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Follow the Stream: Imaging of
Urinary Diversions1
Lauren N. Moomjian, MD
Laura R. Carucci, MD
Georgi Guruli, MD
Adam P. Klausner, MD
Abbreviation: IVP = intravenous pyelography
RadioGraphics 2016; 36:0000–0000
Published online 10.1148/rg.2016150180
Content Codes:
1
From the Departments of Radiology (L.N.M.,
L.R.C.) and Urology (G.G., A.P.K.), Virginia
Commonwealth University Medical Center,
1250 E Marshall St, PO Box 980615, Rich-
mond, VA 23298; Hunter Holmes McGuire VA
Medical Center, Richmond, Va (G.G., A.P.K.).
Presented as an education exhibit at the 2014
RSNA Annual Meeting. Received June 10,
2015; revision requested August 6 and received
September 2; accepted October 5. For this jour-
nal-based SA-CME activity, the authors, editor,
and reviewers have disclosed no relevant rela-
tionships. Address correspondence to L.N.M.
(e-mail: lmoomjian@mcvh-vcu.edu).
©
RSNA, 2016
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
■ Describe the various types of urinary
diversions, including continent and in-
continent diversions.
■ Recognize the normal imaging appear-
ance of various types of urinary diver-
sions at CT, MR imaging, and fluoro-
scopic evaluation.
■ Identifyboth early and late postopera-
tive complications after urinary diversion.
See www.rsna.org/education/search/RG.
1
GENITOURINARY IMAGING
Urinary diversion is a surgical technique to redirect the stream of
urine, most often after cystectomy. Cystectomy may be performed
both for benign and for malignant conditions. Bladder cancer is the
most common indication for cystectomy, and most patients who
undergo radical cystectomy and urinary diversion have muscle-
invasive or high-risk non–muscle-invasive bladder cancer. There are
two major surgical approaches for urinary diversions performed
after radical cystectomy: continent and incontinent diversions.
For incontinent urinary diversions, a cutaneous ostomy is used for
continuous urine drainage (eg, ileal conduit). With a continent di-
version procedure, the patient may void through the native urethra
or self-catheterize through a surgically created stoma. The goals of
imaging after urinary diversion are to assess postoperative anatomy,
detect postoperative complications, evaluate for residual or recur-
rent tumor and metastatic disease, and monitor for upper tract
distention and/or deterioration. Multiple imaging modalities and
techniques may be used to evaluate urinary diversions, including
computed tomographic and magnetic resonance urography, intra-
venous pyelography, ultrasonography, pouchography, loopography,
and nephrostomy studies. Knowledge of the expected postopera-
tive appearance after urinary diversions and potential postopera-
tive complications is crucial because many complications may be
clinically silent. Radiologists must be able to recognize the expected
postoperative appearance as well as complications to facilitate ap-
propriate diagnosis and treatment of patients after cystectomy and
urinary diversion.
©
RSNA, 2016 • radiographics.rsna.org
Introduction
Urinary diversion is a surgical technique to redirect the stream of
urine, most often after cystectomy. It is important for radiologists to
be familiar with the various types of diversions that may be performed
(including incontinent and continent diversions). Radiologists must
have knowledge of the various procedures and examination techniques
to provide appropriate imaging evaluation and interpretation of com-
plications in patients after cystectomy.
Cystectomy may be performed for both benign and malignant
conditions. Bladder cancer is the most common indication for
cystectomy, and most patients who undergo radical cystectomy and
urinary diversion have muscle-invasive or high-risk non–muscle-
invasive bladder cancer (1). Bladder cancer is now the fifth most
common malignancy in the United States (2) and the ninth most
common cancer worldwide, with approximately 333 000 new cases
diagnosed each year (3,4). There is a male predominance, with a
male-to-female ratio of nearly 4:1 (4). Risk factors for bladder cancer
2 May-June 2016
TEACHING POINTS
■ It should be recognized that a “radical cystectomy” procedure
differs on the basis of the patient’s sex. In men, the prostate is
also removed (the procedure is essentially radical cystoprosta-
tectomy). Female patients undergo anterior exenteration with
simultaneous cystectomy, hysterectomy, and resection of the
anterior vaginal wall.
■ There are two major surgical approaches for urinary diversions
performed after radical cystectomy: continent and inconti-
nent diversions. In incontinent urinary diversions, a cutaneous
ostomy is used for continuous urine drainage (eg, ileal con-
duit). With a continent diversion, the patient voids through
the native urethra or self-catheterizes through a surgically cre-
ated stoma.
■ Identification of the ureteroileal anastomoses, ileal segment,
cutaneous urostomy, and ileal-ileal anastomosis is essential
for detecting possible genitourinary and gastrointestinal com-
plications such as urine leak, leak of fecal contents from the
small-bowel anastomosis, postoperative fluid collections, ab-
scess, bowel obstruction, and ileus.
■ Positive luminal oral contrast material may help differentiate
the newly created urinary tract from the gastrointestinal tract
in the nephrographic phase, before opacification of contrast
material in the genitourinary tract that occurs in the later ex-
cretory phase. It is important to examine the gastrointestinal
tract carefully to determine which bowel segment has been
resected and used to create the pouch and stoma.
■ Unlike other diversion procedures, the orthotopic neobladder
enables patients to void through the native urethra by means
of either abdominal straining or self-catheterization and does
not require a stoma or external appliance.
include smoking, occupational chemical exposure
(ie, dyes, rubbers, textiles, paints, and leathers),
external-beam pelvic radiation therapy, chronic
urinary tract infections, long-term indwelling
urinary catheters (5), schistosomiasis infection,
and chemotherapy. Of patients with bladder can-
cer, 20%–30%, are found at initial diagnosis to
have muscle-invasive disease necessitating radical
cystectomy and urinary diversion (4). Patients
without muscle-invasive disease may require
cystectomy owing to disease progression after an
initial attempt at organ-sparing treatment. Benign
indications for cystectomy may include neuro-
muscular bladder dysfunction, radiation cystitis,
congenital anomalies, and refractory interstitial
cystitis (6–8).
It should be recognized that a “radical cys-
tectomy” procedure differs on the basis of the
patient’s sex. In men, the prostate is also removed
(the procedure is essentially radical cystoprosta-
tectomy). Female patients undergo anterior exen-
teration with simultaneous cystectomy, hysterec-
tomy, and resection of the anterior vaginal wall.
After cystectomy, urine must be rerouted.
There are two major surgical approaches for
urinary diversions performed after radical cys-
tectomy: continent and incontinent diversions.
radiographics.rsna.org
In incontinent urinary diversions, a cutaneous
ostomy is used for continuous urine drainage (eg,
ileal conduit). With a continent diversion, the
patient voids through the native urethra or self-
catheterizes through a surgically created stoma.
The vast majority of currently performed urinary
diversion procedures involve the use of bowel as a
conduit or reservoir for urine storage. With these
procedures, the bowel segment is resected and
anastomosed to the genitourinary tract, sepa-
rating the urine and fecal contents. Procedures
combining the urinary and fecal stream, such as
ureterosigmoidostomy, where the ureters are im-
planted into the intact sigmoid colon, have largely
been discontinued (7) because of an increased
risk of colon neoplasm and infection (9). How-
ever, ureterosigmoidostomies are still occasionally
performed in select patients and in third-world
countries because of cost and/or limited access to
external collecting appliances.
Patients are evaluated before cystectomy and
urinary diversion to determine whether they are
suitable candidates for continent diversion or if
they will require an incontinent diversion. Con-
tinent diversion procedures require more patient
compliance and capability than do incontinent
diversions. Patients must also be motivated and
able to learn techniques for voiding and/or be
able to self-catheterize routinely. Continent uri-
nary diversions also necessitate a longer surgery
time than incontinent diversions and are overall
more technically complex (10,11). Criteria for
the type of technique used include patient age;
physical condition; intestinal, hepatic, and renal
function; tumor stage and location; previous
radiation therapy; and life expectancy (12). More
recent surgical procedures developed in the past
10 years involve robotic-assisted techniques to
create urinary diversions instead of an open sur-
gical technique.
In this article, we review the surgical tech-
niques for the most common urinary diversion
procedures, the expected imaging appearance,
and the role of radiologists and imaging studies
in detecting complications of urinary diversion
procedures.
Incontinent Diversions
With incontinent urinary diversion procedures,
urine drains via a cutaneous stoma. In the past,
cutaneous ureterostomy was performed with
each ureter anastomosed to the skin surface,
thereby creating two separate stomas. Because
of problems with strictures and renal failure,
this procedure is no longer routinely performed
(13). In rare cases, a modified version of this
procedure, the uretero-ureterocutaneostomy, is
performed for palliation (14). Current inconti-
RG • Volume 36 Number 3 Moomjian et al 3

