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212 B. Gurland et al.
Fig. 17.12 A V-shape skin
incision is made at the previously
marked location and the stoma is
created. Illustration © CCF
Fig. 17.13 The ACE orifi c e
References
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value of colonic irrigation in patients with continence disturbances.
Dis Colon Rectum. 1997;40(7):802–5.
2. Malone PS, Ransey PG, Kiely EM. Preliminary report: the ante-
grade continence mechanism. Lancet. 1990;336:1217–8.
3. Monti PR, Lara RC, Dutra MA, De Carvallo JR. New techniques
for construction of efferent conduits based on the Mitranoff principle. Urology. 1997;49:112–5.
4. Willams NS, Hughes SF, Stuchfi eld B. Continent colonic conduit
for rectal evacuation in severe constipation. Lancet. 1994;343(8909):
1321–4.
5. Kiely EM, Ade-Ajayi N, Wheeler RA. Caecal fl ap conduit for
antegrade continence enemas. Br J Surg. 1994;81(8):1215.
6. Mitrofanoff P. Cystostomie continenente trans-appendiculare dans le
traitment des vessies neurologiques. Chir Pediatr. 1980;21:297–305.
7. Sinha CK, Grewal A, Ward HC. Antegrade continence mechanism
(ACE): current practice. Pediatr Surg Int. 2008;24(6):658–8.
8. Worsoe J, Christensen P, Krogh K, Buntzen S, Laurberg S. Longterm results of antegrade colonic enema in adult patients: assessment
of functional results. Dis Colon Rectum. 2008;51(10):1523–8.
9. Poirier M, Abcarian H, Nelson R. Malone antegrade continent
enema: an alternative to resection in severe defecation disorders.
Dis Colon Rectum. 2007;50(1):22–8.
10. Dick AC, McCallion WA, Brown S, Boston VE. Antegrade colonic
enemas. Br J Surg. 1996;83:642–4.
11. Gerharz EW, Vik W, Webb G, Leaver R, Shah PJ, Woodhouse CR.
The value of the MACE procedure in adult patients. JAM Coll Surg.
1997;185:544–7.
12. Teichman JM, Harris JM, Currie DM, Barber DB. Malone antegrade continence mechanism for adults with neurogenic bowel disease. J Urol. 1998;160:1278–81.
13. Hirst GR, Arumugam PJ, Watkins AJ, Mackey P, Morgan AR, Carr
ND, et al. Antegrade continence enema in the treatment in the treatment of obstructed defecation with or without fecal incontinence.
Tech Coloproctol. 2005;9:217–21.
14. Lees NP, Hodson P, Hill J, Pearson RC, MacLennan I. Long term
results of the antergrade continent enema procedure for adults with
constipation. Colorectal Dis. 2004;6(5):362–8.
15. Rongen MJ, van der Hoop Gerritsen, Baeten CG. Cecal access for
antegrade colon enemas in medically refractory slow transit constipation. Dis Colon Rectum. 2001;44:1644–9.
16. Nanigian DK, Kurzrock EA. Intermediate – Term outcome of the
simplifi ed laparoscopic antegrade continence enema procedure:
less is better. J Urol. 2008;179:299–303.
17. Webb HW, Barraza MA, Crump JM. Laparoscopic appendicostomy
for management of fecal incontinence. J Pediatr Surg. 1997;32:457–8.
18. Sinha CK, Butler C, Haddad M. Left Antegrade Colonic Enema
(LACE): review of the literature. Eur J Pediatr Surg. 2008;18(4):215–8.
19. Uno Y. Introducer method of percutaneous endoscopic cecostomy
and antegrade continence enema by use of the Chait Trapdoor
cecostomy catheter in patients with adult neurogenic bowel.
Gastrointest Endosc. 2006;63:666–73.
Urinary Stomas
Amit R. Patel and Amr F. Fergany
1 8
Introduction
The formation of a urinary stoma may be indicated in the
patient that requires urinary diversion. Patients with urologic/
gynecologic malignancy such as bladder cancer or cervical
cancer; benign conditions such as neuropathic bladder,
extensive urethral stricture disease, complex urinary fi stulas,
or congenital malformations; and infl ammatory disorders of
the lower urinary tract with either irradiation or immunologic
etiology are all indications for lower urinary tract diversion.
The use of bowel has remained a constant for the last
150 years in diverting the genitourinary tract.
