1994, The British Journal of Radiology, 67, 1057-1061

Recurrent upper tract urothelial tumours: the

use of loopography following cystectomy for
bladder cancer
1
J NOBLE, FRCS, 2Z A M I N , MRCP, 2 D KESSEL, MRCP and 2 D RICKARDS, FRCR, FFRDSA

Departments of 1Urology and 2Radiology, The Middlesex Hospital, London W1 N 8AA, UK

Abstract
Recurrent upper tract tumours following cystectomy for transitional cell carcinoma are not uncommon.
Conventional follow-up to identify preclinical recurrent disease often involves a combination of excretory
urography and urine cytology. This study investigates the possible advantages of loopography in the follow-up
of these patients. 41 patients who had undergone cystectomy and ileal loop diversion for transitional cell
carcinoma of the bladder were studied. At the time of evaluation with a loopogram, eight out of 41 (19.5%)
were symptomatic. Loopography was well tolerated by all of the patients with no reported side-effects or
complications from the procedure. Six out of 41 (14.6%) of the loopograms demonstrated an abnormality
with recurrent transitional cell carcinoma identified in two patients. In only one case was excretory urography
necessary where a ureteric stricture prevented retrograde imaging of the upper tract. Loopography is a safe
and well-tolerated investigation for the follow-up of these patients. Excretory urography should be reserved
for cases where upper tract imaging is impaired because of obstruction within the loop or ureters.

Urothelial carcinoma is a common disease with tran- Patients and methods

sitional cell carcinoma (TCC) of the bladder accounting
for 7% of all cancers in men and 2.5% in women. The
urinary tract is lined with transitional epithelium from
the collecting tubules of the kidney proximally to the
distal five-sixths of the urethra and TCC may occasion-
ally involve the renal pelvis, ureters or urethra. Urothe-
lial carcinoma may occur as a single lesion but is often
multifocal, this being attributed to either seeding of
exfoliated malignant cells [1] or to a field change in the
entire urothelium rendering it increasingly susceptible to
urinary carcinogens [2].
Ureteric tumours account for 3% of all urothelial
carcinomas. The majority of these are related to either
synchronous or metachronous vesical TCC with up to
5.9% of patients with bladder TCC developing upper
tract TCC at some stage [3]. Patients who have under-
gone cystectomy for bladder TCC are therefore at risk
of developing upper tract tumours and are convention-
ally followed-up with clinical examination, urinary
cytological analysis and excretory urography (EU).
Loopography confers several advantages over EU in the
evaluation of ileal conduits. The aim of this study was
to assess the role of loopography in the follow-up of
patients who have undergone cystectomy and ileal loop
diversion for bladder TCC.
Received 17 January 1994 and in revised form 13 May
1994, accepted 1 June 1994.
41 patients (18 men, 23 women), aged 62-84 years
(mean 77.3 years), were assessed in a retrospective study.
All had undergone cystectomy and ileal loop diversion
for bladder TCC between 1977 and 1988 (mean follow-
up 7.9 years). In addition to clinical examination, renal
function tests and urinary cytology, each patient under-
went loopography. This examination either formed part
of a routine yearly assessment (n = 36) or was performed
in response to a change in symptomatology, e.g. haema-
turia (n = 5 ) .
Loopography was carried out by the insertion of
a 10—14 gauge Foley catheter into the stoma site,
advancing the tip for a few centimetres and inflating
the retaining balloon. Residual loop urine was then
aspirated and contrast medium (e.g. Conray 280) was
injected under screening control. During filling of
the ileal loop and upper tracts, several details were
noted.
(1) During filling of the loop the rate of passage of
contrast medium was assessed. Gentle pressure ap-
plied to the injecting syringe during instillation of
contrast medium provides a qualitative assessment
of loop distensibility. Most loops easily accommo-
date 50 ml of contrast medium. Care should be taken
not to apply excessive pressure to the instilling
syringe, especially where a rigid stenosed loop is
visualized, because loop perforation and subsequent
extravasation of contrast medium can occur.

