LOOPOGRAM

Richard Danieli

Patient Information

A 68 year old male with history of muscle

invading bladder cancer.
Post operative robotic assisted radical
cystoprostatectomy
Post operative ileal conduit urinary
diversion performed

Patient History

History of bladder cancer

Prior CT
Filling defects in the dilated left renal pelvis
Absence of contrast opacification of the left
ureter,
Recommend direct inspection of the left
collecting system with cystoscopy and
ureteroscopy.
Interval worsening of the left
hydroureteronephrosis.
Anastomotic stricture at the junction between
the ureter and ileal conduit cannot be
excluded

Reason for the

Examination

Recommendation from prior CT

Evaluate Ileal Conduit
Evaluate left ureter by retrograde
contrast administration

Relevant Information

History of bladder cancer

Obstructed proximal left ureter seen on
prior CT

Radiographic Procedure

24-gauge Foley catheter inserted into stoma

with 30 cc balloon inflated
Conray-60 introduced into ileal conduit by
gravity infusion
Reflux into right ureter
No contrast entered the left ureter despite
various positional changes and delayed
imaging.
Patient vomited possibly due to relative over
distention of the ileal bladder in attempts to
induce left ureteral reflux

Examination Results

Normal right upper urinary tract

Normal ileal conduit contour
No reflux into left ureter due to
obstruction at the ureteroileal junction

Loopogram Spot Film AP

Note: No
contrast in
left ureter
Catheter
Right ureter

Catheter
balloon

Ileal conduit

Loopogram Spot Film Slight LPO

Catheter

Note: No
contrast in
left ureter

Catheter
balloon
Right ureter
Ileal
conduit

Loopogram Spot Film Steep LPO

Right
ureter

Note: No
contrast in left
ureter

Catheter
balloon
Catheter

Ileal
conduit

Abdomen/Pelvis CT with IV
Contrast Coronal Image

IV contrast
in right
ureter

IV contrast
remained in
left renal
pelvis

Abdomen/Pelvis CT with IV
Contrast Axial Image

IV
contrast
in right
ureter

IV contrast
remained
in left renal
pelvis

Differential Diagnosis

No contrast extravasated therefore obstructed

Ureteral obstruction post ileal conduit

Improperly fashioned anastomosis

Ischemia of the ureter with subsequent fibrosis and
stricture
Recurrent tumor in the ureter (rare)
Infection or abscess formation with reaction
Edema
Calculus
Sloughed papilla
Adhesions or scarring.
Torsion or compression at the sigmoid

Discussion

No extravasation of contrast outside of

the ileal conduit or the right ureter
Normal contour of ileal conduit and right
ureter
No contrast filling into the left ureter
during the loopogram.
Left ureter not evaluated from retrograde
contrast administration via loopogram or
antegrade contrast administration via CT

Suggestions

Renal ultrasound
Renal radionuclide studies,
Percutaneous nephrogram/ureterogram
Intravenous pyelogram (IVP)
Abdomen/pelvis CT (with oral contrast,
with and without IV contrast)

Discussion Questions

John:
1. Where are post operative ileal conduit obstructions
most common?
2. Besides obstruction, what is the other most common
abnormality post operative ileal conduit surgery.

Stacy:
1. Describe pseudoobstruction (conduit malfunction) and
the cause.
2. What is a mucus plug in reference to a loopogram?

Tina:
1. Describe two renal complications of an ileal conduit.
2. What risks are associated with an excessive length of
an ileal conduit?

References

Appleby,S.,&Atala,A.(2010,September2).UrostomyandContinentUrinaryDiversion.National
Kidney and Urologic Diseases Information Clearinghouse.RetrievedJuly7,2012,from
http://kidney.niddk.nih.gov/kudiseases/pubs/urostomy/index.aspx

Banner,M.P.,Pollack,H.M.,Bonavita,J.A.,&Ellis,P.S.(1984).Theradiologyofurinary
diversions.Radiographics,4,885-913.Retrievedfrom
http://radiographics.rsna.org/content/4/6/885.full.pdf+html?sid=b58c27e0-59a3-40e3-bba6-39316da2f
87d

Fernbach,S.,&Holland,E.(1988).Undiversionoftheurinarytract:Thepre-andpostoperatie
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Noble,J.,Amin,Z.,Kessel,D.,&Rickards,D.(1994).Recurrentuppertracturothelialtumours:the
useofloopographyfollowingcystectomyforbladdercancer.British Journal of Radiology,67(803),
1057-1061.Retrievedfromhttp://www.ncbi.nlm.nih.gov/pubmed/7820396

Thiruchelvam,N.,Harrison,M.,&Page,A.C.(2007).Thedoublewiretechnique:animproved
methodfortreatingchallendingureteroilealanastomoticstricturesandocclusions.British Journal of
Radiology,80,103-106.Retrievedfromhttp://bjr.birjournals.org/content/80/950/103.long