The fi rst stomas were internal, such as ureterorectal ligations
for bladder exstrophy by Sir John Simon in 1851, Boari’s
mechanical button in 1895 to avoid ureteral stenosis, and
Madyl’s intraperitoneal bladder trigone reimplantation into the
sigmoid. Coffey developed the ureterosigmoidostomy in 1911,
which remained the preferable alternative to noncontinent external drainage. Eventually urinary stomas evolved into cutaneous
stomas. Verhoogen’s continent catheterizable ileocecal pouch
was introduced in 1909, later abandoned, brought back into
favor by Gilchrist, and fi nally re-emerged as the Indiana pouch.
Bricker’s reintroduction of ileal conduit in 1950 as a diversion
with fewer complications and greater technical feasibility [ 1 ]
made it one of the most commonly used urinary stomas. Today,
urologic surgeons can choose from an arsenal of urinary stomas
from ileovesicostomies to noncontinent conduits to pouches
with continent cutaneous catheterizable stomas.
A. R. Patel (*)
Urologic Oncology , University of Chicago
Medical Center , Chicago , IL , USA
e-mail: amitpdoc@gmail.com
A . F . F e r g a n y
Glickman Urological and Kidney Institute ,
Cleveland Clinic Foundation , Cleveland , OH , USA
The scope of this chapter will cover urinary stomas,
including the use of bowel to create urinary stomas. We will
discuss the indications, operative techniques, and complications of cutaneous vesicostomies, conduits, and continent
pouches with catheterizable cutaneous stomas.
Vesicostomy
Indications
The vesicostomy is the procedure of choice in patients requiring immediate, temporary urinary diversion. It is often used
in children as a temporizing measure for acute renal failure,
urinary sepsis, or bladder outlet obstruction from posterior
urethral valves. The continent vesicostomy procedure can be
performed for patients who have a large capacity bladder but
do not have good bladder-emptying function. Patients with
lower motor neuron lesion or prune belly syndrome may
benefi t from continent catheterizable vesicostomy made
from the bladder itself.
Operative Technique: Noncontinent Vesicostomy
The noncontinent vesicostomy is usually placed between the
pubic symphysis and the umbilicus. A 2–3-cm midline incision is made through the anterior rectus fascia. Using a
Balfour or other self-retaining retractor, the rectus bellies are
separated, and the space of Retzius is entered. The peritoneum is bluntly dissected off the bladder wall. The bladder is
opened adjacent to the midline near the dome of the bladder.
The bladder wall adjacent to the cystotomy is secured to the
rectus fascia with interrupted 4-0 polydioxanone (PDS)
suture. The mucosa is approximated to the skin edges using
interrupted 4-0 chromic suture.
V.W. Fazio et al. (eds.), Atlas of Intestinal Stomas,
DOI 10.1007/978-0-387-78851-7_18, © Springer Science+Business Media, LLC 2012
213
214 A.R. Patel and A.F. Fergany
Operative Technique: Continent Vesicostomy
The bladder is exposed through a midline or Pfannenstiel
incision. The peritoneum is swept off of the dome and posterior aspect of the bladder. The bladder is fi lled with saline
and distended through a urinary catheter. A bladder fl ap
measuring approximately 7 cm in length and 2 cm in width
is marked just lateral to the midline (Fig. 18.1a ). The strip is
ab
rotated cephalad, and an additional 3 cm of mucosal fl ap is
dissected free from the detrusor (Fig. 18.1b ). The mucosal
fl ap is tubularized over a 12 French catheter using a running
4-0 Vicryl suture (Fig.
18.1c, d ). The full-thickness bladder
fl ap is tubularized over the catheter using a running 3-0
Vicryl suture (Fig. 18.1e, f ), ensuring full-thickness mucosa
and serosa into the anastomosis. The tubularized bladder fl ap
will serve as the continent catheterizable stoma.
cd
Fig. 18.1 Continent vesicostomy. ( a ) A fl ap is created from the
mobilized bladder. ( b , c ) A submucosal fl ap is created and tubularized
over a catheter. ( d , e ) The internal mucosal layers are closed over the
catheter in two layers. ( f ) The bladder is closed with full-thickness
sutures involving mucosa and serosa. Illustration © CCF
Fig. 18.1 (continued)
21518 Urinary Stomas
ef
Catheterizable Stoma Formation (for Continent Vesicostomies and Pouches)
The stoma site should be selected to allow for a tension-free
anastomosis. A V-shaped skin incision is made at the stomal
site for interposition into the stoma. The fl ap is dissected
through the subcutaneous fat to the fascia. A cruciate incision is made in the fascia and bluntly dilated to just beyond
the caliber of the stoma. The stoma is brought out through
the anterior abdominal wall to the skin and spatulated to
allow for a cosmetic closure and to reduce stomal stenosis
(Fig. 18.2a ). The apex of the triangular skin fl ap is secured to
the apex of the spatulated stoma using interrupted 4-0 Vicryl
suture (Fig. 18.2b ). The stomal anastomosis is completed
using interrupted 4-0 Vicryl suture. The stoma should be
catheterized several times to ensure ease of catheterization
without kinking of the stoma. The stoma can also be secured
with a single interrupted 3-0 Vicryl suture to the posterior
abdominal wall to reduce kinking. The anterior bladder wall
is secured to the posterior rectus sheath using 2-0 Vicryl
suture.
