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218 Stern and Dalton
Figure 3 In isolation of the ileal loop, distal end of loop should be 10 to 15 cm
proximal to ileocecal junction.
The ileal segment is irrigated and, if necessary, the proximal end is
closed in a watertight fashion with absorbable suture. The left ureter is
delivered under the sigmoid mesentery, with care taken to avoid sharp an-
gulation. The ureteroileal anastomosis then can be constructed, with either
an end-to-side or a conjoined technique [5] (Fig. 5C). We typically place
indwelling ureteral stents, although this is not a universal practice [6,7].
The proximal end of the conduit may be secured to the presacral area with
absorbable suture.
Careful attention is paid to the creation of the abdominal wall stoma.
The skin and the underlying subcutaneous tissue are removed circumferen-
tially down to fascia at the previously marked stoma site (Fig. 6A). We use
the end of a 20 mL syringe plunger to mark the amount of skin to be
removed. A cruciate incision is made in the anterior rectus fascia and four
separate 2-0 chromic sutures are placed at the four points of the incision
(Fig. 6B). The fibers of the rectus muscle are separated, and the posterior
sheath and the peritoneum are opened bluntly with a clamp (Fig. 6C). This
opening should freely admit two fingers. The previously marked distal end
of the ileal loop is delivered through the abdominal wall; it should rest
without tension 3–4 cm above the skin (Fig. 7A). The conduit is secured
Methods of Urinary Diversion 219
Figure 4 After standard ileoileostomy is performed, mesentery is closed with
3-0 chromic suture.
to the anterior fascia with the previously placed chromic sutures, and a
protruding, nipple-type stoma is created. To create the nipple stoma, four-
quadrant 2-0 chromic sutures are placed sequentially through conduit sero-
muscular tissue, the full-thickness distal margin of conduit, and the subcuti-
cular layer of skin (Fig. 7B). After all sutures have been placed, they are
tied. Interrupted 3-0 chromic sutures are placed to seal bowel mucosa to
skin (Fig. 7C). A finger is placed carefully in the stoma to determine that
narrowing or angulation is not present at the fascial level, and a collecting
device is applied. Before closing, several 3-0 chromic sutures can be placed
to secure the conduit to the posterior fascia. Alternatively, particularly in
obese individuals, a Turnbull-type loop stoma can be constructed (Fig. 8).
JEJUNAL CONDUIT
Jejunal conduits have a high incidence of metabolic and electrolyte abnor-
malities; therefore their use has been abandoned by most urologic surgeons
unless no other bowel segment is available. The inefficiency of the jejunal
mucosa in absorbing sodium gives rise to the classic “jejunal conduit syn-
drome,” consisting of hyponatremic, hypochloremic, hyperkalemic meta-
bolic acidosis [8,9].
220 Stern and Dalton
Figure 5 Methods of constructing ureteroenterostomies. Careful mucosa-to-
mucosa apposition with fine absorbable suture is done. A, End-to-side anastomosis.
B, Conjoined ureteroileal anastomosis. C, Nonrefluxing ureteroileostomies.
COMPLICATIONS AND LONG-TERM RESULTS
WITH ILEAL CONDUITS
The reported rates of perioperative morbidity range from 19.7–55.9%; mor-
tality rates from 0.7–13% [10–24].
Complications are typically divided into early and late. Nurmi [25]
reported that the most common early postoperative complication was wound
infection, followed by ureteroileal leakage, intestinal obstruction, intestinal
fistula, and acute pyelonephritis. The most common long-term sequelae in-
Methods of Urinary Diversion 221
Figure 6 Preparation of stoma site.
cluded pyelonephritis, followed by parastomal hernia, severe parastomal
eczema, and ureteroileal obstruction.
Superficial wound infections occur in 5–10% of cases, and fascial
dehiscence has been reported in approximately 3%. Complications such as
atelectasis, small bowel obstruction, and thromboembolic disease occur
with a frequency similar to that associated with other major intra-abdominal
procedures.
