Stomal Stenosis After Cutaneous Ureterostomy: Etiology and Management

Vol. 105, Jan. Printed in U.S.A.

THE JouRNAL OF UROLOGY

Copyright© 1971 by The Williams & Wilkins Co.

STO:VIAL STENOSIS AFTER CUTANEOUS URETEROSTOMY: ETIOLOGY AND MANAGEMENT A. SHAFIK From the Department of

Faculty of Medicine, Cairo University, Egypt, United Arab Republic

Stomal stenosis is one of the main complications of cutaneous ureterostomy_L 2 Stenosis causes ureteral obstruction and ascending renal infection. Herein is reported the etiology and management of ureterostomy stenosis in 110 cases of cutaneous ureterostomy performed for bladder cancer-100 cases as a combined operation with radical cystectomy and 10 cases as a palliative diversion for advanced cases (see table). Bilateral cutaneous ureterostomy was done in 20 cases and cutaneous ureteroureterostomy3 was done in 90 cases (70 double-barrel ureterostomies, 15 end-to-side ureterostomies and 5 side-to-side ureterostomies) (fig. 1). Four techniques were used for anastomosis of the ureter to the skin: 1) direct anastomosis (fig. 2), 2) free-nipple anastomosis (fig. 3), 3) everted-nipple anastomosis (fig. 4) and 4) cuff anastomosis (fig. 5). In cuff ureterostomy a disk of bladder wall, ¾ cm. in diameter, is preserved around each ureteral orifice. 4 The technique is performed on vesical tumors away from the trigone.

bilization results in devascularization of the ureter. The ureter receives its arterial supply, segmentally, through its bed, and the vessels either form a plexus in the ureteric adventitia (plexiform pattern) or collect into one or two longitudinal arterial channels (channel pattern) that lie in the adventitia along one or both sides of the ureter or in its pseudo-mesentery (fig. 6). 5 Interference with the plexus or the arterial Stomal stenosis after cutaneous ureterostomy: 110 cases Stenosis No. Cases No. Cases % Techniques of cutaneous ureterostomy: Bilateral cutaneous ureterostomy Double-barrel ureterostomy after crushing

45

20

70

spur

End-to-side ureterostomy Side-to-side ureterostomy Totals Techniques of ureter-toskin anastomosis: Direct anastomosis Free nipple Everted nipple Cuff anastomosis

ETIOLOGY

The basic cause of stomal stenosis was found to be failure of union per primam between the skin and ureteral mucosa because of 1) avascularity of the distal end of the ureter, 2) tension on the suture line and/or 3) improper technique of ureter-to-skin anastomosis. These factors can lead to deterioration of the suture line, healing by granulation, and stenosis. Interference with ureteral vessels during mo-

Totals

15

6 0

40 0

17

15.4

18

10

55.5

12 10

0 0

0 0

l!O

17

15.4

110

70

10

channels during mobilization leads to ureteric ischemia. Use of the diathermy, application of crushing clamps to the end of the ureter, introduction in the ureter of large-sized, badly-fitting catheters and superimposition of sepsis all assist in devascularization of the ureter. Furthermore, the type of implanted ureter is important during mobilization. The thickened hypertrophied ureter which is dilated and has a hypertrophied muscle coat is best for mobilization and anastomosis because of its high vascularity. This type of ureter holds the stitches of anastomosis well.

Accepted for publication December 10, 1969. 1 Rinker, J. R. and Blanchard, T. W.: Improvement of the circulation of the ureter prior to cutaneous ureterostomy. J. Urol., 96: 44, 1966. 2 Williams, D. I. and Rabinovitch, H. H.: Cutaneous ureterostomy for the grossly dilated ureter of childhood. Brit. J. Urol., 39: 696, 1967. 3 Shafik, A.: Cutaneous uretero-ureterostomy. A simplified technique for urinary diversion. Brit. J. Urol., 40: .568, 1968. 4 Shafik, A.: Cuff ureterostomy. A technique of ureteric implantation to avoid stenosis. J. Egypt. Surg. Soc., 4: 4, 1969.

5 Mehrez, I. and Shafic, A.: Arterial supply of the ureters. New study. Kasr-EI-Aini J. Surg.,

7: 443, 1966.

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SHAFIK

A

DOUBLE-BARREL URETEROSTOMV

B

SIDE-TO-SIDE URETERO~URETEROSTOMY

C

ENO-TO-SlOE URETERO-URETEROSTOMY

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FIG. 1. A, double-barrel ureterostomy. B, side-to-side ureteroureterostomy. C, end-to-side ureteroureterostomy. D, ascending ureterogram shows double-barrel ureterostomy.

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Frn. 2. A, direct anastomosis. B, bilateral cutaneous ureterostomy with direct anastomosis Devascularization, sloughing or stenosis is less likely. Free-nipple anastomosis can be safely done. The thin hydroureter with atrophic wall is less vascular and sloughing and stenosis are more common. The least vascular ureter is the thick, fibrosed, calcified ureter with periureteral adhesions, occasionally encountered in bilharzia!

infestation. Mobilization of this type of ureter is difficult and there is great risk of extensive devascularization. Extensive mobilization of this ureter must be avoided but, if necessary, cautiously performed after identification and preservation of the vascular plexus or longitudinal channels.

STOMAL STENOSIS AFTER CUTANEOUS URETEROSTOMY

67

--

SLOVGr'llNG DEEP

TO SKIN LEVEL

SLOUGHING

RING OF GRANULATJONS

FIG. 3. A, free-nipple anastomosis. B, double-barrel ureterostomy with free-nipple anastomosis (2 weeks postoperatively). C, sloughing of nipples (3 weeks postoperatively).

