the stoma. It af-
fects 1.5%–8% of ileal conduits (53). Conserva-
tive management includes use of a prolapse belt,
but this carries a risk of stoma necrosis. If the
prolapse is too large to manage conservatively,
surgical repair is needed.
Conduit Stenosis
Conduit stenosis is a rare late complication, usu-
ally occurring more than a decade after surgery
(58). Conduit stenosis is unique to ileal con-
duits, and it has never been described in colonic
conduits. In this condition, the whole conduit or
part of the conduit is transformed into a thick-
walled tube, causing upper urinary tract obstruc-
tion (21). Although its pathogenesis is unknown,
microvascular insufficiency or fibrosis caused by
chronic infection has been suggested (11). Pa-
tients may present with recurrent upper urinary
tract infection or colicky flank pain (58). Loop-
ography is useful to visualize the site and length
of stenosis within the conduit (Fig 11).
The treatment is surgical removal of the ileal
conduit or resection of the stenotic segment.
Although balloon dilation of the stenotic segment
has been described, the long-term outcomes
are unknown, and the risk of recurrent stenosis
remains (59). For patients who are not surgical
candidates, a Foley catheter may be placed proxi-
mal to the stenosis. However, bilateral nephro-
ureteral stents are needed in those with diffuse
stenosis for optimal urinary drainage (Fig 11).
Urolithiasis
Urolithiasis, stone formation in the urinary tract,
is a common late complication in patients with
urinary diversion. The incidence of urolithiasis in
patients with an ileal conduit has been reported
to range from 2.6% to 13.4% (60). Metabolic
derangements resulting from reabsorption of
urinary solutes through the ileal conduit, for-
eign bodies such as chronic ureteral stents, and
urinary tract infection or bacterial colonization
due to urinary stasis or ureteroileal anastomotic
stricture all promote formation of urinary stones
(61). Most stones formed in patients with urinary
diversion are composed of magnesium ammo-
nium phosphate hexahydrate (struvite) produced
by urea-splitting bacteria such as Escherichia coli
or Proteus mirabilis (18). Because the stones are
usually infected, patients with an ileal conduit
who develop urinary stones are more likely to
present with symptomatic urinary tract infection
than the general population (62).
262 January-February 2021
Nonenhanced multidetector CT is the imag-
ing modality of choice for initial evaluation in
patients with suspected urolithiasis (63). It is not
only highly sensitive and specific in depicting uri-
nary stones but also can reveal the number, size,
location, and composition of the stones, factors
critical for selection of management. Contrast-
enhanced imaging performed in the excretory
phase can contribute to planning for percuta-
neous access to the kidney by visualizing the
three-dimensional anatomy of the pelvicaliceal
system and its relation to nearby organs. It can
also contribute to determination of candidacy
for the retrograde approach to the upper urinary
tract by depicting the length and shape of the
ileal conduit as well as the type and locations of
ureteroileal anastomosis (28).
Management of urinary stones in patients with
urinary diversion is similar to that in the general
population and is based on the patients’ symptoms
and the stone characteristics (size, location, and
composition) (64). If a patient has an obstructing
stone and a suspected infection, the renal collecting
system needs to be drained first with a nephros-
tomy tube or ureteral stent before definitive stone
treatment. Stones more than 1.0 cm in diameter
within the ureter or kidney may be treated with ex-
tracorporeal shock-wave lithotripsy, ureteroscopy,
or percutaneous nephrolithotomy (PCNL).
Interventional radiologists can play a pivotal
role in obtaining percutaneous access to the
kidney before PCNL or ureteroscopic procedures
