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.     

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.     

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.     

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.     

Modified technique for improving tubeless cutaneous ureterostomy by Ariyoshi method

Objectives:   The cutaneous ureterostomy is the simplest urinary diversion method; however, it often causes stomal stenosis, requiring sustained catheterization with regular catheter exchange. In an attempt to prevent stomal stenosis after surgery, the fascia (S-U fascia) between the spermatic cords and the ureters, which is usually cut off, was preserved. The remaining capillaries in the fascia could supply blood to the ureters, which is one of the most important factors for ureter patency.
Methods:   In 58 patients (93 renal units) undergoing cutaneous ureterostomy, 36 patients (66 renal units) were treated by the modified technique.
Results:   The surgeries carried out with the modified technique were significantly different in the type of operation, the side relationship, and the catheter-free rate using the univariate analysis by means of the predicted tests, in comparison with 22 patients (27 renal units) that were treated with the conventional technique. Multivariate analysis for the type of operation determined that of the side relationship and the method, only the latter was a significant factor. The modified method allowed ∼90% of the patients to have a catheter-free life; otherwise 74% of the patients had stomal stenosis, followed by catheterization.
Conclusion:   The presented cutaneous ureterostomy technique to preserve the fascia is useful not only to prevent stomal stenosis and maintaining good quality of life without catheterization, but also to apply to other types of ureter surgery.     

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.     

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。     

Combined urinary and fecal diversion using a no bowel anastomosis technique

PURPOSE: We present the experience at our institution with combined fecal and urinary diversion using 3 variations of a no anastomosis technique that avoids bowel anastomosis. MATERIALS AND METHODS: The charts of 10 female and 2 male patients who underwent the no bowel anastomosis technique were identified and reviewed. Information on the etiology of urination and defecation abnormalities, surgical resolution, complications, hospital stay and other pertinent aspects of management were retrospectively reviewed. RESULTS: Mean patient age was 64 years (range 36 to 83). Of the 12 patients 7 had a history of cancer treated with external beam radiotherapy, while 4 had neurological disorders with combined fecal and urinary incontinence or a history of colostomy. Mean hospital stay was 14.6 days (range 6 to 31) and mean followup was 26.6 months (range 14 to 52). There were no postoperative deaths, although a nonQ wave myocardial infarction occurred in 1 patient. CONCLUSIONS: The no anastomosis technique of combined diversion is recommended in patients with preexisting or planned diversion of the fecal stream. Avoidance of bowel anastomosis makes this technique especially advantageous in those with a history of radiotherapy.     

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.     

Refluxing ureterointestinal anastomosis for continent cutaneous urinary diversion

PURPOSE: We question the statement that anti-refluxing ureteral implantation is mandatory in low pressure, high capacity reservoirs. In a series of patients with ureteral obstruction after implantation with an anti-refluxing submucosal tunnel reimplantation was performed as a direct ureter-pouch anastomosis. The same technique was used for primary anastomosis in a later group of patients as the method of choice for ileocolic and colonic continent urinary diversion. MATERIALS AND METHODS: Direct ureteral reimplantation was performed in 10 patients in whom a total of 19 obstructed renal units were associated with an ileocolic reservoir. The retroperitoneal supracostal approach was used to avoid complications caused by repeat laparotomy. The ileocecal reservoir was opened superior and the obstructed ureter was identified and reimplanted via a buttonhole. The same technique was used for primary anastomosis in 20 patients (40 renal units), in whom the ureter was implanted in an ileocecal (10) or colonic (10) pouch. RESULTS: Postoperatively complications did not develop in any patient. Radiography of the pouch postoperatively showed renal reflux in only 1 renal unit. In the group with reimplanted ureters median followup was 81 months (range 10 to 120). Of the 19 obstructed ureters 14 returned to normal, while 5 showed persistent grade I dilatation. Median followup in patients with primary direct ureteral anastomosis was 20 months (range 2 to 36). Of the 22 preoperatively dilated systems 20 returned to normal and none of the 18 nondilated systems was obstructed. CONCLUSIONS: Direct ureter-pouch reimplantation proved to be simple and safe. When performed primarily for continent urinary diversion, the anastomosis was anti-refluxing in pouches with high capacity and low pressure. The advantage of this technique is the low risk of ureteral obstruction and subsequent deterioration in kidney function.     

