Clinical outcome of tubeless cutaneous ureterostomy by the Toyoda method

AIM: Cutaneous ureterostomy is the least invasive method of urinary diversion, but it carries a risk of stomal stenosis. We retrospectively examined the long-term outcome of tubeless cutaneous ureterostomy by the Toyoda method. METHODS: Since 1983, the Toyoda cutaneous ureterostomy has been performed in 97 patients (169 renal units) with a minimum follow up of 3 months. The ureteral patency rate was reviewed according to whether the stomal type was single (one ureter, one stoma) or double-barrel (two ureters, one stoma). RESULTS: After a median follow up of 23 months (range 3 to 169), a tubeless condition was achieved in 102 (82%) of 124 renal units associated with double-barrel stoma and in 35 (78%) of 45 renal units associated with single stoma. Although mild to moderate hydronephrosis was observed in 19% of patients, serum creatinine levels did not change after a minimum of 12 months after surgery (median 35). CONCLUSIONS: A high ureteral patency rate was achieved with cutaneous ureterostomy using the Toyoda method. This procedure, especially double-barrel stomal creation, is a reasonable alternative to other forms of urinary diversion in patients at high risk.     

Trans-mesosigmoid cutaneous ureterostomy

BACKGROUND: A new method was developed in order to create a single stoma cutaneous ureterostomy in which both ureters traverse the abdominal cavity and yet are buttressed by the mesosigmoid and covered by its visceral peritoneum. METHODS: The long mesenterium which is attached to the most mobile part of the sigmoid colon was used for the bilateral ureteral pathway. Tunnels for the ureteral path were made just underneath the visceral peritoneum on the bilateral side of the mesosigmoid. Through the tunnels both ureteral ends were brought from the retroperitoneal space to the mesenterocolonic junction (MCJ) and the MCJ is then approximated and sutured to the inside of the ureteral tract through the abdominal wall. The ureters brought outside the skin, are conjoined and sutured to the V skin flap. Eight patients who carried a high risk for operation and/or had a bladder tumor judged to be incurable underwent this cutaneous ureterostomy. RESULTS: All cases except one with low urinary output could be managed without catheter indwelling during the follow-up period. Three patients suffered from paralytic ileus and one required laparotomy for mechanical ileus during the short postoperative period. Postoperative excretory urography evaluated 14 kidneys during the follow-up period from 2 to 61 months and showed normal upper urinary tract in 11 and a mildly hydronephrotic tract in three. CONCLUSIONS: Transmesosigmoid cutaneous ureterostomy provides a single catheterless stoma even when the available ureters are relatively short. It appears to be a good method for supravesical urinary diversion when indicated.     

膀胱全切后双输尿管一侧汇合皮肤造口术的临床疗效

目的探讨膀胱全切后双输尿管一侧汇合皮肤造口术进行尿流改道的临床疗效。方法回顾分析膀胱全切术后双输尿管一侧汇合皮肤造口术32例的临床资料。主要技术包括：①左右输尿管均游离至肠系膜下动脉分叉附近,于腹主动脉表面穿过后腹膜转到腹腔;②左右输尿管汇合后,远端纵行剖开约6 cm,侧-侧吻合3.54 cm,留末端22.5 cm皮肤造口用;③皮肤造口在右侧标准腹壁造口部位,采用3角缝合固定法;④输尿管末端与皮肤的造口吻合采用双“V”形皮瓣嵌入双输尿管瓣之间成形术;⑤左右双“J”的留置大于2月后拔除。结果所有病例获随访,平均为（22.3±8.1）个月,并发症总发生率为12.5%,粘连性肠梗阻1例,上尿路积水2例,逆行感染1例。结论双输尿管一侧汇合皮肤造口术手术时间短、创伤小、易操作,不涉及肠道、术后并发症率低,是值得推广的一种尿液改道术。     