Appendicovesicostomy and the Mitrofanoff Principle
Mitrofanoff reported the use of isolated appendix implanted
into the bladder as a continent cystostomy [
principle relies on a narrow conduit (appendix, ureter, or
tapered bowel) connected between the skin and a large urinary reservoir (augmented bladder or urinary pouch) in an
2 ] . The Mitrofanoff
anti-refl uxing manner. The conduit remains continent and is
easy to catheterize to drain the reservoir.
Operative Technique
The right colon is mobilized beyond the hepatic fl exure, and
the appendix and its mesentery is carefully dissected off of the
cecal attachments (Fig. 18.3a ). Care is taken to preserve the
appendiceal artery, a branch off of the ileocolic artery.
Assessment of the mobilized appendix is necessary to ensure
adequate reach to the bladder and chosen stoma site. The
appendix is detached from the cecum sharply, and the cecal
opening is closed using absorbable running suture, followed
by Lembert sutures to over the closure line. An edge of cecum
should be left on the appendix to provide a distal stoma that
has reduced risk for stricture. The terminal end of the appendix is opened, and the lumen is dilated using serial metal
sounds to ensure passage of a 12-Fr catheter.
A bladder hiatus is chosen for implantation of the appendix or Monti-Yang segment (see Yang-Monti Ileovesicostomy ),
ensuring adequate distance to reach the selected stoma site.
The conduit is brought into the bladder through the hiatus
(Fig. 18.3b ). At least a 2–3-cm submucosal tunnel should be
made and the conduit passed under the tunnel . Of note, the
location of the hiatus and submucosal tunnel should be made
away from the bladder neck and bladder trigone to avoid
painful catheterization. The stoma is formed as discussed
previously (see Catheterizable Stoma Formation ). The cath-
eter is usually secured in place for 3 weeks prior to initiating
intermittent catheterization.
216 A.R. Patel and A.F. Fergany
Fig. 18.2 Catheterizable stoma
formation. The catheterizable
tube is brought through the
V-shaped skin incision,
spatulated, and secured to the
skin using interrupted sutures.
Illustration
©
CCF
Yang-Monti Ileovesicostomy
The Mitrofanoff principle can be applied to a retubularized
segment of ileum if the appendix has been removed or harvested for other purposes. A 2–3-cm segment of ileum is harvested with its mesentery demonstrating adequate vascular
fl ow to the segment (Fig. 18.4 ). The segment is opened along
its antimesenteric side. The opened segment is retubularized
transversely in two layers over a 14 Fr catheter. The mucosa
is approximated using running 5-0 Vicryl suture and the
seromuscular layer is brought together using interrupted 4-0
Vicryl suture, leaving the stomal end spatulated for the
stomal anastomosis. The tube is implanted into the bladder
in similar fashion as the appendicovesicostomy. Stoma formation for this tube is described under Catheterizable Stoma
Formation .
Complications
Diffi culties with catheterization and/or stomal stenosis represent the most common complications in long-term studies,
ranging from 20% to 60% for all types of catheterizable vesicostomies. Over 80% of patients remain continent after the
initial surgery, with up to 96% achieving continence following a maximum of two revision procedures [
3 ] . Most stomal
complications are related to the technical placement of the
stoma and may be avoidable [ 4 ] . Studies in pediatric popula-
tions demonstrate normal bladder function in a majority of
patients with various congenital uropathies [ 5 ] . Urolithiasis
complications can occur in up to 15% of patients [ 3 ] . The
appendicovesicostomy, Yang-Monti ileovesicostomy, and
continent vesicostomy, all provide adequate continent urinary stomas for patients when indicated.
Ileal Conduit
The uretero-ileal-cutaneous diversion was fi rst described by
Seiffert in 1935 [ 6 ] . Due to the technical diffi culty to effec-
tively collect and store urine, the procedure was abandoned.
