Cutaneous ureterostomy as palliative diversion in adults with malignancy

doi:10.1016/0090-4295(87)90567-X

Urology

Volume 30, Issue 1, July 1987, Pages 31-34

https://doi.org/10.1016/0090-4295(87)90567-X Get rights and content

Abstract

Over a twenty-one-year period (1963–1984) 46 patients underwent a permanent urinary diversion using cutaneous ureterostomy. Thirty-seven of these patients had this method of diversion employed as palliation for pelvic malignancies. In 70 per cent of the patients diversion was done secondary to ureteral obstruction and in the other patients because of either severe lower urinary tract symptoms or a failed alternate form of diversion. Forty-nine per cent of the patients experienced a postoperative complication. The late postoperative complications were either related to the choice of diversion or presumed progression of the patient's disease. Palliative diversion is now best initially attempted with percutaneous nephrostomy or indwelling ureteral stents if bladder function allows. Cutaneous ureterostomy no longer is indicated as a primary form of palliative diversion, however, it may be used as an alternative to open nephrostomy tube placement or intestinal conduit should other more conservative forms of management fail. The presence of at least one dilated ureter is a prerequisite to the success of this form of diversion.

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Cited by (24)

Cutaneous Ureterostomy Following Radical Cystectomy for Bladder Cancer: A Contemporary Series
2023, Urology
To report peri-operative outcomes of a contemporary series of bladder cancer patients undergoing radical cystectomy (RC) with cutaneous ureterostomy (CU) urinary diversion at a tertiary referral center.
We retrospectively identified patients who underwent RC with CU at Mayo Clinic between 2016 and 2021. Clinicopathologic and perioperative characteristics were analyzed using standard descriptive statistics.
A total of 31 patients underwent RC with CU at our institution. Median age was 72 years and 21 were male. This was highly comorbid cohort (83% had an American Society of Anesthesiologists [ASA] Physical Status Classification System ≥3; median Charlson Comorbidity index = 8). Median time to flatus, tolerating regular diet, and length of stay were 3 (interquartile range [IQR] 3-3), 3 (IQR 3-4), and 4 days (IQR 4-7), respectively. A total of 14 patients experienced a high-grade complication (Clavien-Dindo ≥3) within 30 days of surgery, and 8 were readmitted. The most common 30-day complication was sepsis, which affected 13% (4/31) of patients. At 90 days postsurgery, the readmission rate was 32% (10/31), most commonly for sepsis. Three patients required reoperation within 90 days, including one patient who required CU revision due to stomal ischemia. One patient died within this time frame from causes unrelated to bladder cancer.
In a comorbid, relatively elderly bladder cancer cohort undergoing RC, the use of CU was associated with expeditious surgery and postoperative recovery. CU represents an option for urinary diversion in high-risk patients undergoing RC. Higher rate of postoperative ureteral obstruction can be pre-emptively addressed with chronic stent placement.
Recommendations for follow-up of muscle-invasive bladder cancer patients: A consensus by the international bladder cancer network
2018, Urologic Oncology: Seminars and Original Investigations
Citation Excerpt :
Analysis of the different guidelines shows that early detection of tumor recurrence is the main focus and nearly half of them stratify between low- and high-risk groups to develop recurrent disease. However, prospective studies addressing the effectiveness of early recurrence detection after RC and the effect on survival are lacking [5–7,11–22,24,26,27,45–47,49]. We conclude that recommendation of an extensive patient work-up including imaging (e.g., CT scan) is not justified in all patients, especially in those with poor performance status and severe medical comorbidities, as treatment of recurrences is mostly palliative.
Several guidelines exist that address treatment of patients with nonmetastatic muscle-invasive bladder cancer (MIBC). However, most only briefly mention follow-up strategies for patients and hence the treating physician is often left to infer on what the preferred follow-up schema would be for an individual patient. Herein, we aim to synthesize recommendations for follow-up of patients with MIBC for easy reference.
A multidisciplinary MIBC expert panel from the International Bladder Cancer Network was assembled to critically assess currently available major guidelines on surveillance of MIBC patients. Recommendations for follow-up were extracted and critically evaluated. Important considerations for guideline assessment included both aspects of oncological and functional follow-up—frequency of visits, the use of different imaging modalities, the role of cytology and molecular markers, and the duration of follow-up.
