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Advantages of the Prone Position for the Excretory Urogram in Ileal Conduit Urinary Diversion
Vol. 111, April
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1974 by The Williams & Wilkins Co.
ADVANTAGES OF THE PRONE POSITION FOR THE EXCRETORY UROGRAM IN ILEAL CONDUIT URINARY DIVERSION JULIUS SOLO VAY
From the Department of Radiology, Veterans Administration Hospital, Montgomery, Alabama
Radiograms of 3 patients are included in this report, which show some of the advantages of the prone position in ileal conduit urography (figs. 1 to 3). This use of the prone position for IVP in ileal conduit urinary diversion has not been reported previously. 2 • 3 The IVP is performed by the high dose or infusion technique. The bag which drains the
The ileal conduit is an effective and widely used method of urinary diversion. In the radiological study after this operation, the excretory urogram (IVP) with the patient in the supine position shows the collecting systems of the kidneys, the proximal portions of the ureters and the ileal conduit. The lower abdominal portions of the ureters and their course to the conduit are usually not demon-
FIG. 1. J. B. H., 39-year-old white man, had partial paraplegia and neurogenic bladder secondary to compression fracture of 1st lumbar vertebra and anterior subluxation of 12th dorsal vertebra sustained 6 years previously. Ilea! conduit was constructed 4 years ago. A, supine view of IVP shows filling of normal collecting systems of both kidneys and proximal portions of ureters. B, prone view shows filling of slightly dilated lower portions of ureters and slightly kinked unobstructed ilea! conduit.
strated. However, radiograms with the patient in the prone and prone oblique positions often show the lower portions of the ureters, their relationship to the ileal segment and sometimes better filling of the ileal segment. It may thus be possible to obviate the performance of the retrograde ileagram in which the entire urinary tract can be filled, by virtue of the usually present ileoureteral reflux. 1 Accepted for publication August 17, 1973. Koehler, P. R. and Bowles, W. T.: Radiological
1
ileostomy is emptied at the beginning of the examination and is replaced over the ileostomy after the scout film is made. Moderate compression evaluation of the upp!lr urinary tract following ilea! loop urinary diversion. Radiology, 86: 227, 1966. 2 Elkin, M.: The prone position in intravenous urography for study of the upper urinary tract. Radiology, 76: 961, 1961. 'Handel, J. and Schwartz, S.: Value of the prone position for filling the obstructed ureter in the presence of hydronephrosis. Radiology, 71: 102, 1958.
530
PRONE POSITION FOR IVP IN ILEAL CONDUIT URINARY DIVERSION
F1G. 2. F. J. W., 50-year-old black man, had cy1;te1~tomv for carcinoma of bladder and ileal conduit perfoncwd several months previously. A, supine view of IVP filled, normal collecting systems of kidneys and ileal conduit. B, prone view shows partial filling of normal lower portions of both ureters and slight emptying of conduit. There is angulation of lower portion of left is not obstructive.
over the lower abdomen and ileostomy is applied means of a folded bath towel and compression band or band which encircles the over foam pads situated over the lower anterior abdomen. When the films made in the supine position show amounts of contrast medium in the pelves and calices of the and upper of the ureters, the patient is turned on his stomach ,Nith the folded bath towel or foam t•m-nn,roc pads still in position. One or 2 films m the prone position are Pv1nnc:Pn and also in the and left prone oblique These usually filling of the lower ends of the ureters, the ureteroileal anastomoses and the ilea[ It is believed that there are anatomic and physiologic explanations for the improved ureteral filling in the prone Anatomically, the lower abdominal of the ureters are more anterior than the and upper ureters because the ureters follow the normal lordotic curve of the lumbar spine in their course through the retroperitoneal tissues of the abdomen.' unne m
after ileac didisorders. J. Ural.,
In of the ilea! conduit operation, the lower cut ends of the ureters are mobilized from their bed EWfi still further forward into the abdomer: isolated segment of ileun,. there is an absence of a valve mecha nism at the ureteroileal and low pressure in the ilea! conduit.' In the prone a steeper course of t hs ureters in the abdomen and there is less resistance to the flow of urine into the conduit. role in the flow of urine than normallv position. ureters appears to be less of a factor movement of the urine. The normal stimulus to 1s distension of an upper ment of the ureter a bolus of urine. 5 the downhill flow of heavier contrast urine through the entire length of the ureten;, the upper ends of the ureters may not be distended enough to excite normal peristaltic may also be less in the ureters 5 Lap ides, J.: ;\I euromuscular, vesical and ureteral function. In: Urology, 3rd ed. Edited M. F. CampbeE and J. H. Harrison. Philadelphia: W. Saunders p. 1344, 1970.