End cutaneous ureterostomy for the management of severe hydronephrosis

PURPOSE: Although rarely indicated, surgical treatment of severe megaureter can pose a formidable technical challenge, especially in the small infant. We present our experience and outcomes with end cutaneous ureterostomy as a temporizing adjunct to future ureteral reimplantation. MATERIALS AND METHODS: We performed a retrospective cohort study of patients who underwent end cutaneous ureterostomy between 1993 and 2005. Patient demographics, surgical details and outcomes were recorded. RESULTS: A total of 29 patients (22 males, 7 females) underwent diversion of 34 renal units. Primary megaureter was diagnosed in 15 patients (17 renal units). Secondary megaureter was found in 10 patients (12 renal units). Postoperative megaureter was diagnosed in 4 patients (5 renal units). Mean patient age at time of diversion was 3.2 months for those with primary megaureter and 1.4 years overall. Bilateral diversion or diversion of a solitary functioning kidney was performed in 14 patients (48%), of whom 4 had renal insufficiency. Nine patients (31%) had a febrile urinary tract infection while awaiting undiversion, with no evidence of renal scarring on followup. Undiversion was performed in 12 patients (13 renal units) with primary megaureter at a mean age of 18 months. Overall, undiversion was performed in 21 patients (23 renal units), and ureteral tailoring was required in only 5 renal units (22%). Mean followup after undiversion was 4.2 years for primary megaureter and 3.9 years overall. CONCLUSIONS: End cutaneous ureterostomy is a safe and effective procedure to temporize massive hydronephrosis while awaiting definitive ureteral reimplantation.     

Terminal loop cutaneous ureterostomy in renal transplantation: an under utilized urinary diversion technique

PURPOSE: We evaluated the effectiveness of terminal loop cutaneous ureterostomy as a means of urinary drainage in kidney transplant recipients during a 20-year period. MATERIALS AND METHODS: Five cadaveric and 2 living related patients underwent kidney transplantation with terminal loop cutaneous ureterostomy between 1984 and 2004. These patients had no usable bladder or they were not suitable candidates for intermittent catheterization. RESULTS: Followup was 20 months to 17 years. One patient underwent stomal revision 5 months after renal transplantation. Current serum creatinine 4 years later was 166 mumol/l. The remaining 6 patients had no evidence of ureteral obstruction and rarely had bacteriuria or urinary tract infections. Four patients had a functioning allograft with normal serum creatinine. One patient died with a normally functioning allograft and the remaining patient lost his graft due to chronic rejection. No patient in this series lost the graft due to a urological cause. Overall outcomes included excellent allograft function with minimal infection or stomal stenotic complications. CONCLUSIONS: Terminal loop cutaneous ureterostomy is a simple, safe and alternative means of urinary diversion in patients with renal transplant and a defunctionalized lower urinary tract.     

Tubeless cutaneous ureterostomy: the Toyoda method revisited

PURPOSE: Cutaneous ureterostomy is a less invasive method of urinary diversion and an attractive option especially in patients at high risk. We retrospectively examined the long-term outcome of the method introduced by Toyoda. MATERIALS AND METHODS: Since 1983 the Toyoda cutaneous ureterostomy has been performed in 61 patients (103 renal units) with a minimum of 3 months of followup. The ureteral patency rate was reviewed. RESULTS: Of the 92 renal units (89%) that achieved a tubeless condition 53 (51%) had no hydronephrosis, 23 (22%) had mild to moderate hydronephrosis without the need for treatment, 14 (14%) were not evaluated during followup and 2 (2%) were removed due to subsequent renal pelvic and/or ureteral carcinoma. CONCLUSIONS: A high ureteral patency rate was achieved with the Toyoda cutaneous ureterostomy. This procedure is a reasonable alternative to other forms of urinary diversion.     

Cutaneous ureterostomy using the transverse mesocolon

Cutaneous ureterostomy cannot be carried out by the retroperitoneal method in cases showing an insufficient length of the available ureter. We therefore proposed and carried out cutaneous ureterostomy transperitoneally on a ureter of minimum length using the transverse mesocolon. The right and left ureters are drawn from the retroperitoneum into the peritoneal cavity in the renal hilus area. The right ureter is then led from the root of the transverse mesocolon to the area attached to the transverse colon under the subserous part of the transverse mesocolon, and penetrates the gastrocolic ligament. The left ureter is led to the area attached to the transverse mesocolon under the subserous part of the transverse mesocolon, and penetrates the transverse mesocolon, bursa omentalis and gastrocolic ligament. Next, both the right and left ureters are drawn up to the abdominal wall and a ureterstoma is constructed. The transverse mesocolon can be used as supporting tissue for the ureter. Furthermore, this also ensures blood flow in the ureter.     

Simple correction of ureteral stomal stenosis for cutaneous ureterostomy

Cutaneous ureterostomy is a simple procedure to perform, but has some morbidity owing to stomal stenosis. We describe a new and simple technique applied to the stomal stenosis for cutaneous ureterostomy.     