when an antegrade approach is necessary. Since
initial access to the kidney determines which renal
calices can be reached by a rigid nephroscope or
the degree of maneuverability of the ureteroscope,
preprocedural discussion with the endourologist
regarding the calix that needs to be accessed and
the needle trajectory to the calix is crucial.
At the authors’ institution, access to a stone-
bearing calix is generally preferred when a renal
stone is treated with PCNL because it enables
the endourologist to easily visualize and remove
the stone. Although US may be used to guide
the needle to the stone-bearing calix, the stone
in the calix can be directly punctured with the
desired needle trajectory under fluoroscopic
guidance (Fig 12). When treating ureteral stones
with ureteroscopy, an antegrade or combined
(antegrade and retrograde) approach is an at-
tractive alternative to a retrograde approach,
since finding the ureteral orifice, accessing the
ureter, or negotiating through a floppy bowel
may be difficult in patients with an ileal conduit
(65). A guidewire placed through the kidney
out to the stoma can provide through-and-
through access to the stone for a ureteroscopic
procedure.
radiographics.rsna.org
Upper Urinary Tract Tumor Recurrence
Recurrence in the upper urinary tract after radi-
cal cystectomy for bladder cancer is relatively
rare, with a reported incidence of approximately
5% (66,67). The upper urinary tract is the most
frequent site of recurrence when it occurs more
than 3 years after surgery (66,67). Risk factors
for upper urinary tract recurrence include his-
tory of carcinoma in situ, history of recurrent
bladder cancer, cystectomy for non–muscle-
invasive bladder cancer, and tumor involvement
of the urethra or distal ureter (66).
The majority of upper urinary tract tumor
recurrence is detected after development of
symptoms such as hematuria but is depicted
less frequently at imaging surveillance (67).
For patients with suspected upper urinary tract
recurrence, access to the upper urinary tract for
ureteroscopic evaluation and possible subse-
quent ureteroscopic biopsy or treatment can be
obtained through percutaneous nephrostomy
when retrograde cannulation of the distal ureter
fails or when obstruction of the ureter is present
(Fig 13). Fluoroscopy-guided collection of urine
from a radiographically abnormal area or brush
biopsy for cytologic analysis may be performed,
but they are rarely indicated if ureteroscopy is
available (68).
Ureteroarterial Fistula
Ureteroarterial fistula, also called arterioureteral
fistula, is an abnormal connection between the
ureter and the artery in any location, but usually
occurs in the iliac arteries where the ureters cross.
Although this potentially life-threatening condition
is considered to be rare, it has been increasingly
reported in recent years (69). Patients with an ileal
conduit are at risk for ureteroarterial fistula forma-
tion because it mostly occurs in those with a his-
tory of extensive pelvic surgery, radiation therapy,
and long-term ureteral stents (70).
In a systematic review of 139 cases of uretero-
arterial fistula, van den Bergh et al (71) reported
that 34% of patients with ureteroarterial fistula
had incontinent urinary diversion, and 61% had
long-term ureteral stents. The pathophysiology of
this condition has been postulated to be abrasive
erosion of the ureter caused by a long-term ure-
teral stent and radiation-induced ischemic injury
of the juxtaposing artery in the setting of fibrosis
and adhesions of the surrounding tissue related
to prior oncologic treatment (72). Patients with
this condition usually present with intermittent
hematuria with or without flank pain related to
hydronephrosis caused by blood clots.
Ureteroarterial fistula poses a diagnostic chal-
lenge to radiologists because none of the cross-sec-
tional imaging modalities are highly sensitive for
RG • Volume 41 Number 1 Kobayashi et al 263