Figure 1. Ileal conduit: incontinent diversion. Images depict the expected surgical anatomy
after the ileal conduit procedure. (a) Diagram shows that a distal ileal segment approximately
10–15 cm proximal to the ileocecal valve is isolated and resected to create the conduit. Gas-
trointestinal continuity is restored with an ileal-ileal anastomosis (arrowhead). The isolated ileal
segment (arrow) is seen in the right lower quadrant leading toward a right lower quadrant os-
tomy opening (circled). The ureters are anastomosed separately to the isolated ileal segment.
(Created by Mary Beatty-Brooks, Hunter Holmes McGuire VA Medical Center, Richmond, Va.)
(b) Image from intravenous pyelography (IVP) obtained with the patient supine shows ex-
creted contrast material in the collecting systems and ureters. Excreted contrast material is
seen in the right lower quadrant conduit (black arrows). Minimal contrast material opacifies
the ostomy ring (arrowhead). Note that the left ureter crosses the midline at L5 (white arrow)
and is then anastomosed to the conduit.

nent diversion procedures use an ileal or colonic
conduit with a single ostomy for continuous
urine drainage.
Ileal Conduit
The ileal conduit, or Bricker procedure, is an
incontinent diversion procedure and is the most
common technique for reconstructing the lower
urinary tract after radical cystectomy (13,15) (Fig
1). This cutaneous loop diversion surgical tech-
nique has been used in practice since the 1930s
and was described and popularized in a landmark
article in 1950 by Bricker (16).
Although there has been an increasing trend
toward continent diversions, especially at major
academic centers, overall approximately 80%
of patients in the United States undergo the
ileal conduit procedure for urinary diversion
(2,17–19). At high-volume and teaching hospi-
tals, approximately 50% of patients undergo this
type of procedure, with a higher percentage of
patients undergoing continent diversions, and
specifically neobladders, as compared with that
in smaller hospitals (13,17,18). Compared with
continent diversion procedures, the ileal conduit
technique is less technically demanding and is
favored in patients with poor functional status,
decreased renal function, poor prognosis, and
limited life expectancy. In particular, for older
patients with many comorbidities, the ileal con-
duit remains a relatively quick, safe, and reliable
method of urinary diversion.
Surgical Anatomy
The ileal conduit technique involves isolating and
mobilizing a 15–20-cm segment of distal ileum
and using this segment for a urine conduit (Fig
1). Gastrointestinal continuity is restored with
an ileal-ileal anastomosis (16). The used distal
ileal segment is typically approximately 10–15
cm proximal to the ileocecal valve (20). Preser-
vation of the terminal ileum allows continued
absorption of vitamin B12 and bile salts from the
gastrointestinal tract (13). The ureters are then
implanted into the proximal end of the isolated
ileal segment (15), anastomosed separately to the
conduit. The ileal conduit typically has refluxing
ureteroileal anastomosis. Antireflux anastomosis
can be performed as well, but these are accompa-
nied by an increased chance of ureteroileal anas-
tomotic stricture. The distal end of the actively
peristalsing conduit (9) is then brought out to
a right lower quadrant as a cutaneous urostomy
(Fig 1). The direction of peristalsis (toward the
ostomy) is preserved, which helps improve the
passive drainage of urine.
4 May-June 2016
Expected Imaging Findings
Abdominal and pelvic CT and CT urography.—Ide-
ally, computed tomography (CT) of the abdomen
and pelvis is performed after a urinary diversion
procedure by using a CT urography technique,
with images obtained before and after intravenous
administration of contrast material and in the de-
layed, excretory phase (21). Newer dual-energy
techniques may eliminate the need for unen-
hanced imaging (22), and the split bolus of intra-
venous contrast material technique may, at some
institutions, be used to combine nephrographic
and excretory phases (23), thereby decreasing nec-
essary radiation exposure. Hydration with intrave-
nous fluids or oral water before the study may be
beneficial for urinary tract distention (24).
Identification of the ureteroileal anastomoses,
ileal segment, cutaneous urostomy, and ileal-ileal
anastomosis is essential for detecting possible
genitourinary and gastrointestinal complica-
tions such as urine leak, leak of fecal contents
from the small-bowel anastomosis, postoperative
fluid collections, abscess, bowel obstruction, and
ileus. The isolated ileal segment and cutaneous
urostomy are typically located in the right lower
quadrant (Fig 2). Failure to identify the ileal seg-
ment could result in improperly diagnosing this
fluid-filled structure as an abscess.
IVP imaging.—IVP is currently much less com-
mon than CT but may still be used to evaluate
patients after urinary diversion. Initially, a scout
radiograph is obtained, followed by intravenous
administration of contrast material. Subse-
quently, a kidney ureter bladder radiograph is ob-
tained 5 minutes after intravenous administration
of contrast material. Images are also obtained 10
and 15 minutes after intravenous contrast mate-
rial administration with the patient in the supine
position to evaluate the kidneys, ureters, and
conduit (Fig 1b). Oblique images should also
be obtained to evaluate the ureters and conduit.
A compression technique for IVP should not be
used in patients with urinary diversion (25).
Abdominopelvic MR imaging and MR urography.—
Magnetic resonance (MR) imaging may also be
used to evaluate patients after urinary diversion
to assess postoperative anatomy, evaluate for re-
current or residual disease, and monitor for post-
operative complications (26). Abdominopelvic
MR imaging may be most appropriate in selected
patients with mild renal insufficiency according
to the renal function criteria for contrast mate-
rial administration. MR imaging is performed in
conjunction with MR urography. This technique
enables imaging of the collecting systems, ureters,
radiographics.rsna.org
Figure 2. Ileal conduit. Coronal oblique maxi-
mum intensity projection CT image obtained in
the excretory phase after intravenous administra-
tion of contrast material shows excreted contrast
material in the collecting systems and ureters.
Contrast material is seen in the right lower quad-
rant conduit (c) and draining in the ostomy bag
(arrow). Note retained contrast material in the
right side of the colon from a previous study that
is of lower attenuation than the excreted contrast
material in the genitourinary tract.
and urinary conduit or reservoir in the excretory
phase after intravenous administration of a gado-
linium chelate (Fig 3) (26). MR urography can
be performed at 1.5 or 3.0 T with a torso coil. If
a gadolinium chelate cannot be administered, T2-
weighted sequences may be beneficial for evaluat-
ing the genitourinary tract.
Loopography.—Loopography is a fluoroscopic
procedure that can be used to examine the con-
duit, ureters, and pelvocaliceal system (Fig 4).
To perform loopography, water-soluble contrast
material is injected in a retrograde fashion (typi-
cally by means of gentle hand injection) through
a 12–14-F Foley catheter inserted into the con-
duit. The catheter balloon is inflated with 5–10
mL of contrast material or fluid. Fluoroscopic
spot images of the conduit, ureters, and collect-
ing systems are obtained in multiple projections,
which may include anteroposterior, bilateral
oblique, and lateral projections. The ileal con-
duit appears as a 15–20-cm tubular structure
on loopogram studies and should demonstrate
peristalsis at real-time imaging. Contrast mate-
rial should reflux into the ureters and collecting
system because the ileal conduit procedure does
not typically employ a surgical mechanism to
RG • Volume 36 Number 3 Moomjian et al 5