Percutaneous ureterostomy as an effective diversion in a newborn

Ectopic ureter in a duplicated system in men is rare and rarely causes bilateral obstructive symptoms. The tendency of the ureter to dilate more than the caliceal system is unique to neonates and makes upper urinary diversions more challenging. However, alternative percutaneous diversions other than nephrostomy might be beared in mind in such cases with huge dilatation in ureters in suffering neonates. As discussed in this case percutaneous ureterostomy may be very effective and have a role in diagnosis and management of neonatal hydroureteronephrosis.     

Clinical results of tubeless cutaneous ureterostomy by Toyoda's method

Tubeless cutaneous ureterostomy by Toyoda's method was conducted in 67 ureters from 43 patients during the last 9 years. Subjects included 30 males and 13 females, with an average age of 61.4 years. Most of them were afflicted with malignant tumors in the bladder, rectum, prostate, or uterus. For bilateral ureterostomy, the double-barrel method was performed in which the stoma was made at the same site in both the right and left ureters. Among 60 ureters in which pre- and postoperative changes in the renal pelvis could be traced by IVP, satisfactory results were obtained in 16 of 20 ureters treated by unilateral surgery. Of the 40 ureters treated by the double-barrel method, moderate or severe pyeloectasis was observed in 3 of the 20 ureters on the side of the stoma, while moderate pyeloectasis was seen in 3 of 20 ureters of the side opposite the stoma, and severe pyeloectasis or loss of renal function was noted in 5. Thus, renal function on the side opposite the stoma was frequently influenced by the procedure. A patient who died of disseminated intravascular coagulation syndrome soon after the operation was excluded from analysis. Tubeless cutaneous ureterostomy could be conducted in 39 of 42 patients (92.8%), excluding one whose stoma and its periphery were covered with severe inflammatory granulation and 2 with ureteral constriction.     

Experimental data on the application of a stoma prothesis in cutaneous ureterostomy

Summary The main problem with urinary diversion via cutaneous ureterostomy is stomal stenosis. Results with experimental and clinical implants of carbon polymer stoma prostheses (max. clinical observation period: 31 months) for vesicostomies have encouraged us to find out whether implants of this material would be suitable for cutaneous ureterostomies as well. The first step was dilatation of the ureters in 16 mongrel dogs, 4 mini pigs and 4 sheep. This was done by knotting a thread over a splint which had been introduced into the ureter. After 7 days the ureter was ligated prevesically and a carbon polymer stoma was implanted into the ureter.37 of the 48 stoma implants were well tolerated and provided water tight urinary drainage; slight encrustation occurred but, radiologically, a smooth flow of contrast medium was seen. Ten of these 37 cases had transient urinary leakage. Eleven of the 48 stoma implants were unsuccessful because of insufficient healing, urinary extravasation, parastomal inflammation or severe encrustations.The results of these experiments on animals would seem to justify initial clinical use. It is conceiveable that in this way stomal stenosis of the cutaneous ureterostomy can be avoided.     

膀胱癌输尿管皮肤造口患者自我隐瞒现状及影响因素分析

目的了解膀胱癌输尿管皮肤造口患者自我隐瞒现状并分析其影响因素,为针对性干预提供参考。方法对184例膀胱癌输尿管皮肤造口患者采用一般资料调查表、自我隐瞒量表、事件相关反刍性沉思问卷、社会影响量表进行调查,分析影响因素。结果患者自我隐瞒得分30.97±6.27;与侵入性反刍性沉思呈正相关,与目的性反刍性沉思呈负相关,与病耻感呈正相关(均P<0.01);多元线性回归分析显示,病耻感水平、反刍性沉思水平、文化程度、年龄、造口接受程度是患者自我隐瞒倾向的影响因素(调整R 2=0.589;P<0.05,P<0.01)。结论膀胱癌输尿管皮肤造口患者自我隐瞒倾向处于中等水平,受多种因素的影响;护理人员应针对影响因素实施个体化干预措施,以降低其自我隐瞒倾向。     

