Cutaneous Ureterostomy

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Cutaneous Ureterostomy

• Gary P. Kearney MD FACS

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Patients

• 30 Patients
• 13F 17M
• Age Range 20-79
• Mean age 66 yrs
• Excluding 3 patients lt 40 yrs
• Mean age 70 yrs

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Surgical options

• Cutaneous ureterostomy
• Bilateral Cutaneous ureterostomy
• Cutaneous ureterostomy with contralateral
  nephrectomy
• Cutaneous ureterostomy with contralateral renal
  embolism
• Cutaneous ureterostomy with transureteroureterosto
  my

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Renal Function

• No Deterioration
• Renal pelvis dilates 20-30cc
• Low pressure system
• Cultures/- No Rx
• Uses 5-8F. Feeding tub to assist
• Serum creatinine creatinine clearance to follow
  
• Ultrasound not useful

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Complications

• Acute tubular necrosis -1
• Stomal stenosis -1
• Loss of solitary kidney Dialysis -1
• Operative mortality Stroke -1
• Obstructed stent -1

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Primary Diseases

• Primary diagnosis of patients with Cutaneous
  Ureterostomy
• Tumor Patients
• Cervical Carcinoma 7
• Carcinoma of Bladder 13
• Rectal Carcinoma 4
• Carcinoma of Prostate 4
• Carcinoma of Testes 1
• Carcinoma of Ovary 1

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Operative Technique

• Surgical options
• Preoperative preparations
• Stomal site selection
• Nephropexy
• Ureteral Stoma
• Stomal appliance
• Intraoperative considerations

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Preoperative preparation

• Percutaneous nephrostomy
• Hyperalimentation
• Trial of ureteral stent
• Cutaneous Ureterostomy is an elective procedure

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Stomal site selection

• Patient selected sitting
• Right or Left upper quadrant
• Skin devoid of wrinkles of scars
• Site easily managed by appropriate patient

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J. B. (Postop)
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Past problems

• Retraction of ureter
• Abcess
• Urinoma

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Surgical technique

• One inch subcoastal incision
• Rib resection not required
• Extraperitoneal procedure (take care anteriorly)
• Dissect Gerotas fascia completed but not
  vascular pedicle
• Rotate lower pole to lie directly anteriorly
• Make sure ureter assumes a short straight course
  to skin
• Renal capsulotomy 2-3 inches on inferior surface
• Complete nephropexy to anterior or lateral
  abdominal wall (6-8
• sutures)
• Fashion skin pedicle incise ureter 2cm
• Suture skin flap to apex of spatulated ureter
  with 5-0
• Dexon/Vicryl
• Use diversion stent - 7F

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Nephropexy

• Method of George Prather MD
• Importance of procedure can not be over
  emphasized
• Provides fixation of kidney and prevents
  retraction of ureter and
• stomal stenosis
• Renal capsule is stripped back where possible to
  promote
• adherence to abdominal wall

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Ureteral Stoma

• Turned back ureter is brought through anteriorly,
  spreading
• rectus muscle, anterior rectus fascia large
  enough to
• admit the index finger
• Ureter should extend 1.5-2cm beyond skin surface
• Using skin flap technique increases surface area
  of stoma
• helps prevent stomal retraction and stenosis

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Stomal appliance

• Base of skin pedicle arises from 12 o'clock
  position when patient
• is viewed standing.
• Conduit collection devise has small diameter
  opening.
• Single belt can be used for bilateral
  ureterostomies
• Single stomas are to be encouraged where possible

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Intra-op considerations

• Historically Mannitol 12.5gms used to promote
  diuresis
• Minimize manipulation of kidney to avoid injury
  to vasculature
• Stage diversion where necessary in bilateral
  cases
• Sacrifice contralateral kidney by nephrectomy to
  gain single
• stoma when renal function is adequate
• Embolization has been effective when patient
  condition
• precludes a second operation

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Expanded Indications

• Solitary kidney
• Extended life expectancy in high risk patients

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Palliative Diversion

• Classic indication
• Poor surgical risk
• Limited life expectancy

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Types

• In-Situ (ISU)
• Loop (LCU)
• End Cutaneous

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Recent Considerations

• Newer antegrade and retrograde catheters
  frequently allow
• placement of indwelling ureteral stents.
• Percuatenous nephrostomy drainage allow elective
• consideration of permanent diversion
• Current patients represent a subset who are
  healthy enough
• to survive past above diversionary techniques
  with
• long-term complications of sepsis, obstructed
  stents, dislocation
• of nephrostomy tubes etc.