Figure 4. Ileal conduit: multifocal conduit stric-

Figure 3. Ileal conduit. Coronal oblique
T1-weighted MR urogram shows excreted
gadolinium chelate in the right collecting
system, ureter, conduit (arrows), and os-
tomy bag (arrowhead).
tures. Loopogram shows a catheter balloon in
the conduit, inflated with contrast material (ar-
rowhead). Retrograde injection of contrast mate-
rial opacifies the ileal conduit, ureters, and col-
lecting systems. There are multifocal ileal conduit
strictures (black arrows) as well as a subtle stric-
ture of the distal left ureter (white arrow) near its
anastomosis with the conduit.

prevent vesicoureteral reflux. Mild ureteral dila-
tation and caliceal blunting are not unexpected
as the contrast material is being injected under
positive pressure. Failure to opacify a ureter
may occur secondary to a benign process such
as a mucosal flap or edema (19). Stricture and
recurrent tumor are additional considerations. A
follow-up CT urogram may be obtained in this
case to assess for underlying recurrent disease.
It is also important to recognize a variation in
surgical technique called the Wallace anastomo-
sis, in which both ureters are spatulated (incised
longitudinally for a short segment) and then
anastomosed to the ileal segment in a single,
larger diameter unit. In theory, the use of this
technique may reduce that rate of postoperative
stricture formation but may also risk bilateral
renal deterioration if affected by an obstructing
process (27).
A loopogram can be used to evaluate for fill-
ing defects in the collecting systems, ureters, or
conduit; to assess the course and contour of the
ureters; to evaluate for a cause of hydronephro-
sis and/or obstruction; and to evaluate for uro-
thelial lesions. The loopogram can be helpful for
evaluating a leak or stricture at the ureteroileal
anastomosis and ureteral and conduit strictures
(Fig 4) (28).
Ultrasonography.—Routine postoperative surveil-
lance with ultrasonography (US) may be ben-
eficial to assess for hydronephrosis, upper tract
deterioration, and cortical atrophy.
Complications
Although the ileal conduit is a less technically
challenging surgical procedure than other urinary
diversion techniques, postoperative morbidity
in the first 30 days has been reported to be as
high as 22%–46% (29). More recent studies,
however, have demonstrated a lower periopera-
tive morbidity of approximately 18% (30). The
long-term complication rate is also high, with
complications occurring in approximately 66%
of patients; almost 40% of those patients need
surgical intervention (31). Approximately 20% of
patients develop new-onset renal failure an aver-
age of 2 years after the ileal conduit procedure
(2). Patients with ileal conduits must undergo
lifelong surveillance because complications can
occur many years after surgery (15). Radiologists
must continue to have a high index of suspicion,
even at remote follow-up examinations.
Early Complications
Urine leak.—Urine leakage after the ileal conduit
procedure is now uncommon, reported in ap-
proximately 2% of patients, and arises most often
from the ureteroileal anastomosis (Fig 5). Histori-
cally, the incidence of leak was much higher (ap-
proximately 10%); however, surgical modifications
6 May-June 2016 radiographics.rsna.org

Figure 5. Ileal conduit with postoperative urine

leak. (a) Axial contrast-enhanced CT scan shows a
thick-walled collection of fluid and gas in the right
lower quadrant (black arrow) after urinary diversion
with an ileal conduit (white arrow = ostomy). Also
note the metastatic soft-tissue mass involving the
right iliac bone (*). (b) Axial CT scan obtained in
the delayed, excretory phase shows that excreted
high-attenuating urine fills the collection due to ure-
teroileal anastomotic urine leak (L). This is located
just posterior to the now-opacified ileal conduit (ar-
rows). (c) Loopogram shows opacification of the
ileal conduit (C) with extravasation from the medial
aspect of the conduit to opacify a large collection
(arrows), consistent with leak (L).

have decreased the incidence among all urinary

diversions (32). The detection of a leak is crucial
because a urine leak can predispose patients to
periureteral fibrosis and scarring as well as stric-
ture formation (32).
Bowel leak (leakage of bowel contents).—Leakage
of fecal contents is a rare complication of urinary
diversion and has been reported in 1%–5% of
patients (32,33). Bowel leak most often occurs
near the ileal-ileal anastomosis after resection
for conduit creation (20) (Fig 6). Multiple fac-
tors contribute to the development of a leak at
the small-bowel anastomosis, including ischemia,
previous radiation therapy, steroid use, inflamma-
tory bowel disease, and distal bowel obstruction
(32). If bowel leak is not readily detected, peri-
tonitis and abscess formation can occur, and this
can potentially lead to life-threatening sepsis.
Alterations in bowel function.—Postoperative il-
eus is the most common cause of a delay in the
return of bowel function in any intestinal surgery
and has been reported as the most common mi-
nor complication of ileal conduit creation (34).
Small-bowel obstruction may also occur post-
operatively and can manifest as an early or late
complication (Fig 7). Obstruction may be related
to ileal anastomotic problems (including early
edema or delayed stricture) or caused by adhesive
disease. Although most postoperative small-bowel
obstructions are treated conservatively, a small
percentage of patients will require repeat surgery
(32). If postoperative CT is performed, it is im-
portant to determine whether small-bowel dilata-
tion is secondary to ileus or if there is a change in
caliber with transition point to suggest a discrete
cause of bowel obstruction that may necessitate
surgical intervention.
Fluid collections.—Fluid collections are a com-
mon complication in the early postoperative
period. Postoperative fluid collections may in-
clude urinoma, abscess, lymphocele, seroma, and
hematoma.
CT is often used to detect a postoperative
fluid collection. Patients with different types
of fluid collections may present with similar
symptoms, including fever, peritoneal signs, and
abdominal pain. Contrast-enhanced CT, includ-
ing a delayed excretory phase acquisition, may
be necessary to more accurately determine the
type of fluid collection. A postoperative hema-
toma will appear as a nonenhancing complex
RG • Volume 36 Number 3 Moomjian et al 7

Figure 6. Ileal conduit with bowel leak and postoperative abscess. (a) Axial contrast-enhanced CT scan shows a stent tra-
versing the ileal conduit and the right lower quadrant urostomy (arrow). Also note dilated small bowel (*) caused by partial
small-bowel obstruction. (b) Axial contrast-enhanced CT scan shows a thick-walled collection of fluid and gas in the right
lower quadrant consistent with an abscess (arrowhead).The postoperative abscess is adjacent to the ileal-ileal anastomotic
suture line (black arrow).

Figure 7. Ileal conduit with small-bowel obstruction. (a, b) Axial contrast-enhanced CT scans show dilated small-
bowel loops in the left side of the abdomen with a transition point at the ileal-ileal anastomosis (arrowhead in a) and
decompressed distal small-bowel loops (black arrows). Note edema in the right lower quadrant mesentery. The ileal
conduit is seen in the right lower quadrant (white arrows in b) extending to the skin surface (stoma not shown).