532
SOLOVAY
FIG. 3. R. D. M., 45-year-old white man, sustained fracture of 1st lumbar vertebra 6 years previously with paraplegia. Partial recovery of function occurred after decompression laminectomy. Neurogenic bladder persisted. Ilea! conduit was performed 18 months after injury. Following this, patient had several attacks of acute pyelonephritis. A, supine view of IVP shows dilated collecting systems of both kidneys and slightly dilated portions of ureters. B, left prone oblique view shows filling of slightly dilated unobstructed lower portions of ureters and partial filling of normal ilea! segment. Absence of obstruction indicates that infection is probable cause of dilated urinary tract.
patients with urinary diversion because of preexisting damage or disease of the kidneys or ureters. 6 Since active peristalsis ordinarily strips the ureters of contrast medium, its diminution should provide better filling of the ureters with contrast medium in the prone position, with the force of gravity playing a greater role in the transport of the urine. The improved demonstration of the lower portions of the ureters and possibly of the urinary conduit in the routine IVP, supplemented by the prone position, is advantageous in the postoperative period of urinary diversion and subsequent followup as well as in the occasional examination of a patient with urinary diversion who is seen for the first time or has been operated elsewhere. The surgical anatomy of the operative procedure may be demonstrable as well as the presence of pathological involvement. The level of the ureteral diversion, 7 - 9 as well as the possible use of the 6 Boyarsky, S., Kaplan, N., Martinez, J. and Elkin, M.: Cinefluorography of the urinary tract after ureteroileostomy. J. Urol., 88: 325, 1962. 7 Holland, J. M., King, L. R., Schirmer, H. K. A.
cecum or sigmoid instead of the ileum 10 as a conduit, may be determined. Pathological changes include constriction or obstruction at the ureteroileal junction, 11 angulation or displacement of tlre lower portion of the ureter or intestinal ureteral junction, recurrent carcinoma 12 or a leak at the anastomosis.
and Scott, W. W.: High urinary diversion with an ilea! conduit in children. Pediatrics, 40: 816, 1967. 8 King, L. R. and Scott, W.W.: Ilea! urinary diversion. Suc,;ess of pyeloileocutaneous anastomosis in correction of hydroureteronephrosis persisting after ureteroileocutaneous anastomosis. J.A.M.A., 181: 831, 1962. 'Wallace, D. M.: Ureteric diversion using a conduit: a simplified technique. Brit. ,J. Urol., 38: 522, 1966. 10 Byron, R. L., Jr., Yonemoto, R. H., Riihimaki, D. U. and Sise!, R. J.: The ilea! segment as a bladder substitute in extensive operations for malignant conditions in the pelvis. Surg., Gynec. & Obst., 130: 869, 1970. 11 Engel, R. M.: Complications of bilateral ureteroileocutaneous urinary diversion: a review of 208 cases. J. Urol., 101: 508, 1969. 12 Cordonnier, J. J. and Nicolai, C. H.: An evaluation of the use of an isolated segment of ileum as a means of urinary diversion. J. Urol., 83: 834, 1960.
PRONE POSITION FOR !VP IN ILEAL CONDUIT URINARY DIVERSION SUMMARY
The IVP plays an role in the evaluation and management of ail forms of urinary diversion, including the ilea.I conduit and its various modifications. IVPs of patients in the prone position provide more consistent demonstration of the lower portions of the ureters and sometimes of the ilea! segment into which they empty than the radiograms made with patients in the routine supine plays a greater role in the filling of the
lower structures in the prone possible in the normal tract because ventral position of the conduit and lower the low pressure in the ilea! conduit and absence of a valve at the ureteroilea! should, therefore, be to obtain a complete demonstration of the anatomy ,Jf the ilea! conduit and its various modifications conduits involving portions of the which are ventral in Pathological changes, narrowing, displacement or portions of the ureters or appreciated.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1974 by The Williams & Wilkins Co.