The immediate postoperative problems unique to the ileal conduit and
other methods of urinary diversion are urinary extravasation and loop ne-
222 Stern and Dalton
Figure 7 Creation of nipple-type stoma.
crosis (see Table 1). Mild leakage of urine from the ureteroileal anastomo-
sis occasionally occurs. It is recognized clinically by an increase in drain
output with a high blood urea nitrogen (BUN) and creatinine content. This
is usually a self-limited problem that resolves in 2–4 days. Rarely, how-
ever, massive leakage occurs, accompanied by anuria, large drain output,
and urinoma formation. An intravenous urogram should be performed im-
mediately to document the location of the leak, and a catheter should be
left in the conduit and attached to dependent drainage. If marked drainage
persists, distal ureteral necrosis or dehiscence of the proximal conduit must
be considered as possibilities. Percutaneous drainage of one or both kidneys
can be performed; if a stent is not already in place, placement of one in an
antegrade fashion can be attempted. Most major leaks can be managed in
this way in conjunction with maintenance of nutritional status, treatment of
infection, and patience. Reoperation with reconstruction of the anastomosis
and, occasionally, the entire conduit is sometimes necessary, but it is ex-
tremely difficult because of the severe inflammatory changes involved. The
havoc wreaked by postoperative urinary extravasation underscores the im-
portance of adhering strictly to basic surgical principles in constructing the
Methods of Urinary Diversion 223
Figure 8 Turnbull-type loop stoma. After closure of the distal conduit, the loop
of ileum is delivered (A) and opened (B). Bowel is secured to the anterior fascia,
and the mucosa is approximated to the skin with absorbable suture. C, Occasion-
ally, placement of a rod is helpful to prevent early stoma retraction, although it is
usually unnecessary.
conduit. Figure 9 summarizes an algorithm for dealing with urinary extrav-
asation.
Loop necrosis is both disastrous and avoidable. It occurs in less than
1% of cases and has not occurred at all in several large series. An adequate
blood supply and avoidance of torsion and tension on the mesentery should
prevent this calamity. When loop necrosis does occur, the stoma appears
dusky and the patient may become acidotic. Prompt recognition of this
complication and reconstruction of the conduit are mandatory.
Late complications unique to ileal conduit and other forms of urinary
diversion include deterioration in renal function, nephrolithiasis, recurrent
febrile urinary tract infection, obstruction of the ureteroenteric anastomosis,
224 Stern and Dalton
Table 1 Early Complication Rates (%) of Ureteroileal Conduit Diversion*
Peri- Intestinal Wound Uretero- Acute Total
Study & operative ileal Loop pyelone- compli- Renal
year (N) mortality Obstruction Fistula Infection Dehiscence leakage necrosis phritis cations loss
Jaffe et al. 1968
15
(543) 6.6 5.5 1.1 7.6 2.6 2.6 0.2 2.8 38.1 —
Schmidt et al. 1973
16
(178) 3.4 6.2 1.1 6.2 3.4 2.4 — 2.8 33.7 —
Remigailo et al. 1976
17
(152) 0.7 0.7 — 7.2 3.3 2.6 0.7 — 19.7 —
Malgieri et al. 1978
18
(136) 3.7 4.4 — 21.3 8.1 — — 55.9 —
Sullivan et al. 1980
19
(336) 13.7 — 5.4 20.2 3.3 — 19.2 — —
Heath & Eckstein, 1984
20
(144) 1.4 4.9 2.1 3.5 4.9 3.5 5.6 — 22.0 —
Hancock et al. 1986
21
(102) 7.0 — — 18.0 — 3.0 5.0 9.0 — 19.0
Orr et al. 1982
22
(97) 4.0 1.0 — — — 10.3 1.0 21.6 ≥40.0 1.0
Stanhope et al. 1986
23
(156) 3.9 2.6 — 5.1 — 3.2 10.9 9.6 ≥56.0 —
Meyers et al. 1982
24
(293) 2.7 2.8 — 6.0 3.0 0.7 1.3 — 35.0 —
*From Killeen and Libertino: Management of Bowel and Urinary Tract Complications After Urinary Diversion. Urol Clin North Am 1988; 15:2, 184.
Methods of Urinary Diversion 225
Figure 9 Management of complications after ileal conduit diversion. (From Lib-
ertino JA, Eyre RC: Plan for management of complications after ileal conduit di-
version. In Ball TP Jr (ed): AUA Update Series. Lesson 7, Volume III. Houston,
Texas, American Urological Association Inc., 1984, p 3: with permission.)
loop stenosis and other stoma complications, electrolyte abnormalities, nu-
tritional deficiencies, and, perhaps, carcinogenesis (see Table 2).
