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.     

Improved technique of tubeless cutaneous ureterostomy and results of permanent urinary diversion

An improved technique of tubeless cutaneous ureterostomy through a single stoma was devised by modifing the traditional cutaneous ureterostomy. Using this method, urinary diversions were performed on 12 cases with malignancies: 6 had radical cystectomy and the other 6 had pelvic exenteration. Normal bilateral ureters were observed in 11 cases in preoperative intravenous pyelography. Stomal stenosis was found in 1 case (8.3%) requiring operative stomal revision. Generally satisfactory results were obtained. This method could lower the incidence of complications. A long-term follow-up is needed, but 2 cases who have survived for more than 4 years since the operation have shown excellent results. It was thought that it would be difficult to perform tubeless cutaneous ureterostomy on normal-sized ureters, but our clinical results indicate that this method may be able to provide permanent urinary diversion.     

Tubeless cutaneous ureterostomy through a single stoma with new extraperitoneal ureteral route up to stoma

Tubeless cutaneous ureterostomy through a single stoma has been said to be difficult to establish in patients with normal ureters or normal ureters combined with thick fatty abdominal wall, because of the poor blood supply at the end of the ureters. The technical improvements observed were as follows: 1) The peritoneal fold and the upward traction of the gonadal vessels decrease the ureteral tension and keep the blood supply to the ureters in the extraperitoneal approach. 2) The gonadal vessels and its surrounding tissue, covering the subcutaneous fatty tissue, help the ureteral adhesion at the anastomotic site. 3) Full diminution of the skin defect caused by flap formation, decreases the horizontal tension of the side-to-side anastomized ureters. Sixteen patients with normal ureters underwent this procedure. In a short-term (4-37 months) observation, 4 of the patients, including one with thick abdominal fat, showed unilateral hydronephrosis and 2 patients unilateral non-function kidney. The remaining 10 patients had no complications. Moreover, all the patients have kept their ureterostomies tubeless and their serum blood urea nitrogen and creatinine levels were within normal limits except for one patient. It is reasonably concluded that the new method will result in success clinically even in patients with normal ureters and thick abdominal fatty tissue.     

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.     

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.     

Urinary re-diversion from cutaneous ureterostomy to ileal conduit: report of a case

A 73-year-old man, who underwent bilateral cutaneous ureterostomy following total cystectomy due to tumor, was admitted because he had been suffering from complications, such as pyelonephritic attacks, plugging and removal of the indwelling catheters and pain around the stoma. In order to relieve these complications, ileal conduit construction was performed although the length of ureters was thought to be short for ureteroileostomy. However, it was done easily by making ileal segment twice as long as usual and this conduit neither disturbed the serum electrolyte levels nor deteriorated renal function. Re-diversion to ileal conduit resulted not only in relief from the complications associated with cutaneous ureterostomy but also in improvement of the quality of life for the patient.     

Cutaneous ureterostomy in adults.

In the patient with metastatic carcinoma, urinary diversion is usually achieved with indwelling ureteral stents or placement of a percutaneous nephrostomy tube. Most forms of surgical diversion carry an unacceptable morbidity rate, especially in the debilitated patient. Over a fifteen-year period (1974-1989), 29 adult patients with pelvic malignancy (32 ureters) underwent palliative cutaneous ureterostomy. This previously reported technique involves transverse nephropexy and construction of a stoma using a small skin flap. Indications included ureteral obstruction or severe urinary tract symptoms. Hydroureter, often considered a precondition for this procedure, was not present in several patients and was not a prerequisite to success. Complications related to the procedure included one postoperative death due to stroke, one death due to uremia and sepsis, and one instance of severe renal arterial stenosis resulting in renal failure. Preservation of renal function was possible in the 10 patients known to have survived from one to thirteen years postoperatively; only 3 patients eventually required stomal revision. By adherence to the surgical techniques described, the usually high incidence of stomal stenosis was avoided. Our experience reveals that although the indications for cutaneous ureterostomy are limited, this procedure can provide an alternative to permanent nephrostomy drainage or to a higher risk intestinal urinary diversion in carefully selected patients with a reasonable life expectancy.     