Figure 12. Urolithiasis in a 50-year-old woman who underwent simple cystectomy with conduit diversion because of neurogenic
bladder 5 years earlier. The patient presented with signs of urinary tract infection and acute kidney injury. (a) Coronal nonenhanced
CT image of the abdomen demonstrates an obstructing stone in the ureteropelvic junction of the left kidney with hydronephrosis.
Another stone is noted within the lower pole calix. The patient underwent emergent nephroureteral stent placement through a
non–stone-bearing calix for decompression of the pelvicaliceal system. (b) Antegrade nephrostogram obtained after placement of
the nephroureteral stent shows left hydronephrosis. One month after stent placement, the patient underwent PCNL for definitive
stone treatment. (c) Fluoroscopic image shows the stone-bearing lower pole calix accessed with a 21-gauge needle (arrow) before
PCNL. The previously placed nephroureteral stent was replaced by a straight catheter with a guidewire in place. (d) Spot radiograph
obtained during PCNL shows a rigid nephroscope inserted into the left kidney through a 30-F sheath for stone disintegration. CT
image obtained after PCNL showed complete stone clearance (not shown).

Figure 13. Upper urinary tract tumor recurrence caus-

ing distal ureteral obstruction in a 76-year-old woman
who underwent radical cystectomy for bladder cancer
2 years earlier. (a) Coronal CT urogram shows obstruc-
tion of the right distal ureter (arrow). Right hydrone-
phrosis is also present (not shown). Subsequently, the
patient underwent right nephrostomy tube placement.
(b) Right antegrade nephrostogram demonstrates distal
ureteral obstruction (arrow) and multiple filling defects
within the upper urinary tract (arrowheads), which are
suggestive of multifocal tumor recurrence. Biopsy of the
urothelial lesions performed during antegrade uretero-
scopic examination helped confirm low-grade urothelial
cancer.

depicting this condition. CT may be performed
for initial workup of hematuria, but it rarely visual-
izes the fistulous connection between the artery
and the ureter during the quiescent phase (70).
Therefore, if patients with an ileal conduit pre-
sent with massive hematuria, especially when it is
encountered during ureteral stent manipulation,
conventional angiography needs to be performed
immediately with a high index of suspicion for
ureteroarterial fistula because the mortality rate is
high (7%–38%) when treatment is delayed (73).
Digital subtraction angiography is the most sensi-
tive diagnostic study for depicting ureteroarterial
fistula, but it may visualize only a small pseudoa-
neurysm or subtle irregularity of the iliac artery at
the ureteral crossing (71). Multiple oblique projec-
tions are usually needed for diagnosis because
these findings can be masked by the overlying
artery or the angiographic catheter (Fig 14).
Historically, surgical approaches, including
primary arterial repair with omental wraps or
ligation or coil embolization of the affected iliac
artery with or without extra-anatomic bypass,
have been used to treat this condition. However,
these approaches are often hampered by frozen
pelvis secondary to prior oncologic treatment and
are associated with high postoperative complica-
tion rates (74). In recent years, an endovascular
approach with stent-graft placement covering the
site of the fistula has been primarily used as the
definitive method of treatment (Fig 14). A stent-
graft can be placed immediately after diagnostic
angiography, and this technique can obviate high-
risk open surgery.
264 January-February 2021 radiographics.rsna.org

Figure 14. Ureteroarterial fistula in a 74-year-old woman who underwent chemoradiation therapy followed by pelvic exenteration
for recurrent rectal cancer 14 years earlier. Bilateral ureteral strictures were managed with ureteral stents. The patient presented with
massive hematuria and hypotension. (a) Anterior-posterior digital subtraction angiogram (DSA) shows severe stenosis in the right
external iliac artery where the ureteral stents cross (arrow). The right internal artery is not visualized because it was ligated during the
prior surgery. (b) Right anterior oblique DSA shows a pseudoaneurysm (arrow) that was not seen in the anterior-posterior projection.
(c) Anterior-posterior DSA obtained after 10 3 80-mm stent-graft placement shows exclusion of the pseudoaneurysm.