The reported incidence of renal deterioration after conduit urinary di-
version has varied from 10–60%. Long-term follow-up of children with
ileal conduits reveals a significant degree of deterioration of renal function
seemingly directly related to time [26–32]. The longest follow-up was that
reported by Pitts and Muecke [31], which revealed deterioration of renal
function in 35% of patients who were followed for 16–20 years. Recurrent
infection, reflux, nephrolithiasis, and anatomic obstruction all play a poten-
tial role and should be sought and treated. Because most patients with ileal
conduits have asymptomatic bacteriuria, the presence of reflux is particu-
larly bothersome. A classic study by Richie et al. [33] demonstrated an
84% incidence of pyelonephritis in refluxing units as compared to 7% in
nonrefluxing ones. A more recent study [34] with a mean follow-up of 150
months demonstrated renal scarring to be twofold higher among patients
with nonrefluxing anastomoses. As a result, when children or young adults
require urinary diversion, a method incorporating reliable nonrefluxing ure-
teroenteric anastomosis is generally used. Approximately 6% of patients
with ileal conduits die of renal failure [35].
Up to 10% of patients develop nephrolithiasis. Dretler [36] theorized
that the mixture of urea-splitting organisms and high-conduit residual
urines, with resultant acidosis, is the primary cause. We treat asymptomatic
bacteriuria only when a likely urea-splitting organism is found (e.g., Pro-
226 Stern and Dalton
Table 2 Late Complication Rates (%) of Ureteroileal Conduit Diversion*
Renal
Ureter- Total Years of
deterioration Calculi
Intestinal Pyelone- oileal Stomal compli- follow-up
Study & year (N) obstruction phritis Yrs % obstruction stenosis Renal Conduit cations Revision (mean)
Jafee et al. 1968
15
(543) 6.5 — — 7.0 3.7 5.5 — — — — 1–14
Schmidt et al. 1973
16
11–10
(178) 6.2 21.9 — 17.7 7.9 18.9 10.7 — 81.0 — (4)
Remigailo et al. 1–9
1976
17
(152) 10.6 8.6 — — 4.0 12.6 2.6 — 68.2 — (2)
Pitts & Muecke, — 10.7 0–5 6.0 9.1 14.0 5.8 — 38.8 — 1–20
1979
31
(242) 6–10 13.0 1(6.2)
10–15 19.0
Sullivan et al. 1980
19
14.9 — — — 7.5 5.1 4.0 — — — 5–21
(336) 13.4 (L)
2.6 (R)
Heath & Eckstein, 3.5 — <10 6.4 2.1 25.0 5.5 — 28.0 — >6.9
1984
20
(144) >19 19.0
Hancock et al. 1986
21
(102) — 7.0 — 17.0 8.0 2.0 — — ≥35.0 6.0 5– 15
Orr et al. 1982
22
(97) — 38.1 — — 1.0 — 2.4 — — 3.5 1–12
Stanhope et al. 1986
23
(156) 2.5 9.6 — 2.6 8.3 11.0 5.7 — 37.8 — 5–31
Meyers et al. 1982
24
(293) 4.0 — — — 4.0 1.0 — 1.0 35.0 4.0 5–15
*From Killeen and Libertino: Management of Bowel and Urinary Tract Complications After Urinary Diversion. Urol Clin North Am 1988; 15:2, 185; with
permission.
Methods of Urinary Diversion 227
teus mirabilis). Furthermore, a kidney-ureter-bladder (KUB) study should
be performed on the patient every 1–2 years to identify early stone forma-
tion.
Obstruction of the ureteroileal anastomosis occurs in approximately
5% of patients and is due to either ischemia, localized fibrosis, radiation
change, or recurrent tumor. This condition can occur silently, which empha-
sizes the need for performing serial loopograms or renal ultrasounds. When
an obstructed segment is identified and the initial procedure was performed
for a malignancy, its recurrence must be ruled out with cytologies and
brushings of the anastomosis. Endourological management of benign stric-
tures with balloon dilatation and cold-knife incisions is often attempted ini-
tially (Fig. 10), although open reconstruction of the anastomosis has a far
higher long-term success rate [37,38].
Stomal stenosis has been reported in up to 30% of cases, but it proba-
bly has an incidence closer to 5% [39]. Use of a protruding nipple stoma
and the Turnbull loop stoma in obese patients should keep the incidence
low. Nevertheless it does occur and may be a source of significant morbid-
ity. When repair is necessary, simple interposition of a segment of skin
may suffice, although advancement of the conduit and reconstruction of the
stoma may be required (Fig. 11). Stenosis of the conduit itself also may
occur as a result of long-standing infection and fibrosis and often requires
reconstruction [40].
Figure 10 Endourologic management of ureteroenteric structures is becoming
the treatment of choice, although open repair or chronic stenting are still required
for failures.