Upper tract management when posterior urethral valve ablation is insufficient.

Of 105 boys with posterior urethral valves managed during a 10-year period most were managed by primary valve ablation. However, 39 of these boys required concomitant or additional procedures to 71 massively dilated ureters because of azotemia, infection and/or progressive upper tract deterioration. In 17 boys 25 ureters could be reconstructed primarily by varying degrees of ureteral tailoring. When there was severe infection, azotemia and/or doubt as to the function of the affected renal unit, staged reconstruction was initiated by cutaneous ureterostomy. One-fourth of these ureterostomy diverted children died of azotemia despite free urinary drainage. Those who went on to have staged reconstruction, despite multiple surgical procedures, retained intact urinary systems with acceptable function.     

Evaluation of the free nipple method in cutaneous ureterostomy

Cutaneous ureterostomies, in which urostomas were made by a free nipple method, were performed on 14 ureters of 10 patients. The free nipple method was evaluated from the standing point of stoma care. Catheterless cutaneous ureterostomy was applied in 8 of the 10 patients. Six patients had to have catheters, and the catheter was not needed in 2 patients. The reasons for reindwelling the catheter in 6 patients were: 1) the urostoma had come to be at skin level by disturbance of blood supply for the ureter, and 2) urine puddled just on the urostoma and oozed out between the skin and Varicare flange. It may be concluded that the free nipple method is not satisfactory as urostoma in cutaneous ureterostomy for advancing the quality of life of the ostomate. A further study is in progress.     

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。     

Loop cutaneous ureterostomy as a method of urinary diversion in the adult.

A loop cutaneous ureterostomy was performed as an emergency treatment in 6 patients with bladder or prostatic cancer. Out of 9 operated ureters, only one stenosis was observed. Infection is a possible complication which can sometimes alter the renal function.     

An improved non-intubated cutaneous ureterostomy technique for the normal and dilated ureter.

Cutaneous ureterostomy is a simple procedure to perform but is attended by high morbidity owing to recurring abscesses, strictures and stenosis of the stoma. An improved technique applied to the diversion of 4 normal renal units and 3 dilated ureters is described. We have not experienced the complications mentioned in previous studies and none of the patients has required ureteral intubation in this small series with a 3-year followup.     

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.     

Ring ureterostomy.

A method is described for temporary cutaneous ureterostomy which combines the advantage of loop ureterostomy with a well vascularised stoma with those of the Sober Y operation allowing easy restoration of ureteric integrity.     

Bilateral ureterocutaneostomy with modified stoma: long-term follow-up

Ileal conduit and orthotopic bladder substitution have been the preferred options for urinary diversion after cystectomy. Self-catheterisation has revolutionised the management of neuropathic bladder. However, ureterocutaneostomy (cutaneous ureterostomy) described as a means of supravesical urinary diversion 40 years ago still has a definite role for both temporary and permanent diversion particularly in the developing countries. We present a small series of cutaneous ureterostomies performed in four children who have now grown up to become adults without being undiverted. We discuss the technique that we used to modify the stoma, which helped prevent stomal complications over the long term. Our results we believe will rekindle the interest in cutaneous ureterostomy as a viable option for permanent urinary diversion. Four children between ages 2 and 16 years had bilateral side-to-side single stoma tubeless end cutaneous ureterostomy as a primary procedure for permanent urinary diversion. The stoma was modified to prevent retraction and stenosis. Long-term follow-up is presented. All the children have grown up to become adults with their ureterocutaneostomies functioning very well. There have been no biochemical or mechanical complications. Only one out of four stomas had to be refashioned. A simple collection device has proved successful in maintaining a watertight drainage system without apparent problems. Bilateral side-to-side single stoma end cutaneous ureterostomy with modification of the stoma by a plastic surgical technique can help achieve a non-retracting stoma on which a collection device can snuggly fit. It is a viable option for permanent urinary diversion without any significant complications. It is simple, easy and highly practical way of managing urinary diversion especially in the developing countries.     