EVER TED-NIPPLE

MJASTOMOSIS

FIG. 4. A, everted-nipple anastomosis.Band C, double-barrel ureterostomy with everted nipples

Tension on the suture line results from a short ureter or insufficient mobilization. The ureter is shortened by the excision of a segment infiltrated vesical growth or the excision of a stricture

at its lower end. In our series malignant ureteral infiltration was encountered in 3 cases and bilharzial stricture in 30 cases. The trend of some surgeons to limit ureteral mobilization for fear of

68

SHAFIK

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devascularization is another reason that the anastomosis may be under tension. The technique of free nipple ureter-to-skin anastomosis causes the highest incidence of stenosis (55.5 per cent). The nipple will slough either to the skin level or deep into it. Often the nipple may not slough but becomes surrounded by surface granulations (fig. 3, A). Cases of direct anastomosis have a lower percentage of stenosis (10 per cent) which results from either gaping of the wound or sloughing of the ureter (fig. 2, A). No stenosis occurred either in the everted nipple or in the cuff anastomosis. TYPES OF STOMAL STENOSIS

Two types of stenosis could be identifiedsurface and deep. These types should be differ-

entiated smce treatment and prognosis are different. Surface stenosis. A thin ring of fibrous tissue surrounds the most distal end of the ureter. Stenosis is at the skin level and may extend a few millimeters beneath it. The distal end of the ureter is healthy and can be palpated beneath the skin. Surface stenosis results from the gaping of the ureterocutaneous anastomosis and healing by granulations. It may occur in nipple anastomosis due to a ring of fibrous tissue formed around the healthy nipple. Of the 17 cases of stomal stenosis encountered in our series, 11 were of the surface type. Deep stenosis. A tract surrounded by fibrous tissue extends from the skin level through the abdominal wall for a variable distance. The

STOMAL STEKOSIS AFTER CUTANEOUS URETEROSTOMY

ureteral orifice is at the bottom of the tract which may reach U~ inches in length. Deep stenosis is due to the sloughing of the distal end of the ureter by ischemia or to the retraction of the ureter as a result of anastomosis under tension. The tract can be palpated as a firm cord beneath the skin; the distal end of the ureter is not palpable. Of the 17 cases of stomal stenosis 6 were of the deep type. In 2 patients with bilateral cutaneous ureterostomy the stoma on 1 side had closed spontaneously. The kidney on this side was not functioning before the operation. The condition began as a deep stomal stenosis that gradually increased to end in complete closure. This is a result of renal function which did not improve after urinary diversion; therefore, there was no current of urine to keep the fistula opened. In 1 case infection was found which resisted treatment. N ephrectomy was performed.

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suitable for normal, small-calibered and shortened ureters. The best site of the stoma is outside the lateral border of the rectus, below the level of the umbilicus (fig. 7, A). A circular ureterostomy wound is preferred to a vertical incision (fig. 7, B). Treatment. Three methods were used for the treatment of stomal stenosis: 1) reimplantation of the ureter, 2) intermittent dilatation and 3) ureterotomy and dilatation. Reimplantation was performed for deep stomal stenosis in 4 cases. The ureters were dissected out of the skin and abdominal musculature, the stenosed part was excised and the ureters were reimplanted into another area of the skin. Results were discouraging since re-stenosis occurred in all cases because the factors responsible for stenosis are increased by the second implantation. Dissection of the ureter from an area full of fibrous tissue endangers its vascularity. The resection of the stenosed segment may shorten the ureter and MANAGEMEKT put the new anastomosis under tension. In addiSince treatment of stomal stenosis is difficult tion, the new site of the stoma may interfere with the proper application of the collecting bag. the best policy is to prevent its formation. Intermittent dilatation at suitable intervals Prevention. Longitudinal arterial channels should be identified and preserved by mobilizing was carried out on 11 patients-7 with surface the ureter within its adventitia. Tension on the stenosis and 4 with deep stenosis after failure of suture line has to be avoided by sufficient reimplantation. In 2 of the latter cases dilatation ureteral mobilization. Side-to-side ureterostomy was preceded by local injection of cortisone in the and double-barrel ureterostomy with crushing of area of the strictured ureterostomy. In these 2 pathe spur are recommended in normal and small- tients dilatation was continued for a shorter calibered ureters due to the wide ureteral stoma period than in the 2 patients in whom cortisone caused by the union of the distal segments of the was not injected. Cortisone therapy prevents new scar tissue formation and the existing scar tissue 2 ureters. ·when there i~ no trigonal infiltration the best method of ureter-to-skin anastomosis is becomes soft and dilates easily. The results of the cuff ureterostomy. The everted nipple is ad- intermittent dilatation have been gratifying in all vised for tortuous and dilated ureters. The free cases. Ureterotomy was performed in 4 patients with nipple can be safely performed in the thickened hypertrophied ureters. Direct anastomosis 1s surface stenosis. The procedure consists of divi-

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70

SHAFIK

sion of the stenotic ring at 3 and 9 o'clock and intermittent dilatation. It has the advantage of reducing the number of dilatations. The results have been satisfactory. SUMMARY

Etiology and management of stomal stenosis have been studied in llO cases of cutaneous ureterostomy performed for bladder cancer. A

proper functioning ureterostomy depends on careful mobilization of the ureter and proper selection of the method of cutaneous ureterostomy and the technique of ureter-to-skin anastomosis. The importance of meticulous care in fashioning the ureterostomy cannot be overestimated. 2, Talaat Harb St., Cairo, Egypt