heterogeneous or hyperattenuating fluid collec- collections that demonstrate rim enhancement

tion near the surgical bed. Intravenous admin-
istration of contrast material is necessary to
assess for active extravasation. A lymphocele will
manifest as a homogeneous fluid collection with
thin walls near surgical clips, most often after
lymph node dissection. A urinoma may mimic
other postoperative fluid collections on the ini-
tial postcontrast images; however, on excretory
phase images, excreted contrast material will
typically collect in and opacify a urinoma (Fig
5), distinguishing it from other types of post-
operative fluid collections. Postoperative fluid
and internal foci of air may represent abscesses
(Fig 6). Because of the stoma, gas may also be
present within a urinoma. It is important not
to mistake the conduit itself for a postoperative
fluid collection. Depending on the type of fluid
collection and whether infection is suspected,
percutaneous drainage may be necessary. The
diagnosis of a urinoma is also confirmed by
demonstrating an increased creatinine level in
fluid that has been collected by means of aspira-
tion or drainage (usually 10-fold higher than the
serum creatinine level).
8 May-June 2016
Conduit necrosis.—Necrosis of the created ileal
conduit is a rare early complication of this pro-
cedure due to acute ischemia in the bowel seg-
ment (15). At gross inspection, the ostomy often
appears dusky, gray, or black. This complication
typically necessitates surgical intervention.
Late Complications
Stomal complications: parastomal hernia.—Para-
stomal hernia is a common long-term complica-
tion in patients with an ileal conduit, affecting
5%–25% of patients (31,32). Predisposing fac-
tors for parastomal hernia include patient body
habitus, obesity, and patient age (ie, older patients
are at greater risk for developing parastomal
hernia). CT can help detect and evaluate para-
stomal hernias that cannot be palpated by the
physician because of the patient’s body habi-
tus. CT can also help determine the extent of
contents within the hernia sac (Fig 8), as well
as any secondary complications of the hernia.
Surgical intervention may be necessary because
of gastrointestinal and/or genitourinary obstruc-
tion related to the hernia. If surgery is performed,
initial repair often involves stomal relocation rather
than fascial repair (15) and multiple surgeries may
be necessary.
Stomal complications: stomal stenosis.—Stomal
stenosis is a common late complication of the
ileal conduit procedure, and this may be diffi-
cult to appreciate with routine imaging. Stomal
stenosis, or narrowing of the distal aspect of the
conduit near its outlet with the skin surface, may
be best appreciated with a loopogram study of
the conduit. This is best assessed at fluoroscopy
with the patient in the lateral position (with the
stoma viewed in profile). The conduit may ap-
pear elongated and dilated. This complication
can lead to further complications of conduit ob-
struction, including hydronephrosis, renal insuf-
ficiency, and infection (19,32). Stomal stenosis
may be more common after continent diversion
procedures.
Strictures.—Ureteral stricture is an uncommon
complication of incontinent urinary diversion
and occurs in approximately 2%–13% of patients
with an ileal conduit (2,15). The antireflux tech-
nique is rarely used for the ureteral anastomoses,
as these mechanisms can lead to increased risk
of stricture. Ureteral strictures may be benign
or malignant and occur more commonly on the
left than on the right side (15), presumably be-
cause of increased angulation of the left ureter
as it crosses to the right beneath the sigmoid
mesentery to reach the conduit in the right lower
radiographics.rsna.org
Figure 8. Ileal conduit with small bowel containing
parastomal hernia. Axial contrast-enhanced CT scan ob-
tained with oral contrast material shows multiple nondi-
lated opacified small-bowel loops in a large parastomal
hernia (arrows). The unopacified ileal conduit is also seen
(arrowhead).
quadrant.
Ureteral stricture after ileal conduit creation
occurs most commonly at the ureteroileal anas-
tomosis. Anastomotic strictures may occur as a
result of technical factors during creation of the
anastomosis, ischemia of the distal ureter leading
to fibrosis, and stricture or scarring in the setting
of previous abscess or leak (9). Ischemia might
result from previous radiation therapy or com-
promised ureteral blood supply during dissection
(35). Malignant strictures may also occur second-
ary to recurrent tumor in the ureter. Less fre-
quently, ureteral obstruction can be secondary to
compression at the sigmoid mesocolon or extrinsic
compression by a crossing vessel (9). In addition,
conduit strictures may occur (Fig 4). Stenosis
of the ileal loop may be related to microvascular
ischemia, infection, and/or the toxic effect of urine
on the bowel (19).
Urolithiasis.—Urinary tract calculi formation is
a common long-term complication of urinary
diversion procedures, and patients with urinary
diversions are at a higher risk of urinary calculi
(36). Thus, it is important for radiologists to
evaluate all patients with urinary diversion for
calculi. Stones may form in the upper tract or in
the urinary conduit itself (2). The pathogenesis of
stone formation is multifactorial and may include
metabolic phenomena, infection, urine stasis,
and structural factors. Metabolic factors, includ-
ing metabolic acidosis, contribute mainly to the
formation of upper tract stones. Chronic stasis
with upper tract dilatation has also been found to
be a contributing factor in stone formation (37).
RG • Volume 36 Number 3
Figure 9. Sigmoid conduit: incontinent uri-
nary diversion. Diagram depicts the expected
surgical anatomy after sigmoid conduit cre-
ation. A segment of sigmoid colon is resected
and a staple line is seen at the colocolic anas-
tomosis (black arrow). The isolated peristal-
sing segment of sigmoid colon is mobilized
as a conduit in the left lower quadrant (S).
The ureters are anastomosed separately to
the conduit. There is a left lower quadrant
urostomy (white arrow). (Created by Mary
Beatty-Brooks, Hunter Holmes McGuire VA
Medical Center, Richmond, Va.)
Urinary tract infections contribute to the forma-
tion of struvite stones, the most common types of
stone found in patients with urinary diversions.
Nonabsorbable sutures, staples, and foreign
bodies commonly contribute to the formation
of lower tract stones (37). The introduction of
absorbable sutures and staples has reduced the
incidence of stone formation overall after urinary
diversion (37).
Although stones can be identified with kidney
ureter bladder radiography, fluoroscopy, and
US, CT remains the most sensitive modality
for stone detection. It is important to assess
not only for renal and ureteral calculi, but also
for calculi within the conduit to the level of
the urostomy, as these stones may necessitate
medical or surgical therapy. It may be difficult
to differentiate radiopaque suture material along
the conduit from calculi, and comparison with
previously obtained postoperative imaging stud-
ies may be beneficial.
Small-bowel obstruction.—As mentioned earlier
(see Alterations in Bowel Function under Early
Complications), small-bowel obstruction may oc-
cur in the early or late postoperative course (Fig
7). Late obstruction may be related to ileal anas-
tomotic stricture, hernias, or adhesive disease.
Moomjian et al 9
Sigmoid Conduit
Sigmoid conduit is a less common surgical
technique than the ileal conduit for incontinent
urinary diversion. The ileal conduit remains
the preferred technique for incontinent urinary
diversion in part because of the lower incidence
of metabolic complications. In addition, reservoir
pressures tend to be higher in sigmoid conduits
than in ileal conduits (13). A sigmoid conduit
may be preferred over an ileal conduit in pa-
tients with an abnormal distal ileum (including
in patients with a history of inflammatory bowel
disease or pelvic radiation therapy), patients with
short bowel syndrome, patients for whom a left
lower quadrant ostomy is necessary, and patients
with a failed ileal conduit.
Surgical Anatomy
The sigmoid conduit surgical technique involves
isolating a 12–15-cm segment of sigmoid colon,
which is then mobilized and separated from the
gastrointestinal tract. Gastrointestinal continuity is
restored by creating a colocolic anastomosis. The
sigmoid segment is then used for the urine conduit
and brought to the skin surface for a cutaneous
ostomy. The ureters are anastomosed separately to
the isolated sigmoid conduit segment, and a left
lower quadrant urostomy is created (Fig 9) (15).
The sigmoid conduit typically has nonrefluxing
ureterosigmoid anastomoses. Unlike the ileum,
the thicker musculature of the colon allows for
submucosal tunnels for the creation of the ureteral
anastomoses and prevention of reflux. The antire-
flux mechanism results in decreased upper tract
deterioration and pyelonephritis, compared with
refluxing conduits (38).
Expected Imaging Findings
The imaging techniques used after urinary diver-
sion with sigmoid conduit creation are similar to
those used with the ileal conduit and include ab-
dominal and pelvic CT and CT urography, MR
imaging and MR urography, IVP, US, and loo-
pography. The main difference between the pro-
cedures is that the urostomy is typically located
in the left lower quadrant and that the radiologist
will identify a colocolic anastomosis rather than
a small bowel anastomosis. Detailed inspection
of the conduit itself should reveal haustral folds
rather than small bowel circumferential valvulae
conniventes, and the conduit may be more capa-
cious than an ileal conduit (Fig 10).
Early Complications
Early complications after sigmoid conduit
creation are similar to those after ileal conduit
creation and may include urine leak, bowel leak,
fluid collections, ileus, and obstruction (15).
10 May-June 2016 radiographics.rsna.org

Figure 10. Sigmoid conduit: expected imaging findings at CT. (a) Coronal three-dimensional maximum inten-
sity projection reconstruction of a CT urogram shows excreted contrast material within the collecting systems,
ureters, and sigmoid conduit (S). The stoma is not yet opacified. (b, c) Axial delayed excretory phase CT scans
show excreted contrast material in a left lower quadrant sigmoid conduit (S) and left lower quadrant urostomy
(arrowhead) draining into the overlying urine bag. Note the colonic haustra in the conduit (arrows).