Vol. 67, No. 803 1057

 J Noble, Z Amin, D Kessel and D Rickards

Table I. Loopogram findings Table II. Symptoms at time of loopogram

Loopogram findings Number Symptoms Number of patients
Normal 35 Haematuria + right loin pain + UTI 1
Abnormal Haematuria + UTI 1
Recurrent tumour 2 Haematuria 3
Polyp 1 Total 5
Rigid loop 1
High pressure loop 1
Ureteric stricture 1 returned for early review. There was evidence of an E.
Total 41 coli UTI, but no malignant cells were seen on urine
cytology. A loopogram was performed, which demon-
strated a rigid, indistensible loop with two tight stenoses
(2) The loop mucosa was assessed and the presence of in which no peristalsis was identified (Figure 1). This was
any obstruction to the flow of contrast medium, e.g. presumably caused by chronic ischaemia of the bowel
stricture, was visualized. Filling defects within the segment. No deterioration in his renal function was
loop itself could also be assessed. evident and he subsequently underwent a successful loop
(3) When the loop was adequately filled, the presence revision.
and quality of loop peristalsis was visualized. This Patient 2. This patient was reviewed urgently in the
may be absent in ileal conduits that have become urology outpatient clinic after he had noticed frank
stenosed as a result of ischaemia and contribute to blood in his stoma bag. There was no evidence of UTI
stagnation of urine within the loop and subsequent and urine cytology revealed no malignant cells. Loopog-
urinary tract infection (UTI). Stenosis of the stoma raphy demonstrated a rigid, indistensible loop with no
site accompanying a rigid loop may lead to high
pressures within the ileal conduit predisposing to
upper tract dilation and urinary tract infection.
(4) The free retrograde passage of contrast medium into
the upper urinary tract via the ureters was assessed.
Particular attention was paid to the uretero-ileal
anastomosis site, often requiring oblique views, this
being a common site for ischaemic stricture for-
mation. The presence of filling defects within the
ureters or renal pelves was also assessed. Spot films
of the relevant anatomy were exposed.

After the investigation was completed the Foley cath-

eter balloon was deflated and removed. Where visualiz-
ation of the upper tracts was not possible because of an
obstruction of retrograde flow of contrast medium up
into the upper tracts, EU was performed in standard
fashion.

Results
35 out of 41 (85.4%) of the loopograms performed
were normal and all of these patients were free of urinary
symptoms. The usual appearance consisted of a disten-
sible bowel loop in which antegrade peristalsis could be
easily identified. Free reflux up the ureters was achieved
without overdistension of the loop. Six out of 41 (14.6%)
loopograms demonstrated an abnormality (Table I).
Five of these patients had developed haematuria at the
time of evaluation. This was associated with right loin
pain and UTI in one patient and UTI in one other (Table
II). Of these, two patients also had malignant transi-
tional cells in their urine identified by cytological analy-
sis. An abnormality was also identified in one asympto-
matic patient where loopography was undertaken at a
routine follow-up visit. The loopogram findings in each
of these patients were as follows.
Patient 1. The patient had noticed blood in his stoma Figure 1. Loopogram demonstrating rigid, stenosed loop caus-
bag intermittently over the previous 2 months and had ing haematuria and recurrent UTIs.

1058 The British Journal of Radiology, November 1994

Loopography in follow-up of patients post -cystectomy

considered that palliative treatment was appropriate in

this case.
Patient 6. In only one case was EU necessary follow-
ing loopography, where a stricture was noted in the
distal left ureter. This patient was asymptomatic and the
appearances of the stenotic region were ischaemic in
nature (Figure 4). In the absence of positive urinary
cytology and with satisfactory drainage on renal isotope
scanning, no further action was taken.

Loopography was well tolerated by all the patients

studied and there were no reported side-effects or com-
plications as a result of the procedure.