Before stent-graft placement, the internal iliac
artery is often embolized with coils or a vascular
plug to prevent retrograde flow to the arterial defect
if the stent-graft traverses the iliac bifurcation. A va-
riety of stent-grafts, including self-expandable and
balloon-mounted types, have been used with similar
reported high technical success rates (73,74). Re-
ports on the long-term follow-up of patients treated
with stent-grafts are emerging, and the outcomes
are mostly encouraging, with reported minor re-
bleeding rates of less than 15% (73,74). Only a few
cases of stent-graft thrombosis and no stent-graft
infections have been reported to date. Most patients
are treated with antiplatelet agents for various
periods ranging from 3 months to a lifetime, but
few patients are treated with long-term prophylactic
antibiotics after stent-graft placement (74).
To address the concern of urine leakage or
stent-graft infection, a variety of urologic treat-
ments have been performed, including nephro-
ureterectomy, ligation of the ureter, or closure of
the ureter with embolic materials such as coils
(71). However, there is no consensus on the need
for treatment of ureteroarterial fistulas from the
ureteral side after closure of the fistula from the
arterial side with a stent-graft. Some authors
advocate permanent removal of the ureteral stent
and continued urinary diversion with a nephros-
tomy catheter to prevent recurrent fistulization or
infection (70).
Stent-related Complications
Ureteral strictures may be managed with long-
term indwelling stents in patients with signifi-
cant comorbidities or in those with a limited
life expectancy due to cancer recurrence. At
the authors’ institution, retrograde nephroure-
teral stents are preferably used for this purpose.
Long-term indwelling nephroureteral stents
need to be exchanged on a regular basis, nor-
mally at 2–3-month intervals, to avoid stent-
related complications. Stent maintenance is
important because stent malfunction can lead to
urinary tract infection or sepsis, acute renal fail-
ure, or urine leakage at the stoma site. Compli-
cations related to long-term retrograde nephro-
ureteral stents include loss of access to the
renal collecting system during stent exchange,
stent migration, dislodgement, obstruction, and
encrustation.
Loss of access to the renal collecting system
can occur during stent exchange in patients with
an acute angle of the stent in the pelvic portion. If
migration of the distal part of the stent from the
renal pelvis is observed while negotiating the acute
angle with a stiff guidewire, the guidewire needs
to be exchanged for a softer guidewire such as a
hydrophilic guidewire (75). If this problem per-
sists, a peel-away sheath (1–2 F greater than the
caliber of the stent) can be inserted over the stent
up to the distal ureter. The stiff guidewire can
then be advanced through the peel-away sheath to
the renal pelvis, and the stent can be exchanged
in a standard fashion. This technique can also be
used when exchanging obstructed or encrusted
stents. Patients with urinary diversion have a high
incidence of stent encrustation because of urinary
stasis (14).
RG • Volume 41 Number 1 Kobayashi et al 265

Figure 15. Retrograde nephroureteral stent migration into the ileal conduit in
an 82-year-old man with ureteroileal anastomotic stricture who recently under-
went conversion from a nephrostomy tube to a retrograde nephroureteral stent.
(a) Fluoroscopic image shows a retrograde nephroureteral stent that had mi-
grated into the ileal conduit, with the hub (arrowhead) seen caudal and lateral to
the site of stoma. The tip of a hemostat placed over the patient’s lower abdomen
indicates the site of the stoma. (b) Fluoroscopic image shows a Foley catheter
inserted through the stoma into the ileal conduit to retrieve the stent. Note the
balloon of the Foley catheter inflated within the ileal conduit (arrow). By gently
pulling back the Foley catheter, the distal part of the catheter (arrowhead) was
brought back to the distal conduit underneath the stoma, and the stent was
manually captured.

Distal stent migration into the conduit can oc-
cur in patients with an angled ileal conduit when
a short retrograde nephroureteral stent is placed.
Even if the hub of the stent is out of the stoma
when initially placed, it can be retracted and can
migrate deep into the conduit. In this situation,
the distal part of the stent can be captured with a
snare, but this may be difficult to achieve within
the small lumen of the conduit.
At the authors’ institution, we prefer to use a
Foley catheter that is inserted through the stoma
and advanced proximal to the hub of the stent.
After inflating the balloon, the Foley catheter is
gently pulled back with the migrated stent, and
the distal part of the stent is manually captured
underneath the stoma (Fig 15). If the stent can-
not be captured with these techniques, cystos-
copy may need to be used to retrieve the stent.
The stent needs to be exchanged for a longer
one to prevent recurrence of migration.
Conclusion
Most complications related to ileal conduits can
be managed with interventional radiologic tech-
niques alone or in conjunction with endourologic
or surgical intervention. In this article, we have
reviewed the surgical anatomy of ileal conduits
and the diagnostic workup and underlying patho-
physiology of complications associated with ileal
conduits. Technical considerations that are crucial
to the success of the interventional radiologic ap-
proach have also been discussed. When managing
the complications associated with ileal conduits,
collaboration between interventional radiolo-
gists and urologists or endourologists is of great
importance for best preserving patients’ renal
function and maintaining their quality of life.
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