Bricker redescribed the procedure in 1950, and it has since
gained widespread acceptance worldwide [ 1 ] . Advances in
enterostomal treatment and therapy have increased the durability and tolerance of the ileal conduit. The ileal conduit is
technically the fastest and simplest conduit to construct, and
it is the simplest to take care of. The ileal conduit has one of
the largest long-term outcomes, and therefore it is the urinary
diversion procedure to compare to all other techniques. Any
segment of ureter can be attached to the conduit from the
renal pelvis to the trigone, making the ileal conduit construction a versatile method for diversion.
Fig. 18.3 Mitrofanoff
catheterizable stoma. ( a ) The
appendix is harvested with
healthy mesoappendix. ( b ) It is
traversed through a cystotomy
and submucosal channel into the
bladder. The proximal end is
secured to the skin and a catheter
is place through the stoma into
the bladder. The appendiceal
mucosa is secured to the bladder
mucosa. ( c ) The bladder is
secured to the anterior abdominal
wall to prevent tension on the
anastomosis. Illustrations © CCF
21718 Urinary Stomas
a
b
Indications
Any patient requiring urinary tract reconstruction following
extirpative pelvic surgery may be considered for an ileal conduit. It can be used in cases where the bladder is left in-situ;
for example, in neurogenic bladder, although modern man-
c
agement of neurogenic bladder has limited the role of
supravesical diversion for this indication. The decision to
choose the type of urinary diversion also relies heavily on the
clinical condition of the patient, their comorbidities, body
habitus, disability, and any other systemic illness that may
preclude them from other types of urinary diversions.
218 A.R. Patel and A.F. Fergany
Fig. 18.4 Monti-Yang tube. ( a ) A 2–3-cm segment of well-vascularized ileum is harvested and ( b , c ) detubularized closer to the mesenteric edge.
( d ) The segment is retubularized transversely over a catheter, leaving one end spatulated for the stomal anastomosis. Illustration © CCF
Preoperative Preparation
Preoperative preparation of the patient includes a regimen of
clear liquid diet starting 1–2 days prior to surgery, followed
by a 4-L preparation of polyethylene glycol on the afternoon
before surgery. Patients with indwelling urinary catheters or
colonized urinary tracts are admitted the day prior to surgery
for broad-spectrum intravenous antibiotics, which continue
postoperatively for approximately 3–5 days.
The stoma site should be determined preoperatively in all
patients by an enterostomal nurse or specialist. Patients are
examined in the supine, sitting, and standing positions. The
umbilicus, belt line, bony protuberances, prior surgical scars,
and skin folds are noted and avoided when choosing the
stoma site. The ideal stoma site is usually just medial to the
linea semilunaris between the umbilicus and the anterior
superior iliac spine.
Operative Technique
Following cystectomy or pelvic exenteration, the terminal
ileum is identifi ed and examined for length, and radiation
enteritis, infl ammatory bowel disease, or malignancy if
applicable. The optimal length of conduit differs in each
case due to patient body habitus and length of available
ureter. The recommended length of conduit should not
exceed the distance between the sacral promontory and the
stoma site. Transillumination of the mesentery allows for
inspection of the blood supply to the conduit. The ileocecal
artery is spared to ensure vascular fl ow to the ileocecal
junction. It is important to identify at least two vascular
pedicles to the conduit to ensure adequate blood supply to
the conduit. An incision is made in the peritoneum over the
mesentery and the mesenteric vessels are clamped and tied
(Fig. 18.5 ). The length and mobility of the segment that is
Fig. 18.5 Ileal conduit harvest.
( a ) An ileal segment 15 cm
proximal to the ileocecal valve is
isolated and ( b ) placed caudally
to the anastomosis of the small
bowel. Illustrations © CCF
21918 Urinary Stomas
a
b
to reach the skin is only dependent on the distal mesenteric
division; thus, the proximal mesenteric division should be
short, allowing for a broad vascular pedicle to the conduit.
The bowel is divided using a bowel stapler, and the conduit
segment is placed caudal to the remainder of bowel. The
mesenteric window is closed using interrupted 3–0 silk
suture to avoid mesenteric hernia, and bowel continuity is
subsequently reestablished.
The staple line at the distal (efferent) end of the conduit is
excised and the conduit lumen is opened. A small opening
is made in the proximal end of the conduit and the conduit is
irrigated free of enteric contents with normal saline irrigation. At this point, we prefer to prepare the stoma site to allow
for more optimal localization of the ureteroileal anastomosis.