An International Bladder Cancer Network expert consensus recommendation was constructed for the follow-up of patients with MIBC based on the currently available evidence-based data.
Urinary Diversion in Renal Transplantation
2018, Urologic Clinics of North America
Citation Excerpt :
The advantage was thought to lie in avoiding an intestinal anastomosis, which is considered the most morbid part of urinary diversion. However, because of the high stricture rate and infectious complications, it was mostly abandoned.58–62 Older reports of anastomosis of the donor ureter to the native ureter implicated in ureterocutaneous anastomosis has been described with good overall outcome.
Patient Selection and Counseling for Urinary Diversion
2018, Urologic Clinics of North America
Citation Excerpt :
Cutaneous ureterostomy may be employed when use of a bowel segment is absolutely contraindicated and is most often used in the pediatric population. A stenosis rate greater than 50% and difficulty with pouching limit the applicability of this procedure.4,24 Incontinent diversions should be implemented in patients with significant medical comorbidities precluding them from CD, as well as those unable or unwilling to self-catheterize.
Open Techniques and Extent (Including Pelvic Lymphadenectomy)
2018, Bladder Cancer
This chapter deals with various open techniques. The chapter has four subparts. The first part deals with radical cystectomy, which is the surgery with high morbidity and mortality among urologic operations. The second part deals with pelvic lymphadenectomy (PLND), which remains the standard treatment in patients with muscle-invasive bladder cancer and high-risk non-muscle invasive bladder cancer. The third part deals with robot-assisted radical cystectomy. The fourth and the final part deals with several forms of urinary diversion.
Cutaneous ureterostomy technique for adults and effects of ureteral stenting: An alternative to the ileal conduit
2011, Journal of Urology
Citation Excerpt :
These reasons were supported by earlier studies in animals and then confirmed by clinical studies done more than 40 years ago, in which ureters obstructed intentionally with fulguration did much better than thin normal ureters when connected to the skin.14,15 Many reports of CU in adults revealed a greater than 50% incidence of stomal stenosis and the need for periodic dilation or long-term intubation.8,9 This was attributable to the ureters being nondilated and nonthickened with ischemia of the distal end when mobilized out of the pelvis.
We present surgical modifications that improved the outcome of cutaneous ureterostomies.
A total of 310 patients with a median age of 71 years (range 38 to 88) underwent cutaneous ureterostomy as urinary diversion. Median followup was 25 months (range 1 to 172). The technique included 1) transposition of the left ureter above the inferior mesenteric artery, 2) mobilization of the ileocecal segment with repositioning above each terminal ureter, 3) abdominal wall hiatus fixation with 4 angle sutures and 4) YV plasty of the ureters with edge-to-edge anastomosis for stomal creation. In the 161 group 1 patients (59.1%) the Double-J® stents were removed in less than 3 months. Stents remained longer than 3 months in the 111 group 2 patients (40.8%).
Of the 272 patients ureteral obstruction developed in 36 (13.2%). Ureteral obstruction was on the right side in 6 patients (2.2%), on the left side in 27 (9.9%) and bilateral in 3 (1.1%). Ureteral obstruction was treated with restenting in 20 cases (55.4%), stomal revision in 12 (33.3%) and conversion to a conduit in 4 (11%). Ureteral obstruction developed on the right side, on the left side and bilaterally in 3.7%, 13.7% and 1.82% of the patients in group 1, and in 0%, 4.5% and 0%, respectively, of those in group 2. Stenting time impacted only the left ureter with less obstruction in the group with longer stent placement (greater than 3 months) (p = 0.01).
As with other types of urinary diversion, left ureteral obstruction is a common complication of bilateral cutaneous ureterostomies. Long-term stenting for greater than 3 months and the applied surgical modifications improved the clinical outcome of this type of urinary diversion.

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Scientific articleCutaneous ureterostomy as palliative diversion in adults with malignancy

Abstract

J Urol

J Urol

J Urol

Urology

J Urol

Scientific article
Cutaneous ureterostomy as palliative diversion in adults with malignancy