ADVANTAGES OF THE PRONE POSITION FOR THE EXCRETORY UROGRAM IN ILEAL CONDUIT URINARY DIVERSION JULIUS SOLO VAY
From the Department of Radiology, Veterans Administration Hospital, Montgomery, Alabama
Radiograms of 3 patients are included in this report, which show some of the advantages of the prone position in ileal conduit urography (figs. 1 to 3). This use of the prone position for IVP in ileal conduit urinary diversion has not been reported previously. 2 • 3 The IVP is performed by the high dose or infusion technique. The bag which drains the
The ileal conduit is an effective and widely used method of urinary diversion. In the radiological study after this operation, the excretory urogram (IVP) with the patient in the supine position shows the collecting systems of the kidneys, the proximal portions of the ureters and the ileal conduit. The lower abdominal portions of the ureters and their course to the conduit are usually not demon-
FIG. 1. J. B. H., 39-year-old white man, had partial paraplegia and neurogenic bladder secondary to compression fracture of 1st lumbar vertebra and anterior subluxation of 12th dorsal vertebra sustained 6 years previously. Ilea! conduit was constructed 4 years ago. A, supine view of IVP shows filling of normal collecting systems of both kidneys and proximal portions of ureters. B, prone view shows filling of slightly dilated lower portions of ureters and slightly kinked unobstructed ilea! conduit.
strated. However, radiograms with the patient in the prone and prone oblique positions often show the lower portions of the ureters, their relationship to the ileal segment and sometimes better filling of the ileal segment. It may thus be possible to obviate the performance of the retrograde ileagram in which the entire urinary tract can be filled, by virtue of the usually present ileoureteral reflux. 1 Accepted for publication August 17, 1973. Koehler, P. R. and Bowles, W. T.: Radiological
1
ileostomy is emptied at the beginning of the examination and is replaced over the ileostomy after the scout film is made. Moderate compression evaluation of the upp!lr urinary tract following ilea! loop urinary diversion. Radiology, 86: 227, 1966. 2 Elkin, M.: The prone position in intravenous urography for study of the upper urinary tract. Radiology, 76: 961, 1961. 'Handel, J. and Schwartz, S.: Value of the prone position for filling the obstructed ureter in the presence of hydronephrosis. Radiology, 71: 102, 1958.
530
PRONE POSITION FOR IVP IN ILEAL CONDUIT URINARY DIVERSION
F1G. 2. F. J. W., 50-year-old black man, had cy1;te1~tomv for carcinoma of bladder and ileal conduit perfoncwd several months previously. A, supine view of IVP filled, normal collecting systems of kidneys and ileal conduit. B, prone view shows partial filling of normal lower portions of both ureters and slight emptying of conduit. There is angulation of lower portion of left is not obstructive.
over the lower abdomen and ileostomy is applied means of a folded bath towel and compression band or band which encircles the over foam pads situated over the lower anterior abdomen. When the films made in the supine position show amounts of contrast medium in the pelves and calices of the and upper of the ureters, the patient is turned on his stomach ,Nith the folded bath towel or foam t•m-nn,roc pads still in position. One or 2 films m the prone position are Pv1nnc:Pn and also in the and left prone oblique These usually filling of the lower ends of the ureters, the ureteroileal anastomoses and the ilea[ It is believed that there are anatomic and physiologic explanations for the improved ureteral filling in the prone Anatomically, the lower abdominal of the ureters are more anterior than the and upper ureters because the ureters follow the normal lordotic curve of the lumbar spine in their course through the retroperitoneal tissues of the abdomen.' unne m
after ileac didisorders. J. Ural.,
In of the ilea! conduit operation, the lower cut ends of the ureters are mobilized from their bed EWfi still further forward into the abdomer: isolated segment of ileun,. there is an absence of a valve mecha nism at the ureteroileal and low pressure in the ilea! conduit.' In the prone a steeper course of t hs ureters in the abdomen and there is less resistance to the flow of urine into the conduit. role in the flow of urine than normallv position. ureters appears to be less of a factor movement of the urine. The normal stimulus to 1s distension of an upper ment of the ureter a bolus of urine. 5 the downhill flow of heavier contrast urine through the entire length of the ureten;, the upper ends of the ureters may not be distended enough to excite normal peristaltic may also be less in the ureters 5 Lap ides, J.: ;\I euromuscular, vesical and ureteral function. In: Urology, 3rd ed. Edited M. F. CampbeE and J. H. Harrison. Philadelphia: W. Saunders p. 1344, 1970.