Discussion
70-80% of bladder tumours are superficial (Ta or Tl
NO MO), unifocal papillary lesions and can be success-
fully removed endoscopically. Multifocal disease may be
more difficult to control without the use of intravesical
chemotherapy. In more advanced cases, where the dis-
ease has become refractory to endoscopic surgery and/or
intravesical chemotherapy or has invaded the superficial

Figure 2. Adenomatous polyp (black arrow) within an ileal

loop.

peristaltic activity and a stenotic area was noted just

proximal to the stoma site. Once again the appearances
were of an ischaemic rather than malignant stricture and
this was corrected surgically.
Patient 3. The third symptomatic patient had devel-
oped haematuria with no associated UTI. Urine cy-
tology showed no evidence of recurrent malignant
disease. Loopography revealed a small adenomatous
polyp within an otherwise normal loop segment (Figure
2). This was easily removed via a flexible cystoscope and
histology confirmed that the lesion was benign.
Patients 4 and 5. These two patients, who presented
with haematuria, were shown to have malignant transi-
tional cells in their urine. A loopogram performed on the
patient where the haematuria was associated with UTI
and recurrent right loin pain revealed recurrent disease
at the distal end of her right ureter and a ureteronephrec-
tomy was subsequently performed. The second patient
was shown to have extensive invasive disease involving
the loop and distal ureters (Figure 3). He also had Figure 3. Loopogram demonstrating extensive recurrent TCC
evidence of metastatic TCC within the liver and it was (white arrow).

Vol. 67, No. 803 1059


Figure 4. (a) Loopogram showing "hold up" of contrast medium at the lower end of the left ureter, (b) A subsequent intravenous
urogram demonstrating an ischaemic ureteric stricture.
muscle layer of the bladder (T2 N0/N1 MO), more
aggressive treatment is indicated. Although much inter-
est has developed in recent years in continent urinary
diversion, the mainstay of treatment for advanced blad-
der TCC has been cystectomy and ileal loop diversion
combined with radiotherapy [4].
The incidence of upper tract tumours in patients who
have undergone cystectomy and ileal loop diversion has
been reported to be between 3.3 and 8.5% [5-7]. On this
basis it is commonplace to advise regular follow-up in
order to detect recurrent disease at a preclinical stage.
This is usually carried out by a combination of clinical
evaluation, urinary cytology [8] and EU. However,
recent reports have suggested the value of investigating
asymptomatic patients with urinary cytology alone be-
cause the incidence of detecting clinically unsuspected
disease on EU is extremely low [7]. In addition, EU has
several disadvantages when compared with loopography
in the evaluation of ileal loop function and compli-
cations. Despite the advent of non-ionic intravenous
contrast media there is still a risk of contrast medium
reaction reaching 0.04% [9-11], and although following
1060
J Noble, Z Amin, D Kessel and D Rickards
IVU less than 5% of patients develop minor side-effects,
0.1% develop major complications with the mortality
rate (for ionic agents) falling between one in 40 000 and
one in 75 000 [12-14]. EU provides comparatively poor
visualization of the loop itself and an assessment of loop
peristalsis is often extremely difficult to obtain. The
procedure is time consuming for both the patients and
the radiology department.
In comparison, loopography permits excellent defi-
nition of the ileal loop and can provide information
about loop peristalsis. Most conduits allow free reflux of
contrast medium into the upper tracts such that abnor-
malities can be easily visualized. When compared with
EU, loopography is safe, quick and relatively cheap. In
our series only one patient required further imaging after
loopography, confirming its efficacy in assessing these
patients.
We therefore recommend that radiological follow-up
for these patients should be reserved for those where
there is a strong clinical or cytological suspicion of
disease recurrence and/or loop complications. In those
patients who require further assessment, loopography
The British Journal of Radiology, November 1994
Loopography in follow-up of patients post-cystectomy
should be the investigation of choice. EU should be
reserved for those patients in whom upper tract visual-
ization is hampered by obstruction to the flow of
contrast medium introduced via the stoma site.
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