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Cutaneous Ureterostomy. Gary P. Kearney MD FACS. # Patients. 30 Patients 13F 17M Age Range = 20-79 Mean age = 66 yrs Excluding 3 patients < 40 yrs Mean age = 70 yrs. Surgical options. Cutaneous ureterostomy Bilateral Cutaneous ureterostomy

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cutaneous ureterostomy

Cutaneous Ureterostomy

Gary P. Kearney MD FACS

patients
# Patients

30 Patients

13F 17M

Age Range = 20-79

Mean age = 66 yrs

Excluding 3 patients < 40 yrs

Mean age = 70 yrs

surgical options
Surgical options

Cutaneous ureterostomy

Bilateral Cutaneous ureterostomy

Cutaneous ureterostomy with contralateral nephrectomy

Cutaneous ureterostomy with contralateral renal embolism

Cutaneous ureterostomy with transureteroureterostomy

renal function
Renal Function

No Deterioration

Renal pelvis dilates – 20-30cc

Low pressure system

Cultures+/- +No Rx

Uses 5-8F. Feeding tub to assist

Serum creatinine & creatinine clearance to follow

Ultrasound not useful

complications
Complications

Acute tubular necrosis -1

Stomal stenosis -1

Loss of solitary kidney Dialysis -1

Operative mortality Stroke -1

Obstructed stent -1

primary diseases
Primary Diseases

Primary diagnosis of patients with Cutaneous Ureterostomy

Tumor # Patients

Cervical Carcinoma 7

Carcinoma of Bladder 13

Rectal Carcinoma 4

Carcinoma of Prostate 4

Carcinoma of Testes 1

Carcinoma of Ovary 1

operative technique
Operative Technique

Surgical options

Preoperative preparations

Stomal site selection

Nephropexy

Ureteral Stoma

Stomal appliance

Intraoperative considerations

preoperative preparation
Preoperative preparation

Percutaneous nephrostomy

Hyperalimentation

Trial of ureteral stent

Cutaneous Ureterostomy is an elective procedure

stomal site selection
Stomal site selection

Patient selected sitting

Right or Left upper quadrant

Skin devoid of wrinkles of scars

Site easily managed by appropriate patient

past problems
Past problems

Retraction of ureter

Abcess

Urinoma

surgical technique
Surgical technique

One inch subcoastal incision

Rib resection not required

Extraperitoneal procedure (take care anteriorly)

Dissect Gerota’s fascia completed but not vascular pedicle

Rotate lower pole to lie directly anteriorly

Make sure ureter assumes a short straight course to skin

Renal capsulotomy 2-3 inches on inferior surface

Complete nephropexy to anterior or lateral abdominal wall (6-8

sutures)

Fashion skin pedicle & incise ureter 2cm

Suture skin flap to apex of spatulated ureter with 5-0

Dexon/Vicryl

Use diversion stent - 7F

nephropexy
Nephropexy

Method of George Prather MD

Importance of procedure can not be over emphasized

Provides fixation of kidney and prevents retraction of ureter and

stomal stenosis

Renal capsule is stripped back where possible to promote

adherence to abdominal wall

ureteral stoma
Ureteral Stoma

Turned back ureter is brought through anteriorly, spreading

rectus muscle, anterior rectus fascia large enough to

admit the index finger

Ureter should extend 1.5-2cm beyond skin surface

Using skin flap technique increases surface area of stoma

& helps prevent stomal retraction and stenosis

stomal appliance
Stomal appliance

Base of skin pedicle arises from 12 o'clock position when patient

is viewed standing.

Conduit collection devise has small diameter opening.

Single belt can be used for bilateral ureterostomies

Single stomas are to be encouraged where possible

intra op considerations
Intra-op considerations

Historically Mannitol 12.5gms used to promote diuresis

Minimize manipulation of kidney to avoid injury to vasculature

Stage diversion where necessary in bilateral cases

Sacrifice contralateral kidney by nephrectomy to gain single

stoma when renal function is adequate

Embolization has been effective when patient condition

precludes a second operation

expanded indications
Expanded Indications

Solitary kidney

Extended life expectancy in high risk patients

palliative diversion
Palliative Diversion

Classic indication

Poor surgical risk

Limited life expectancy

types
Types

In-Situ (ISU)

Loop (LCU)

End Cutaneous

recent considerations
Recent Considerations

Newer antegrade and retrograde catheters frequently allow

placement of indwelling ureteral stents.

Percuatenous nephrostomy drainage allow elective

consideration of permanent diversion

Current patients represent a subset who are healthy enough

to survive past above diversionary techniques with

long-term complications of sepsis, obstructed stents, dislocation

of nephrostomy tubes etc.