However, postoperative ileus is less common in
patients with a colonic or sigmoid conduit than in
those with an ileal conduit.
Late Complications
As with the ileal conduit, late complications after
sigmoid conduit creation may include stomal
complications (stenosis, hernia), stone disease,
genitourinary or gastrointestinal stricture, and
obstruction. There is a much greater incidence of
metabolic complications when colon is used as
the urine conduit instead of the ileum, secondary
to more rapid fluid and electrolyte shifts (20). For
this reason, the ileal conduit remains the preferred
incontinent diversion procedure when feasible.
Uretero-bowel anastomotic stenosis.—The in-
cidence of uretero-bowel anastomotic steno-
ses is higher in patients with colonic conduits
(12%–22%) than in those with ileal conduits
(4.4%–7.6%) (29). This could in part be owing
to the use of nonrefluxing anastomoses for the
sigmoid conduit.
Upper tract complications.—There is a signifi-
cantly lower rate of upper tract complications,
including pyelonephritis and renal failure, with
the sigmoid conduit than with the ileal conduit,
largely because of the creation of antirefluxing
anastomoses (14,29,38). As mentioned earlier,
the anatomy of the colon more readily allows
for the creation of antirefluxing anastomoses, as
compared with the ileum.
Continent Diversions
Continent urinary diversions allow patients to
maintain voluntary control over voiding after
surgery either by means of self-catheterization or
RG • Volume 36 Number 3
Table 1: Continent Diversion Procedures
Continent Diversion
Continent Diversion with with Neobladder Anasto-
Catheterizable Stoma mosed to Native Urethra
Indiana Studer
Kock Camey
Mainz Kock/hemi-Kock
T-pouch T-pouch
Penn Hautmann
UCLA Y-neobladder
King Mainz
Le Bag
Sigmoid
Note.—Although the table may reflect a preferred
use for a pouch, many of the pouches may be used
for either continent diversion with a catheterizable
stoma or for creation of a neobladder.
Table 2: Examples of Pouches Used in Conti-
nent Urinary Diversion Procedures
Pouch Bowel Segment Used
Mainz Ileocecal
Kock Ileum
Indiana Ileocecal
King Ileocecal
Penn Ileocecal
by voiding through the native urethra. No external
appliance is needed in patients with continent uri-
nary diversions, as ideally there should be no con-
tinuous urine leakage. Initial attempts at creating
continent urinary diversions were complicated by
night-time incontinence secondary to bowel con-
tractions. However, once the surgical technique of
bowel detubularization by reconfiguring the bowel
was put into practice, continence improved and
intraluminal filling pressures decreased (7).
Continent diversions are now increasingly
performed and have substantial quality of life
benefits over incontinent diversions (no external
appliance, allows patient control over voiding) (18).
Although no randomized controlled trials have been
performed with regard to quality of life benefits,
these procedures are typically performed in and
are thought to be preferable for younger patients
in better physical condition and with longer life
expectancy, as compared with incontinent diver-
sions (18). Patients who undergo continent urinary
diversion should have preserved intestinal, hepatic,
and renal function (1). Normal hepatic function is
important because reabsorption of ammonium and
chloride can worsen hepatic impairment (1,32).
Continent urinary diversion procedures, however,
Moomjian et al 11
are overall more technically challenging and take
longer to perform than incontinent diversion proce-
dures, with overall higher complication rates.
There are two major categories of continent di-
versions: (a) creation of a pouch or urine reservoir
with a cutaneous stoma for catheterization and
(b) neobladder formation where a urine pouch or
reservoir is created and anastomosed to the native
urethra such that patients are able to void through
the native urethra (Table 1). For these procedures,
a urine reservoir is fashioned from bowel. The
reservoir is typically a named component of the
procedure and may be created from small bowel,
large bowel, or both (Table 2). A variety of named
surgical procedures have been developed, with dif-
ferences in the surgical procedural techniques and
bowel segment configuration used. In addition,
in many cases the named pouch or reservoir can
be used for a continent diversion with cutaneous
stoma or as an orthotopic neobladder.
Herein, we will describe a few of the most com-
mon continent urinary diversion surgical tech-
niques; however, it is important to be aware that
there are multiple additional surgical techniques
that may vary according to region, surgeon, or
both. If the surgery report is available, it may be
helpful to determine the type of procedure that
was performed. If the surgery report is unavail-
able at the time of interpretation, radiologists can
determine the type of procedure performed by
evaluating the bowel anastomosis, the stoma (if
present), and the configuration of the pouch.
The optimal continent pouch protects the
upper tracts by preventing reflux, provides for
urinary continence, and has sufficient capacity so
that self-catheterization or voiding episodes occur
at least 3 hours apart. Ideally, the pouch should
be a low-pressure system with a high capacity
(39). Overall, continent diversions require much
more patient compliance and function than do
incontinent diversions. Patients with a stoma that
can be catheterized must routinely self-catheter-
ize, and patients with a neobladder must learn
new voiding techniques.
Continent Diversion
with Catheterizable Cutane-
ous Stoma: The Indiana Pouch
There are many types of continent diversion
procedures that use a catheterizable cutaneous
stoma for urine drainage. The Kock pouch is
one of the best established diversion procedures
and uses a small-bowel reservoir. However, the
surgical procedure is complex and lengthy, with
many possible complications (19). Alternative
and relatively simpler procedures, such as the
Indiana pouch, use the ascending colon and ce-
cum as the reservoir (19). The Indiana pouch is
12 May-June 2016 radiographics.rsna.org

Figure 11. Indiana pouch: continent diversion with catheterizable cutaneous stoma. Images
depict the expected surgical anatomy of Indiana pouch creation with a catheterizable stoma.
(a) Diagram shows that a segment of the cecum, ascending colon, and distal ileum is isolated
and resected for creation of the urine reservoir. A staple line is shown at the ileocolic anasto-
mosis (arrow). The right lower quadrant pouch is composed of isolated distal ileum and right
colon (P). The ureters are anastomosed separately to the pouch. The distal ileum is brought to
the skin surface, and a catheterizable stoma is created (arrowhead). Continence is maintained
by means of the native ileocecal valve. (Created by Mary Beatty-Brooks, Hunter Holmes Mc-
Guire VA Medical Center, Richmond, Va.) (b) Radiograph obtained during IVP shows excreted
contrast material in the collecting systems and ureters. Excreted contrast material is seen in the
right lower quadrant Indiana pouch (P). Note the haustra in the pouch created from cecum
and ascending colon. The ileal segment is not opacified because the ileocecal valve prevents
opacification and maintains continence. Note that the left ureter crosses the midline at L5 (ar-
rows) and is then anastomosed to the conduit.

