A cutaneous ureterostomy, also called ureterocutaneostomy, is a surgical procedure that detaches one or both ureters from the bladder, and brings them to the surface of the abdomen with the formation of an opening (stoma) to allow passage of urine.
The bladder is the membranous pouch that serves as a reservoir for urine. Contraction of the bladder results in urination. A ureterostomy is performed to divert the flow of urine away from the bladder when the bladder is not functioning or has been removed. The following conditions may result in a need for ureterostomy.
Bladder disorders afflict millions of people in the United States. According to the American Cancer Society (ACS), there were 54,200 new cases of bladder cancer in 1999, with approximately 12,100 deaths from the disease. Bladder cancer incidence is steadily rising, and by 2010 it is projected to increase by 28% for both men and women.
Urostomy is the generic name for any surgical procedure that diverts the passage of urine by re-directing the ureters (fibromuscular tubes that carry the urine from the kidney to the bladder). There are two basic types of urostomies. The first features the creation of a passage called an "ileal conduit." In this procedure, the ureters are detached from the bladder and joined to a short length of the small intestine (ileum). The other type of urostomy is cutaneous ureterostomy. With this technique, the surgeon detaches the ureters from the bladder and brings one or both to the surface of the abdomen. The hole created in the abdomen is called a stoma, a reddish, moist abdominal protrusion. The stoma is not painful; it has no sensation. Since it has no muscles to regulate urination, urine collects in a bag.
There are four common types of ureterostomies:
Ureterostomy patients may have the following tests and procedures as part of their diagnostic work-up:
The quality, character, and usable length of the ureters is usually assessed using any of the following tests:
The pre-surgery evaluation also includes an assessment of overall patient stability. The surgery may take from two to six hours, depending on the health of the ureters, and the experience of the surgeon.
After surgery, the condition of the ureters is monitored by IVP testing, repeated postoperatively at six months, one year, and then yearly.
Following ureterostomy, urine needs to be collected in bags. Several designs are available. One popular type features an open bag fitted with an anti-reflux valve, which prevents the urine from flowing back toward the stoma. A urostomy bag connects to a night bag that may be attached to the bed at night. Urostomy bags are available as one- and two-piece bags:
The complication rate associated with ureterostomy procedures is less than 5–10%. Risks during surgery include heart problems, pulmonary (lung) complications, development of blood clots (thrombosis), blocking of arteries (embolism), and injury to adjacent structures, such as bowel or vascular entities. Inadequate ureteral length may also be encountered, leading to ureteral kinking and subsequent obstruction. If plastic tubes need inserting, their malposition can lead to obstruction and eventual breakdown of the opening (anastomosis). Anastomotic leak is the most frequently encountered complication.
Normal results for a ureterostomy include the successful diversion of the urine pathway away from the bladder, and a tension-free, watertight opening to the abdomen that prevents urinary leakage.
The outcome and prognosis for ureterostomy patients depends on a number of factors. The highest rates of complications exist for those who have pelvic cancer or a history of radiation therapy.
In one study, a French medical team followed 69 patients for a minimum of one year (an average of six years) after TUU was performed. They reported one complication per four patients (6.3%), including a case requiring open drainage, prolonged urinary leakage, and common ureteral death (necrosis). Two complications occurred three and four years after surgery. The National Cancer Institute performed TUU for pelvic malignancy in 10 patients. Mean follow-up was 6.5 years. Complications include common ureteral narrowing (one patient); subsequent kidney removal, or nephrectomy (one patient); recurrence of disease with ureteral obstruction (one patient); and disease progression in a case of inflammation of blood vessels, or vasulitis (one patient). One patient died of sepsis (infection in the bloodstream) due to urine leakage at the anastomosis, one died after a heart attack, and three died from metastasis of their primary cancer.
There are several alternative surgical procedures available:
Door Mullen, B. & K. A. McGinn. The Ostomy Book: Living Comfortably With Colostomies, Ileostomies, and Urostomies. Boulder, CO: Bull Publishing Co., 1992.
Jeter, K. F. Urostomy Guide. Irvine, CA: American Urological Association, code 05-006.
Cedillo, U., C. Gracida, R. Espinoza, and J. Cancino. "Vesical Augmentation and Continent Ureterostomy in Kidney Transplant Patients." Transplant Proceedings 34 (November 2002): 2541-2.
Hiratsuka, Y., T. Ishii, H. Taira, and A. Okadome. "Simple Correction of Ureteral Stomal Stenosis for Cutaneous Ureterostomy." International Journal of Urology 10 (March 2003): 180-1.
Purohit, R. S., and P. N. Bretan, Jr. "Successful Long-term Outcome Using Existing Native Cutaneous Ureterostomy for Renal Transplant Drainage." Journal of Urology 163 (February 2000): 446-9.
Yoshimura, K., S. Maekawa, K. Ichioka, N. Terada, Y. Matsuta, K. Okubo, and Y. Arai. "Tubeless Cutaneous Ureterostomy: The Toyoda Method Revisited." Journal of Urology 165 (March 2001): 785-8.
American Urological Association (AUA). 1120 North Charles Street, Baltimore, MD 21201. (410) 727-1100. http://www.auanet.org .
United Ostomy Association (UOA). 19772 MacArthur Blvd., #200, Irvine, CA 92612-2405. (800) 826-0826. http://www.uoa.org .
Monique Laberge, Ph.D.
Ureterostomy is performed in a hospital setting by experienced surgeons trained in urology, the branch of medicine concerned with the diagnosis and treatment of diseases of the urinary tract and urogenital system. Specially trained nurses called wound ostomy continence nurses (WOCN) are commonly available for consultation in most major medical centers.