Management of benign ureteral strictures following radical cystectomy and urinary diversion for bladder cancer

PURPOSE: Ureteral obstruction due to benign strictures is a significant complication of radical cystectomy and urinary diversion for bladder cancer that can lead to renal function loss and infection related morbidity. Treatment may be performed surgically or with minimally invasive techniques. We describe the 10-year experience at our department with various treatment modalities for post-cystectomy benign strictures. MATERIALS AND METHODS: The study group consisted of 28 patients treated for benign ureteral strictures following radical cystectomy for bladder cancer. Their medical records were reviewed for clinical presentation, diagnostic procedures, treatment and long-term outcome. RESULTS: The study group represented 12.7% of all 221 patients treated at our department with radical cystectomy for bladder cancer in 1994 to 2004. Ureteral strictures were asymptomatic in 71.4% of cases. Median time to diagnosis was 7.0 months and 75% of the patients were diagnosed within year 1 after cystectomy. Treatment consisted of stenting, dilation and open surgical revision with removal of the strictured segment and reanastomosis. Median followup was 62.5 months. The stenting procedures served as the long-term definitive treatment in 45% of cases, whereas balloon dilation uniformly failed. Although open surgical revision was technically challenging, it had a long-term success rate of 93%. CONCLUSIONS: Benign ureteral strictures commonly occur during postoperative year 1 and they are usually asymptomatic. Early diagnosis and prompt drainage are required to prevent consequent renal parenchymal loss and infectious complications. Although minimally invasive procedures are viable treatment alternatives, open surgical revision is still the preferred long-term definitive treatment.     

The ureter as a pedicle for construction of a ureteral urethra: the double tunnel

PURPOSE: Clean intermittent self-catheterization has been shown to be an effective method for the prevention of upper tract urinary disease in patients who are unable to void efficiently. When the urethra is not available for catheterization surgeons can construct a catheterizable channel from the appendix or retubularized bowel. However, for patients without an appendix and limited bowel segments we have reimplanted the ureter to prevent reflux and tunneled the distal portion of the same ureter to construct a catheterizable stoma, the "double tunnel." MATERIALS AND METHODS: We retrospectively reviewed our 10-year experience with the double tunnel ureteral pedicle. A total of 10 patients (8 girls and 2 boys) were included in this study. The left ureter was used in 7 cases and the right ureter was used in 3. Mean followup for these patients was 4.1 years, with a range of 0.5 to 8.5 years. Outcome measures included intraoperative complications, reoperation rates, postoperative complications and upper urinary tract deterioration. RESULTS: There were no intraoperative complications. Furthermore, there were no cases of stomal stenosis or strictures that required reoperation or excision of the ureteral pedicle in the followup period. In our cohort the renal function associated with the ipsilateral double tunnel ureteral pedicle remained stable or improved. All patients reported that their catheterizable stoma is still functional. CONCLUSIONS: The double tunnel ureteral pedicle provides another option in the urological armamentarium when there are minimal resources with which to construct a catheterizable stoma.     

Efferent tube suspension as a continent diversion mechanism: a preliminary report of a clinical study

PURPOSE: We constructed a reliable continent tube that is surgically simple. MATERIALS AND METHODS: In 12 patients with malignant bladder tumor we performed radical cystectomy with isolation of a 50 cm. ileal loop with pedicle. The proximal segment (8 to 10 cm.) was tapered over a 16Fr catheter as an efferent tube, the remaining segment was detubularized to create a W-shape pouch and the tapered ileum was fixed to the back surface of the rectus muscle with 2 polyester tapers 1 cm. wide with a suspension tension of 500 g. The external orifice of the tapered ileum was anastomosed to the umbilicus. In 2 patients with neuropathic bladder a 15 cm. ileal loop with pedicle was isolated, the proximal segment (8 cm.) was tapered as an efferent tube with 500 g. suspension tension, and the remaining segment was detubularized and anastomosed to the bladder. RESULTS: The patients were followed for 6 to 17 months (mean 11.4) and were completely continent day and night. The stoma was easily catheterized with a 16Fr catheter in all cases. Urodynamic study of the efferent tubes revealed maximum pressure of 84 to 159 cm. water (mean 114). Retrograde radiography of the efferent tubes demonstrated perfect canalization without stenosis. CONCLUSIONS: This study suggests that the continent mechanism of the tapered ileum can be greatly enhanced by a suspension technique. This maneuver also provides easy catheterization and surgical simplicity.