the most common continent cutaneous reservoir
diversion performed and will be described in
greater detail as a representative technique. The
Indiana pouch itself can be used either cutane-
ously or orthotopically (ie, as a neobladder) but
is most often used cutaneously, positioned in the
right lower abdomen and with a catheterizable
stoma.
Surgical Technique
The Indiana pouch surgical technique involves
mobilizing and resecting an approximately
20–25-cm segment of cecum and ascend-
ing colon to the hepatic flexure, including the
terminal ileum (extending approximately 15–18
cm from the ileocecal valve) (Fig 11). Gastroin-
testinal continuity is restored with an ileocolic
anastomosis.
An incision is made along the taenia coli to
detubularize the ascending colon and cecum
and thereby reduce the peristaltic activity. The
ascending colon and cecum are then reconfig-
ured in a spherical shape. Staple reduction and
tapering of the terminal ileum is performed,
and this is brought to the skin surface to create
a small catheterizable stoma. The stoma may be
in the right lower quadrant or brought to the
umbilicus. Suture plication is performed at the
ileocecal valve to create a continence mechanism
so that urine does not continuously reach the
stoma (40). Alternatively, the appendix may be
used for the continent catheterizable mechanism
(Mitrofanoff procedure). The ureters are sepa-
rately anastomosed to the colonic segment, each
tunneled into the posterior taenia of the colon as
a reflux prevention mechanism (41,42).
Various surgical methods may be used to
maintain continence and enable patients to per-
form catheterization. For example, the appendix
may be used as a catheterizable stoma instead
of the terminal ileum (Mitrofanoff procedure)
to create a narrower catheterizable limb with
improved continence. If the appendix cannot be
used, a similar result can be achieved by using
tapered ileum or a small ring of ileum that is
opened and reconfigured as a longer narrower
tube (Monti procedure) (43). The catheterizable
stoma may be in the right lower quadrant or, for
improved cosmesis, the cutaneous stoma may be
located at the umbilicus.
RG • Volume 36 Number 3 Moomjian et al 13

Figure 12. Indiana pouch. Axial de-

layed contrast-enhanced excretory phase
CT scan shows excreted contrast material
in right lower quadrant Indiana pouch
(P). Note haustral folds in the pouch, cre-
ated from the cecum. The ileal segment
extends toward a catheterizable stoma
along the skin surface (not shown). The
left and right ureter can be seen insert-
ing separately on the pouch posteriorly
(arrow).

Figure 13. Indiana pouch mimicking abscess. (a) Initial axial contrast-enhanced CT scan shows a fluid collection in the right
lower quadrant initially thought to represent a right lower quadrant abscess (arrow). Surrounding bowel loops are well opaci-
fied with oral contrast material. (b) Subsequent axial delayed excretory phase CT scan shows excreted contrast material now
opacifying the “collection.” The right lower quadrant collection can now be seen to represent an Indiana pouch (P). The ileal
limb can be seen extending toward the catheterizable stoma (arrows). Also note bowel containing ventral hernia (*) in the
vicinity of the catheterizable stoma.

Expected Imaging Findings occurs in the later excretory phase. It is important

The imaging techniques used after continent
diversion with a catheterizable stoma are similar
to those used with the ileal conduit (mentioned
earlier), including abdominal and pelvic CT and/
or CT urography, MR imaging with MR urogra-
phy, IVP, and US.
Abdominal and pelvic CT and CT urography.—As
with incontinent urinary diversions, CT is ide-
ally performed in the nephrographic and delayed
excretory phases after intravenous administration
of contrast material. Positive luminal oral contrast
material may help differentiate the newly created
urinary tract from the gastrointestinal tract in
the nephrographic phase, before opacification by
contrast material in the genitourinary tract that
to examine the gastrointestinal tract carefully to
determine which bowel segment has been resected
and used to create the pouch and stoma.
Identification of the colonic pouch, the ileal
limb leading toward the stoma, the ureterocolic
anastomoses, and the gastrointestinal ileocolic
anastomosis is important to identify any potential
postoperative complications (Fig 12). The Indiana
pouch will be seen on CT scans as a fluid-filled
structure in the right lower quadrant that may
contain air secondary to catheterization and can
easily be mistaken for an abscess at imaging if
not appropriately recognized (Fig 13). Haustra
can be mistaken for septations within the “fluid
collection” if the interpreting radiologist does
not recognize the postoperative anatomy of the
14 May-June 2016
Indiana pouch (39). Excretory phase imaging may
help prevent this problem and may also reveal the
ureterocolic anastomoses.
US Imaging.—The Indiana pouch will be seen
as an irregular fluid-filled structure in the right
lower quadrant at US. The haustra can be mis-
taken for septations within a fluid collection at
US, similar to CT. US may be most beneficial for
surveillance for hydronephrosis and upper tract
deterioration.
Pouchography.—Pouchography is a fluoroscopic
study performed by means of retrograde injection
of the pouch with water-soluble contrast mate-
rial. A 12–14-F catheter is inserted into the cath-
eterizable stoma, and contrast material is gently
hand injected or instilled under gravity pressure.
With this procedure, pouch size, shape, contour,
distensibility, and capacity can be assessed. The
Indiana pouch appears as a distensible, rounded
segment of colon on pouchograms (Fig 14). A
pouchogram may also be used to examine the
ureters and pelvocaliceal systems. However, this
may not be possible if an antirefluxing technique
was employed for the uretero-colonic anastomo-
sis. A postdrainage image is useful to determine
if there is any residual content in the pouch after
catheterization.
Complications
Many of the early complications associated with
continent cutaneous urinary diversion are similar
to those that occur after conduit formation. The
various continent pouches have similar postop-
erative complications overall (44).
Early Complications
Early complications may include urinary leak
from the pouch or ureteral anastomosis, ab-
scess, fistulas between the pouch and adjacent
bowel or skin, small-bowel obstruction, and
pyelonephritis (39). Initially, urine leakage was
much more common after continent diversion
as compared with incontinent diversion (ie, ileal
conduit), occurring in up to 10% of patients
(32). However, surgical modifications, such as
intraoperative silicone elastomer stent place-
ment across the ureteroenteric anastomoses,
have reduced the overall incidence of postopera-
tive urinary leak to approximately 2%, similar to
that of incontinent diversions (32).
Late Complications
Late complications common to continent
pouches include incontinence, calculus forma-
tion, strictures, and problems with catheterization
of the pouch or stoma (39).
radiographics.rsna.org
Figure 14. Indiana pouch. For this pouchogram, a
catheter was advanced through the catheterizable
stoma into the pouch, with contrast material injected in
retrograde fashion. Contrast material is seen in the Indi-
ana pouch (P), and the pouch has a spherical configura-
tion. Also note bilateral ureteral stents (arrows).
Urolithiasis.—Stone disease is a common compli-
cation of continent cutaneous urinary diversion,
occurring in approximately 10% of patients. Pa-
tients with cutaneous continent diversions are at
higher risk for urolithiasis than are patients with
orthotopic diversions, possibly secondary to uri-
nary stasis and chronic bacteria associated with
catheterization (32) (Fig 15). In contrast to ileal
conduit, stones are predominantly lower tract cal-
culi and patients do not have a higher incidence
of upper tract calculi overall.
Stomal complications.—Most late complications in
patients with a continent cutaneous diversion are
stomal complications, including difficulty cath-
eterizing the efferent limb or stomal stenosis (Fig
16). Stomal stenosis can lead to hydronephrosis
and renal failure.
Stricture.—The risk of ureteral stricture is higher
with continent diversions than with incontinent
diversions. Ureteral stricture is an uncommon
complication of incontinent urinary diversion
procedures, occurring in only approximately 2%
of patients with ileal conduits. However, after
continent diversion with an Indiana pouch, ap-
proximately 8% of patients develop ureteral stric-
tures—in particular ureteroenteric anastomotic
strictures (45).
Postoperative ureteroenteric anastomotic stric-
ture tends to manifest approximately 1 year after
surgery. Benign strictures secondary to ischemia
are the most common, with involvement of the left
ureter more common than involvement of the right
(Fig 17). However, malignant strictures secondary
RG • Volume 36 Number 3 Moomjian et al 15

Figure 15. Indiana pouch with calculi. (a) Axial unenhanced CT scan shows multiple radiopaque calculi (arrowhead)
in the Indiana pouch (P) and ileal limb (arrows) leading to the catheterizable stoma at the umbilicus. (b) US scan ob-
tained in the sagittal plane relative to the Indiana pouch shows shadowing echogenic calculi in a right lower quadrant
Indiana pouch (arrows). The pouch is not optimally distended with fluid.