输尿管皮肤造口患者经济毒性状况及影响因素分析

目的 了解膀胱癌输尿管皮肤造口患者经济毒性现状并分析其影响因素,为探索干预策略提供参考。方法 采用便利抽样法抽取就诊于伤口造口门诊的130例输尿管皮肤造口患者,采用一般资料调查表、患者报告结局的经济毒性综合评分量表、恐惧疾病进展简化量表、患者健康问卷抑郁量表进行调查。结果 输尿管皮肤造口患者经济毒性发生率为86.15%,经济毒性总分为23.00(17.00,25.00)分;相关性分析结果显示,恐惧疾病进展水平、抑郁水平与经济毒性呈正相关(均P<0.01);多元线性回归结果显示,恐惧疾病进展、抑郁、年龄、家庭人均月收入、医保类型、到达医疗机构的乘车时间是患者经济毒性的影响因素(P<0.05,P<0.01)。结论 输尿管皮肤造口患者经济毒性阳性率较高,在临床工作中应特别关注年轻、低收入、未参保、到达医疗机构的乘车时间较长的输尿管皮肤造口患者经济毒性的评估,对高危患者进行早期干预,防止因经济毒性引起不良结局事件。     

Continent cutaneous urinary diversion: long-term follow-up of more than 800 patients with ileocecal reservoirs

We report the clinical outcome of more than 800 patients, who underwent continent cutaneous urinary diversion with an ileocecal reservoir (Mainz-pouch I) in two urological tertiary referral centers at a mean follow-up of 7.6 years. Complications related to the continence mechanism (intussuscepted ileal nipple vs. submucosally embedded in situ appendix) and the antirefluxive uretero-intestinal anastomosis (submucosal tunnel vs. serosa-lined extramural tunnel) were recorded retrospectively. Stomal stenosis was observed in 23.5% of the patients with appendix stoma and in 15.3% of the patients with intussuscepted ileal nipple. The incidence of calculi was 10.8% in reservoirs with intussuscepted ileal nipple and 5.6% in reservoirs with appendix stoma. Eleven patients (eight with appendix, three with ileal nipple) required reoperation because of ischemic degeneration of the continence mechanism. The overall continence rate (day and night) was 92.8%. Anastomotic strictures of the afferent limb occurred in 6.5% of renal units (RUs) with a submucosal tunnel and in 5.0% of RUs with a serosa-lined extramural tunnel. Continent cutaneous urinary diversion with an ileocecal pouch is a highly satisfactory and safe option for patients, in whom orthotopic urinary diversion is impossible or contraindicated.     

A modified technique of tubeless anaesthesia for microlaryngoscopy and bronchoscopy in young children with stridor

Sixty children including neonates and infants, with stridor undergoing investigations under general anaesthesia, were studied retrospectively. General anaesthesia was induced using an inhalational technique with halothane and was maintained with propofol infusion without the use of tracheal intubation. The ages ranged from three days to two years and five months. In most of the cases after propofol infusion, there was a slight drop in blood pressure without change in heart rate. This modified technique was found to be satisfactory in most of the cases.     

Experience with coapted gastric tube outlet and composite gastrointestinal reservoir for continent cutaneous urinary diversion

PURPOSE: Established techniques for urinary diversion are not ideal for certain patients such as those with extensive pelvic irradiation, metabolic acidosis, short bowel syndrome or renal insufficiency. In a multi-institutional study a gastrointestinal reservoir was previously found to provide metabolic balance in such patients. We used a coapted gastric tube as the continent outlet in patients undergoing gastrointestinal urinary diversion. We evaluate the long-term functional results of the gastric tube to provide continence and report our long-term followup results. MATERIALS AND METHODS: A composite reservoir was constructed from gastric and transverse colon or ileal segments. In addition, a gastric strip, in continuity with the gastric segment of the composite reservoir, was tubularized and coapted to provide the continence mechanism. RESULTS: A total of 19 patients with a gastrointestinal reservoir and coapted gastric tube outlet were followed for 24 to 101 months, of whom 18 are continent day and night on intermittent catheterization every 3 to 8 hours. Four of 34 ureters (12.5%) became obstructed. One patient had significant preoperative renal insufficiency, which progressed to end stage renal disease. Another patient had slow progression of renal insufficiency. In the remaining 17 patients mean serum creatinine did not change significantly while serum chloride and bicarbonate improved or remained normal. CONCLUSIONS: A coapted gastric tube functions well as the continence mechanism in patients with a gastrointestinal urinary reservoir. We also confirm the metabolic advantages of a composite gastrointestinal urinary reservoir. Gastrointestinal cutaneous urinary diversion can be an alternative to incontinent diversion in select patients who are not suitable for other forms of diversion.