The fi nal maturation of the stoma in obese patients can be
performed after the ureteroileal anastomosis is performed, to
avoid diffi culty in passing the stents through a large abdominal wall.
Stoma Formation
The skin edge, fascial layer, and peritoneal edge are brought
into alignment using Kocher clamps. A circular plug of skin
is excised from the predetermined stoma site. Dissection,
using electrocautery, is carried through the subcutaneous fat
to the anterior rectus fascia. A cruciate incision is made in
the fascia, exposing the belly of the rectus muscle. The
220 A.R. Patel and A.F. Fergany
Fig. 18.6 End-loop stoma
formation. The end-loop stoma is
brought up 3 cm above the skin
surface and sutured in an everting
fashion in four quadrants. This is
followed by supporting dermal
sutures. Illustration © CCF
muscle is bluntly separated to expose the posterior rectus
fascia. A linear incision is made through this layer as well as
the peritoneum. Throughout the completion of this portion of
the procedure, the epigastric vessels can be palpated simultaneously and avoided. The abdominal wall defect should
allow for the passage of two fi ngers, or approximately 2–3-cm
breadth, to allow for passage of the conduit without compromising the blood supply. A larger area defect may increase
the risk of parastomal hernias. The distal end of the conduit,
in an isoperistaltic orientation, is brought through the stoma
site with care.
End-Loop Nipple Stoma
In the standard end-loop nipple stoma, the distal end of the
conduit is brought through the previously prepared stoma
opening using Babcock clamps to approximately 3 cm
above the skin surface. Four quadrant sutures of 3-0 chromic are placed through the dermis edge, the serosa of the
conduit well below the skin level, and through the fullthickness edge of the conduit (Fig. 18.6 ). Additional 3-0
chromic sutures are placed between the quadrant sutures to
secure the conduit to the dermis. A securing suture of 2-0
Vicryl may be placed to secure the conduit to the inside of
the abdominal wall. The proximal end of the conduit and
the ureteroileal anastomosis can be covered with the posterior peritoneum to assist in minimizing leakage of urine
and promote healing.
Turnbull Stoma
The Turnbull stoma may be used in obese patients with a short
mesentery [ 7 ] . For this stoma, the distal (efferent) end of the
conduit remains stapled closed. A small mesenteric opening
should be made in the conduit segment 3 cm from the distal
end (Fig. 18.7 ). A umbilical tape is placed through the opening
and the antimesenteric side of the loop is brought out through
the stoma opening at least 2–3 cm without tension or twisting
the conduit. The blind end of the loop is positioned cephalad.
A plastic rod replaces the umbilical tape and is secured in
place (Fig. 18.8 ). The loop is opened transversely and is
matured in the same everting manner as the end-loop stoma.
The Turnbull stoma provides an advantage to use over the
end-loop nipple stoma when there is a short, bulky mesentery
and thick abdominal wall commonly seen in obese patients.
It has less of a tendency for retraction and stenosis; however,
parastomal hernias are more commonly associated with the
Turnbull stoma [ 8 ] . The end-loop nipple stoma provides for
excellent appliance placement and less skin irritation, but stomal
stenosis is more common with the end-loop nipple stoma.
Ureteroileal Anastomosis
The principles to consider during creation of the ureteroileal
anastomosis include: maintenance of adequate distal ureteral
blood supply, the maintenance of a tension-free anastomosis,
absence of malignancy in the distal ureter (in cancer cases), and
Fig. 18.7 Turnbull stoma
formation. The Turnbull stoma is
started by bringing up the distal
loop of conduit by placing
umbilical tape through the
mesentery 3 cm from the distal
end. Illustration © CCF
22118 Urinary Stomas
Fig. 18.8 Turnbull stoma
completion. A plastic supporting
rod replaces the umbilical tape.
A myotomy is made transversely
and the stoma is matured in
an everting fashion. Illustration
© CCF
the avoidance of ureteral kinking or twisting. If the stoma site
is located on the right lower quadrant of the abdomen, the left
ureter is passed under or through the sigmoid mesocolon to the
right side. The hole in the sigmoid mesentery is usually made
at the level of the sacral promontory; however, it may be more
cephalad depending on the length of ureter and to avoid kinking
the ureter. The ureteroileal anastomosis can be made using the
Bricker, Wallace, or Lahey Clinic techniques and may be completed before or after the stoma maturation. The authors prefer
securing the base of the conduit to the sacral promontory or to
the retroperitoneal fi brous tissue after completing the ureteroileal anastomosis using 3-0 Vicryl suture (Fig.
18.9 ).