Figure 16. Indiana pouch with stomal stenosis. (a) Axial and (b) coronal contrast-enhanced CT scans obtained
in the excretory phase. Image a shows moderate bilateral hydronephrosis (arrows) with mild bilateral cortical
thinning, while b shows a dilated fluid-filled Indiana pouch (P) in the right midabdomen. There is minimal mix-
ing of dilute excreted contrast material with a large amount of retained urine in the pouch in this patient with
stomal stenosis. Excreted contrast material is seen in the ureters (arrows in b). Subsequent successful catheteriza-
tion revealed markedly purulent urine owing to secondary infection.

to recurrent neoplasm will also occur. Radiologists
who interpret CT scans in patients with a history of
radical cystectomy and continent urinary diversion
must be aware of the high rate of stricture to accu-
rately diagnose this often clinically silent complica-
tion. Although mild caliectasis may be normal after
urinary diversion, the development of hydronephro-
sis or progressive pelvocaliceal dilatation should
raise concern for underlying stricture.
Continent Diversion
with Anastomosis to Native
Urethra: Orthotopic Neobladder
The Camey procedure, the first successful
procedure for bladder replacement, was initially
performed in 1959 (46,47). However, orthotopic
bladder replacement was not popularized until
1982, when the Koch pouch, a variation of the
Camey pouch, was described.
The technique used to create an orthotopic
neobladder is more complex than that used with
other urinary diversions and necessitates a longer
surgical time. In addition, the bowel segments
needed to construct the neobladder are longer
than those used with other diversion techniques.
However, unlike other diversion procedures, the
orthotopic neobladder allows patients to void
through the native urethra by means of either ab-
dominal straining or self-catheterization and does
not require a stoma or external appliance (Fig
18). Patients who undergo neobladder creation
are generally younger patients who are motivated
16 May-June 2016 radiographics.rsna.org

Figure 17. Indiana pouch with ureteral

stricture. Coronal oblique T1-weighted
maximum intensity projection image
from MR urography, obtained in the ex-
cretory phase after gadolinium chelate
administration, shows a left ureteral stric-
ture (arrow) at the location where the ure-
ter crosses the left common iliac vessels.
The right kidney is not shown.

Figure 18. Orthotopic neobladder. (a) Diagram shows the expected surgical anatomy after
neobladder creation. A 60-cm segment of small bowel is resected with a primary ileal-ileal
anastomosis (arrow). The neobladder is created from ileum (Studer neobladder), a portion of
which is folded on itself with creation of a pouch configuration. There is also an ileal limb for
the two separate ureteroileal anastomoses. The neobladder (N) is placed in the cystectomy bed
and anastomosed to the native urethra (arrowhead). (Created by Mary Beatty-Brooks, Hunter
Holmes McGuire VA Medical Center, Richmond, Va.) (b) IVP image shows excreted contrast
material in the left renal collecting system, with opacification of the left ureter and neobladder
(N). (The patient had undergone right nephroureterectomy.) The neobladder has a pouchlike
configuration inferiorly in the cystectomy bed and a small-bowel appearance more cephalad.
The left ureter is anastomosed to the intact small bowel component of the neobladder (arrow).

and able to learn techniques for proper care of the
neobladder. Most patients who receive a neoblad-
der are males who undergo a cystoprostatectomy
for bladder cancer (40). The orthotopic neoblad-
der procedure is contraindicated in patients with
positive urethral resection margins and in male
patients with tumor involvement of the prostatic
urethra (40). This procedure is performed less
commonly in female patients because bladder
neck preservation is required for women who
undergo the procedure, and urethral and/or blad-
der neck involvement may be identified in up to
RG • Volume 36 Number 3
25% of female patients who undergo cystectomy
(48). Therefore, an orthotopic neobladder is re-
served for women with transitional cell carcinoma
confined to the bladder with no bladder neck
involvement and a normally functioning urethra
(7). Although most patients in the United States
and worldwide still undergo ileal conduit urinary
diversion, the percentage of patients undergoing
neobladder urinary diversion now approaches
80% at a few pioneering institutions (18).
The neobladder may be created from ileum,
colon, or both, and, in general, the use of small
bowel as a reservoir is now the preferred tech-
nique. Ileal neobladders have a smaller initial
capacity, but there is a lower risk of diarrhea and
vitamin B12 absorption problems secondary to
preservation of the terminal ileum and the ileoce-
cal valve, as compared with colonic neobladders
(49). A low-pressure reservoir is also an impor-
tant feature of the reservoir (50–52), and the
ileum has been found to be the least contractile
segment of bowel (53).
Surgical Anatomy
The Studer (most common) and Hautmann
pouches are two of the most commonly used
surgical techniques to create orthotopic neo-
bladders and will be described as representative
techniques (49).
Studer pouch.—The Studer neobladder is an il-
eal pouch. To create a Studer pouch orthotopic
neobladder, a 60-cm segment of ileum is isolated
20–25 cm proximal to the ileocecal valve and re-
sected (54). The proximal 40 cm of the segment
is opened along its antimesenteric border and
folded in half. Then, the borders are oversewn
to create a pouch. The 20-cm distal portion of
the segment is left intact (with a small-bowel ap-
pearance), and the ureters are anastomosed to
this segment. The urethra is anastomosed to a
1-cm defect in the most dependent portion of
the surgically created ileal pouch (54) (Fig 18).
The intact proximal ileal limb acts as an antire-
flux mechanism owing to peristalsis away from
the uretero-ileal anastomoses, and continence is
maintained by an intact external urethral sphinc-
ter. There is an ileal-to-ileal small-bowel anasto-
mosis for gastrointestinal continuity (Fig 18).
Hautmann pouch.—The Hautmann neobladder
is also an ileal pouch. To create a neobladder by
using the Hautmann technique, a 60-cm segment
of ileum is isolated. The segment is detubularized
and arranged into a W shape. The ureters are
anastomosed to the neobladder by using an anti-
refluxing technique. The urethra is anastomosed
to a buttonhole incision in one of the limbs. The
Moomjian et al 17
outside edges of the W are closed to each other in
a side-to-side fashion (13).
Expected Imaging Findings
Abdominal and pelvic CT and CT urography.—As
in the case of the other urinary diversion proce-
dures, the ideal CT technique for evaluating pa-
tients after neobladder creation is CT urography.
After neobladder creation, it is important to iden-
tify the neobladder pouch and any bowel limb
leading to the pouch, the uretero-neobladder
anastomoses, and the urethra-neobladder anasto-
mosis (Fig 19).
The neobladder is typically round or ovoid,
although a variety of shapes are possible. The af-
ferent bowel limb is seen as a fluid filled tubular
structure, often in the right lower quadrant, and
this segment maintains a normal ileal mucosal fold
pattern (Fig 20) (49). A neobladder may require
several months to fully mature and reach expected
capacity. If a radiologist is unfamiliar with the neo-
bladder technique, they may mistake a neobladder
for an abnormal native bladder. Identification of
the afferent limb may help radiologists determine
that the patient has a neobladder if they do not
have access to the surgery report or patient history.
CT evaluation of the upper tract may show mild
pelviectasis or pelvocaliectasis, which is not unex-
pected in the postoperative period and may persist
(49). On delayed images (10–20 minutes after con-
trast material administration), the collecting system
may appear dilated because the peristaltic capac-
ity of the afferent limb is exceeded when contrast
material–induced diuresis is maximal (54). Severe
dilatation of the collecting systems should raise
suspicion for obstruction, however.
Pouchography.—Pouchography is the procedure
of choice to determine pouch size, configuration,
distensibility, and capacity (Fig 21). For pouchog-
raphy, a catheter is inserted through the native
urethra into the neobladder, and water-soluble
contrast material is instilled in retrograde fashion
(often by means of gravity pressure) at fluoros-
copy. A scout image should be obtained before
instillation of contrast material. Anteroposterior,
bilateral oblique, and lateral fluoroscopic spot im-
ages are obtained. A postdrainage image may also
be obtained to evaluate for extravasation (44) and
residual urine content in the neobladder.
For evaluation of the neobladder in the early
postoperative period, the infusion is stopped
when the patient feels fullness or after about
100–300 mL of contrast material is instilled (44).
Filling defects in the neobladder in the early
postoperative period may represent mucus or
blood clots (40). After the pouch has “matured,”
18 May-June 2016 radiographics.rsna.org

Figure 19. Orthotopic neobladder. (a) Axial CT

scan obtained in the early excretory phase shows ex-
creted contrast material within the neobladder (N)
placed in the cystectomy bed. Note the appearance
of small-bowel folds dependently in the small-bowel
neobladder. (b) Sagittal contrast-enhanced CT scan in
the same patient shows the neobladder (N) and the
anastomosis between neobladder and native urethra
(arrow). (c) Coronal contrast-enhanced CT scan shows
the expected tubular appearance (arrows) of the proxi-
mal portion of the neobladder (N).