532
SOLOVAY
FIG. 3. R. D. M., 45-year-old white man, sustained fracture of 1st lumbar vertebra 6 years previously with paraplegia. Partial recovery of function occurred after decompression laminectomy. Neurogenic bladder persisted. Ilea! conduit was performed 18 months after injury. Following this, patient had several attacks of acute pyelonephritis. A, supine view of IVP shows dilated collecting systems of both kidneys and slightly dilated portions of ureters. B, left prone oblique view shows filling of slightly dilated unobstructed lower portions of ureters and partial filling of normal ilea! segment. Absence of obstruction indicates that infection is probable cause of dilated urinary tract.
patients with urinary diversion because of preexisting damage or disease of the kidneys or ureters. 6 Since active peristalsis ordinarily strips the ureters of contrast medium, its diminution should provide better filling of the ureters with contrast medium in the prone position, with the force of gravity playing a greater role in the transport of the urine. The improved demonstration of the lower portions of the ureters and possibly of the urinary conduit in the routine IVP, supplemented by the prone position, is advantageous in the postoperative period of urinary diversion and subsequent followup as well as in the occasional examination of a patient with urinary diversion who is seen for the first time or has been operated elsewhere. The surgical anatomy of the operative procedure may be demonstrable as well as the presence of pathological involvement. The level of the ureteral diversion, 7 - 9 as well as the possible use of the 6 Boyarsky, S., Kaplan, N., Martinez, J. and Elkin, M.: Cinefluorography of the urinary tract after ureteroileostomy. J. Urol., 88: 325, 1962. 7 Holland, J. M., King, L. R., Schirmer, H. K. A.
cecum or sigmoid instead of the ileum 10 as a conduit, may be determined. Pathological changes include constriction or obstruction at the ureteroileal junction, 11 angulation or displacement of tlre lower portion of the ureter or intestinal ureteral junction, recurrent carcinoma 12 or a leak at the anastomosis.
and Scott, W. W.: High urinary diversion with an ilea! conduit in children. Pediatrics, 40: 816, 1967. 8 King, L. R. and Scott, W.W.: Ilea! urinary diversion. Suc,;ess of pyeloileocutaneous anastomosis in correction of hydroureteronephrosis persisting after ureteroileocutaneous anastomosis. J.A.M.A., 181: 831, 1962. 'Wallace, D. M.: Ureteric diversion using a conduit: a simplified technique. Brit. ,J. Urol., 38: 522, 1966. 10 Byron, R. L., Jr., Yonemoto, R. H., Riihimaki, D. U. and Sise!, R. J.: The ilea! segment as a bladder substitute in extensive operations for malignant conditions in the pelvis. Surg., Gynec. & Obst., 130: 869, 1970. 11 Engel, R. M.: Complications of bilateral ureteroileocutaneous urinary diversion: a review of 208 cases. J. Urol., 101: 508, 1969. 12 Cordonnier, J. J. and Nicolai, C. H.: An evaluation of the use of an isolated segment of ileum as a means of urinary diversion. J. Urol., 83: 834, 1960.
PRONE POSITION FOR !VP IN ILEAL CONDUIT URINARY DIVERSION SUMMARY
The IVP plays an role in the evaluation and management of ail forms of urinary diversion, including the ilea.I conduit and its various modifications. IVPs of patients in the prone position provide more consistent demonstration of the lower portions of the ureters and sometimes of the ilea! segment into which they empty than the radiograms made with patients in the routine supine plays a greater role in the filling of the
lower structures in the prone possible in the normal tract because ventral position of the conduit and lower the low pressure in the ilea! conduit and absence of a valve at the ureteroilea! should, therefore, be to obtain a complete demonstration of the anatomy ,Jf the ilea! conduit and its various modifications conduits involving portions of the which are ventral in Pathological changes, narrowing, displacement or portions of the ureters or appreciated.