Cutaneous urinary diversion

ByMohamed Elgendy

Assistant lecturer of urology Assuit University

Definition

• Artifictial orifice for urinary diversion.

Indication of urinary diversion

• When the bladder has to be removed either due to malignant tumour or post tramatic.

• When the sphincters of the bladder & the detrusor muscle have been damaged or have lost their normal neurological control.

• When there is irremovable obstruction in the bladder & distal to that.

• neglected Ectopic vesicae or failure of repair

• Incurable vesico- vagina fistula.

Types/Classification(1) According to elevation from surrounding surface: Two types of stomas may be made on the anterior abdominal wall:• The flush stoma is preferable for the continent

type of diversion. • The stoma that protrudes is preferable for

incontinent type of diversion.

Types/Classification Cont.2) According to Shape:

1. Nipple Stoma: “Rosebud”

• the stoma is grasped and brought out for a distance of 5 to 6 cm through the abdominal wall.

• it is preferred in the incontinent stoma

2) Loop End Ileostomy

• It is preferred in obese patients that have a thick abdominal wall and often a thick, short ileal mesentery

• the distal end of the loop is closed and the bowel is drawn through the rent in the abdominal wall.

3) Flush Stoma

It is preferred in the continent types of urinary diversion.

It can be done by appendix or tapered ileum.

It can be placed in umbilicus or away from umbilicus.

To avoid stomal stenosis a skin flap should be incorporated in the stoma.

It has different shape V shaped and VQZ stomaplasty.

Flush Stoma

The site of the stoma should be selected preoperatively

done by marking the stomal site with the patient in the sitting position, as well as in the supine position.

at least 5 cm away from the planned incision line.

well away from skin creases, scars, belt lines, and bone prominences.

• placed through the belly of the rectus muscle. be brought through a circular incision made at the

predetermined site.

Types of Incontinent Cutaneous urinary diversion

Ileal Conduit• the most common method of

urinary diversion in the United States

• a segment of ileum 18–20 cm long and located approximately 15–20 cm proximal to the ileocecal valve

Ureterocutaneous shunt

• Ureter is implantened direct to the skin

• Common in developing country

Loop ureterostomy

• Anterior part of the ureter is implanted to skin with maintenance of posterior wall continuity.

Incontinent vesicostomy

• Bladder opened directly to the the skin

CONTINENT CUTANEOUS URINARY DIVERSION

• Continent urinary diversion differs according to types of channels.

• The creation of a reliable continence mechanism that is easily catheterizable is considered the final and most important principle of continent urinary reservoir construction.

• the catheterizable channel should be brought up to reach the skin without tension. It should be short and secured to the peritoneum beneath anterior abdominal wall fascia to prevent kinking and problems with catheterization.

1) Nipple valves

• created by intussuscepting an intestinal segment to create a sphincteric compression mechanism.

2) Mitrofanoff • using the vermiform appendix• Its opened distal end was implanted submucosally, and the base

was brought to the abdominal wall.

• His principle was that any supple tube implanted submucosally with sufficient muscle backing acts as a flap valve and results in a reliable continent cutaneous catheterizable channel.

• As the reservoir fills, the rise in intravesical pressure is transmitted through the epithelium and to the implanted conduit, clothing its lumen.

Mitrofanoff

3) Yang-Monti technique

• In this procedure, a 2 cm segment of small bowel is opened longitudinally along the antimesenteric border and then closed transversely.

• its problem is the relatively short length of the channel.

4) Casale

• modification of Yang-Monti technique

• Increase length of the tube

• Two segment open opposite each other Paramesentric

• But its blood supply is irreliable.

5) In situ ileocecal valve

• used as continence mechanism in reservoirs formed by the cecum

• A short segment of terminal ileum, whether tailored or not, is used as catheterizable channel.

6) Continent Vesicostomy

• Parallel incisions 3 cm apart are made into the anterior bladder and used to form a long rectangular flap.

• The full-thickness strip is tubularized down to the bladder.

• The bladder mucosa from either side of the tube is then mobilized and closed over the mucosal tube to create a flap valve.

Complication of cutaneous urinary stoma

Early complications–Ischemia–hemorrhage–stenosis–fistula –retraction.

Late complications

– Prolapse – obstruction– para stomal

hernia – skin irritation

Stoma Ischemia/Necrosis

Causes–Aggressive

stripping of mesentery– Stenotic fascia

defect– Extensive tension

Hemorrhage• Mild hemorrhage common and self limiting. – Usually mucosal.– Apply pressure

• Active bleeding– Implies failure to ligate a mesenteric vessel– Identify and ligate.

Stomal Stenosis/Stricture• Could manifest early or late

• Ischemia is usual underlying factor

• May leads to upper-tract obstruction.

• Other causes: -Infection and retraction

• Treat initially with dilation

• Definitive Stoma revision

Edema

• TTT mainly medical.

Mucocutaneous Separation

• Separation along mucocutaneous border

• Caused by underlying tension or separation of sutures

• Usually treated medically.

• Could lead to stricture.

Peristomal abscess and fistula

• Caused mainly by infected hematoma

• May lead to fistula

Stoma Retraction• Causes– Tension– Obesity– Steroids use. Poor

wound healing

• Can lead to leakage and severe skin problem.

• Most eventually need revision

Prolapse

Parastomal Hernia• Predisposing factors

– Stoma placement lateral to rectus (common)– Large stoma – Obesity– Prior abdominal incisions– Malnutrition– Wound infection

• May present with intestinal obstruction

• Minor cases ttt by Abdominal binder

• Major cases – Repair with mesh.

Peristomal Skin Complication

causes• Due to prolonged contact of the skin with

urine.• Pressure trauma from belt• Allergic reaction in sensitive patient.

Skin Complications

• Fungal infections• Ttt by Antifungal

powder (Nystatin) or systemic therapy with fluconozole

Skin Complications(Pyoderma Gangrenosum)

• Treatment conflicting–Wound

debridement–Steroids

injection–Systemic

therapy

Skin Complications

• Allergic contact dermatitis

• Ttt by Identify irritant (skin patch test) and discontinue products.

• Apply hydrocortisone cream for short period

• Topical antihistamines

Skin Complications(Granulomas)

May be due to– Granulation

tissue (poor wound healing and infection)

–Bowel metaplasia

Skin Complications(Stoma warts)

• Warty raised macerated lesions around the stoma. • May cause

bleeding and pain.

Pyelonephritis & Renal Deterioration

• Pyelonephritis occurs in approximately 10% of patients who have undergone urinary diversion.

• Obstruction and stasis of urine within the reconstructed urinary tract are risk factors for the development of infection

• The presence of hydronephrosis, particularly in patients with a conduit diversion, may indicate the presence of ureteric reflux or obstruction at the ureterovesical junction.

finally

• “care and expertise are important in creating urinary stomas because some patients must live with the technical result for the rest of their lives”

Thank you