Figure 20. Ileal orthotopic neobladder. CT demonstration of the ileal pouch and ileal limb. (a, b) Axial delayed
contrast-enhanced CT scans show the expected tubular appearance of the proximal portion of neobladder (arrows),
opacified with excreted contrast material at the time of imaging, and the pouchlike appearance of the remainder of
the neobladder (N).

a greater volume of contrast material can be
instilled (approximately 500 mL) to evaluate the
pouch and assess for possible complications.
Early Complications
There is a high rate of early postoperative compli-
cations after neobladder creation; approximately
22% of patients experience major complications
in the first 90 days after surgery (55). The types
of early postoperative complications after neo-
bladder creation are similar to complications
after ileal conduit and continent diversion with
a pouch and catheterizable stoma (32). Early
complications include urine extravasation, pouch
RG • Volume 36 Number 3 Moomjian et al 19

Figure 21. Pouchogram of orthotopic neo-

bladder. Fluoroscopic pouch study (poucho-
gram) obtained with the patient in the supine
position shows a well-distended orthotopic
neobladder (N). Contrast material was in-
stilled under gravity pressure via a Foley cath-
eter. The imaging study allows evaluation
of the pouch configuration and capacity, as
well as assessment of reflux or postoperative
complications. A neobladder may take several
months after surgery to mature and reach ex-
pected capacity.

leak, abscess and other fluid collections, as well as
alterations in bowel motility including ileus and
small bowel obstruction (49).
Late Complications
Fistula.—Postoperative fistula is a rare complica-
tion of urinary diversion (56) and is most common
after orthotopic neobladder formation, occurring
in 2% of patients (45). The most common site of
fistula is from the anterior neobladder to the ileal-
ileal small bowel anastomosis (45). Most patients
present with symptoms of fecaluria, pneumaturia,
or recurrent urinary tract infection; however, pa-
tients may be asymptomatic, with fistula diagnosed
at routine postoperative surveillance CT (45). Ra-
diologists should examine the neobladder carefully
for findings of fistula (eg, air in the neobladder or
upper urinary tract). However, such air could also
be due to instrumentation.
Ureteral stricture.—Strictures most often develop
approximately 7–18 months after surgery (57).
The overall risk of ureteral stricture after continent
diversions is greater than the risk after incontinent
diversions, with the highest rates reported with
orthotopic neobladder. The rate of ureteroenteric
anastomotic stricture is as high as 11% after or-
thotopic neobladder (45). However, the stricture
rate varies on the basis of the surgical techniques
used, with a higher rate of stricture after the non-
refluxing ureteroneovesical implantation tech-
nique. A significantly lower rate of stricture is seen
when a refluxing surgical technique is used to cre-
ate the anastomosis (8,45,58).
Subneovesical obstruction.—A rare complica-
tion after neobladder formation that occurs in
approximately 1% of patients is subneovesical
obstruction (56). Possible causes include local
tumor recurrence along the pelvic floor involving
the neobladder neck, stricture of the neovesico-
urethral anastomosis, and urethral stricture (56).
Rupture.—Neobladder rupture is an extremely
rare complication in the late postoperative period.
Similar to the native bladder, a neobladder can
rupture after blunt trauma. In addition, sponta-
neous neobladder rupture has been reported after
previous radiation therapy (56). Rupture may
also occur spontaneously after acute or chronic
overdistention of the neobladder (13), and radi-
ologists should have a high index of suspicion for
this complication when patients with a neoblad-
der present to the emergency room with acute
abdominal pain.
Recurrent Tumor
Recurrence of urothelial neoplasm may occur
locally or in the upper urinary tract. CT is most
useful for assessing recurrent pelvic tumor, nodal
disease, and distant metastases.
Local Tumor Recurrence
The local recurrence rate after cystectomy with
urinary diversion is approximately 5%–15%, and
local tumor recurrence most commonly occurs in
the first 24 months after surgery (59).
Local recurrence may be detected in the form
of a pelvic mass, ureteral stricture, including stric-
ture at the ureterointestinal anastomosis, or pelvic
lymphadenopathy (Fig 22). Recurrent tumor in
the ureter may appear as a stricture, filling defect,
or flattening and deformity of the ureteral wall.
Local recurrence can also occur at the urethral-
reservoir anastomosis in the setting of orthotopic
neobladder. Urethral recurrence is more common
in patients with bladder neck involvement, in male
20 May-June 2016 radiographics.rsna.org

Figure 22. Urinary diversion with tumor recurrence in two patients. (a) Axial CT scan obtained after oral and intra-
venous contrast material administration in a patient with ileal conduit after cystectomy shows a pelvic sidewall nodal
mass (arrow) consistent with tumor recurrence. The mass is posterolateral to and abuts the ileal conduit (C). (b) Axial
contrast-enhanced CT scan in a patient with orthotopic neobladder after cystectomy shows extensive recurrent tumor
(arrows) posterior to and partially surrounding the neobladder (N). This tumor causes pouch obstruction. The pouch is
dilated and elevated out of the pelvis. There was associated bilateral hydronephrosis (not shown).

Figure 23. Neobladder ileal limb mistaken for a right pelvic sidewall lesion. (a) Axial contrast-enhanced CT scan shows
an apparent pelvic sidewall lesion next to a surgical clip (arrow), which is suspicious for tumor recurrence. (b) Repeat CT
study, which included excretory phase imaging, shows that the apparent pelvic sidewall lesion actually represents the ileal
limb (arrow) of the normal small-bowel neobladder (N). There was no evidence of tumor recurrence.

patients with tumor involvement of the prostate,
and in women with involvement of the anterior
vaginal wall (48,59).The urethral anastomosis and
pelvic floor soft tissues should be carefully evalu-
ated in patients with a neobladder. Knowledge of
the expected postsurgical anatomy is essential to
prevent misdiagnosis (Fig 23).
Upper Tract Recurrence
Upper tract recurrence is relatively uncommon
and occurs in approximately 2%–8% of patients
(60). However, patients with ureteral involvement
at cystectomy are at a higher risk for upper tract
recurrence (59). As in the case of local recur-
rence, many upper tract recurrences occur in the
first 2–3 years; however, there is a continued risk
of recurrence over time and upper tract recur-
rence has been reported to occur up to 9 years
after surgery (61).
Distant Metastases
Distant metastatic disease may be identified
with surveillance imaging and most often occurs
within 24 months after surgery. Common sites
for metastatic disease include the liver, lungs,
and bone.
RG • Volume 36 Number 3
Conclusion
Bladder cancer, one of the most common cancers
in the United States, is often treated with radical
cystectomy. There are a variety of surgical tech-
niques that may be performed to reroute the urine
stream after cystectomy, including continent and
incontinent diversions. Multiple different imag-
ing modalities may be beneficial for evaluating
the various types of diversions, and it is essential
for radiologists to know when each modality is
indicated to help guide the appropriate work-up.
Knowledge of the expected imaging appearance
after these procedures helps prevent misdiagnosis,
including misinterpretation of a component of the
diversion as an abnormal pathologic condition or
disease recurrence. Accurate imaging diagnosis is
crucial because many postoperative complications
may be clinically silent. Radiologists must be able
to recognize the expected postoperative appear-
ance, as well as complications, to facilitate appro-
priate diagnosis and treatment.
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