CUTANEOUS URETEROSTOMY FOR ADULTS AS AN ALTERNATIVE TO THE ILEAL CONDUIT

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Describtion






INTRODUCTION
Early complications after radical pelvic surgery are closely related to the type of urinary diversion. Delayed small bowel function and paralytic ileus were reported in up to 6% of >300 small bowel end-to-end anastomoses, with urinary fistula in 5.6% and digestive fistula in 2.5%, reaching a total major complication rate of 25.5% [1–3]. Ureterocutaneostomy is simple, with low morbidity and almost no mortality. It is accompanied frequently by stomal stenosis and ureteric obstruction. A modified
technique, uretero-ureterocutaneostomy (UUCS) using the greater omentum, is described


INDICATIONS, LIMITATIONS, RISKS AND CONTRAINDICATIONS
A permanent incontinent urinary diversion has been used to date only in high-risk patients with symptomatic bladder cancer, combined with palliative cystectomy. It is of limited use in obese patients and/or patients irradiated by external beam radiation, and contraindicated in patients with short ureteric stumps, poorly vascularized ureters, those torsion-free and where aspects of the stoma are questionable

PREPARATION OF THE PATIENT BEFORE SURGERY
Complete clinical staging for bladder cancer should be used to evaluate the retroperitoneum and pelvis, along with the most common metastatic sites including the lungs, liver and bone. A chest X-ray, liver function tests and serum alkaline phosphatase assays should be obtained routinely; patients with an elevated serum alkaline phosphatase or with/with no complaints of bone pain should have a bone scan. CT of the chest is used when pulmonary metastases are suspected by history, or because of an abnormal chest X-ray. CT of the abdomen and pelvis is routine to evaluate the pelvis and retroperitoneum for any significant lymphadenopathy or local contiguous spread. This radiography should also be used in patients with suspected metastases, elevated liver functions tests, a bladder tumour associated with hydronephrosis, or in those with an extensive primary bladder tumour that is either not mobile or fixed, the results of which may affect the decision for neoadjuvant therapy. However, CT of the primary bladder is neither sensitive nor specific enough to evaluate the degree of bladder wall tumour invasion, or to accurately determine pelvic lymph node involvement with tumour [4,5]
Other requirements are:
 Complete blood count and chemistry; 
‘Type and screen’ blood group; 
Stoma marks are placed bilaterally the day before surgery;
Tight and high antithrombotic stockings;
Subcutaneous prophylaxis for deep vein thrombosis started the evening before surgery;
• Osmotic bowel cleansing; •
(Antibiotic treatment started on the day of surgery (cephalosporin
• Patient counselling and consent (changing the decision to a conduit if there are short
ureters, risk of stomal stenosis with consequent revision, or stenting with J catheters to be changed every 4–6 months). Anaesthesia: general and epidural block for pain treatment
Instruments and materials.
• Ring retractor (Omnitract®, Aesculap);
• Standard instruments for cystectomy;
• Fine instruments for microsurgery;
• Magnifying loupe, × 2.5; 
• Suturing material: 5–0 and 6–0 glycolide;
Bipolar coagulation

Figure 1 Cystectomy completed
. Landmarks are represented by:
 xyphoid; 
 12th rib;
• umbilicus;
• superior iliac spine;
• symphysis.
The stoma is marked between umbilicus and xyphoid, preferably pararectal on the left side
figure-1 

Untitled-jpg-1.jpg

Figure 2 The lateral reflection of the peritoneum of the ascendant and descendent are already incised along the avascular/white line of Told during cystectomy. A bilateral and careful ureteric preparation by preserving the meso-ureter and the testicular artery is carried out until the PUJ, to avoid angulating the ureter. Once both ureters have been mobilized the right ureter is crossed over to the left side. The right position is between Treitz ligament and the inferior mesenteric artery, looking for a wide vessel-free window of the mesentery behind the descending colon.

Untitled-figure-2jpg.jpg

Figure 3 The skin incision to create the stoma is circular and its diameter is related to that of both ureters, usually 4.5–5 cm. The subcutaneous fat is excised and its place taken later by the greater omentum tissue. Once cleared of fatty tissue, the anterior rectus sheet is incised cross-like to obtain the minimum possible obstruction of the ureters by the fascia

Untitledfigure-3.jpg

Figure 4 The rectus muscle is bluntly separated. A cross-like incision is made in the dorsal rectus sheet and the peritoneum on the tip of the underlying finger.
Untitledfigure-4.jpg


Figure 5 Both ureters are pulled through for at least 1.5 cm above skin level. Observe capillary bleeding from both ureter stumps and spontaneous urinary ejaculation. Both ureters are split medially, one at the 3 and the other at the 9 o'clock position for ≈1.5 cm. A 6–0 glycolide suture is placed to connect both ureters medially, thus creating a ‘fish mouth’ stoma.

Untitled-figure5jpg.jpg

Figure 6 The thinnest part of the far end of the mobilized greater omentum is wrapped around both ureters like a sheet (with no constriction), placed and fixed subcutaneously. Again observe capillary bleeding from both ureteric stumps and spontaneous urinary ejaculation

Untitled-ifgure-5jpg.jpg

The ‘fish mouth’ ureter is fixed with interrupted 5–0 glycolide sutures to the epidermis. Two 6 or 8 F J catheters are inserted and fixed to the skin, and a stoma bag placed.
5.jpg

Figure 8 If there is stomal stenosis the scar tissue surrounding the ureteric orifices is excised and substituted by a buccal mucosal graft taken from the inner surface of the lip.
Untitled-jpg5.jpg

POSTOPERATIVE CARE The day after surgery the patient is mobilized and oral nutrition started; then: • Fluid balance and creatinine controls daily; • Antibiotic treatment until removal of the stents; • On day 6 the patient starts to learn the handling of the stoma bag; • Removal of the J catheters at 21 days; • After removing the J catheter, an IVU flush is used to document the upper urinary tract status; • At weekly intervals monitoring of the upper urinary tract by ultrasonography for 3 months; • Creatinine levels are assessed once monthly for the first 6 months..
 


Surgical Atlas Cutaneous ureterostomy LUKAS LUSUARDI, MICHELE LODDE and ARMIN PYCHA Department of Urology,    General Hospital, Bolzano, Italy Accepted for publication 3 August 2003

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