A successfully treated case of aortouretric fistula associated with pelvic exenteration

A 64-year-old man was hospitalized for massive bleeding from the cutaneous ureterostomy. He had undergone pelvic exenteration with the ureterostomy for rectal cancer invading the bladder five months previously and retrograde ureteric catheters were inserted bilaterally into the ureters. An aortography revealed a pseudoaneurysm of the abdominal aorta in the region transversed by the left ureter. He was successfully treated by en bloc resection of the aortoureteric fistula and the left ureter and repair of the aorta by Dacron patchplasty. Left nephrectomy was also performed because of pyelonephritis. He has had no signs of cancer recurrence or graft infection five years after this operation.     

腹腔镜下膀胱癌根治术中完全腹膜外经皮输尿管造口术

目的 介绍一种腹腔镜下膀胱癌根治术中,完全腹膜外输尿管造口新技术,评价其治疗一例T₄期高级别膀胱浸润性尿路上皮癌患者的疗效。方法 以1例75岁男性高级别膀胱浸润性尿路上皮癌(T₄N₀M₀)为例,介绍一种腹腔镜下膀胱根治性切除术中,完全腹膜外输尿管造口技术的4个关键步骤,包括游离输尿管(将左侧输尿管游离足够长度)、汇集两根输尿管(腹腔镜下将左侧输尿管经直肠后方拉至右侧)、建立腹膜外通道(游离扩大右侧腹膜外间隙,将两根输尿管从此通道拉出)、腹膜重建。结果 手术共耗时(从消毒铺单开始计时到输尿管造口结束)248 min,出血量100 ml,造口处可见清晰尿液流出,患者术后住院时间8 d。结论 本例输尿管造口术是一种完全腹腔镜下经皮输尿管造口技术的尝试,相较于传统输尿管造口术而言,该术式创伤小,出血量少,术后恢复时间缩短。对于需要永久性尿流改道,但心肺功能差,手术风险高或没有机会做肠道尿流改道的患者,该术式是一种可行且安全的尿流改道方式。     

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.     

Reimplanted ureter as an alternative to the catheterizable Mitrofanoff tube

OBJECTIVE: We performed this study in dogs to investigate whether a ureter can be used as an alternative to the appendix without disrupting the uniformity of the gastrointestinal system. MATERIALS AND METHODS: This study comprised 10 adult healthy female mongrel dogs. The procedure was done in 2 stages: in the first stage, we performed a left-end cutaneous ureterostomy at the lower left quadrant just above the inguinal ligament. A second operation was performed 6 weeks later. The left ureter was divided and using Paquin's technique, the proximal end of the distal third of the left ureter was reimplanted in the anterolateral surface near the dome of the bladder. A high transureteroureterostomy with the remaining left proximal ureter to the opposite ureter completed the reconstruction. The bladder neck was ligated in order to create an experimental bladder outlet obstruction. At the time of creating the distal ureteral stoma, a feeding tube was left in the bladder, passing through the ureterostomy stoma and sutured to the skin. This catheter remained in place for 20 days, preventing the bladder form distending. Then in the following 6 months, intermittent catheterization was applied through the stoma at 3- to 4-hour intervals. Exploration was performed at the end of the 6th month. RESULTS: No animal died. The dogs were still continent. Intravenous urography, urea and creatinin values were normal. The ureteral stoma was viable in all 10 cases. Stenosis of the ureteral stoma developed in 1 dog and required surgical revision. Possible traumatic effects were investigated by histological sections, but no harmful effects were found at the ureteral endothelium. CONCLUSION: This method may be an alternative to the Mitrofanoff method, which uses the appendix.