Edouard J. Trabulsi, MD, FACS
BASICS
DESCRIPTION
• Urostomy is an incontinent urinary diversion and relies on an external appliance (pouching system) for the collection of urine.
• Urostomy can be made of either small or large intestine, with the distal ileum being the most common bowel segment used:
– Also called ileal conduit, cutaneous ureteroileostomy if made up of ileum
– Colon conduit, if made up of segment of large bowel.
– Very rarely, a urostomy can consist of the ureters being directly anastomosed to the skin (cutaneous ureterostomies). These are uncommon in adults but are sometimes performed in children.
• Complications of the abdominal urinary stoma (urostomy) are the most common problem encountered in the postoperative period in patients undergoing urinary diversion.
EPIDEMIOLOGY
Incidence
• 2.8–19% of patients develop stomal stenosis with ileal conduits.
• 10–20% of patients with colon conduits develop stenosis.
• Parastomal hernia:
– Occurs in 2–6.6% of patients with loop ileostomies
– Rare with end stomas (1–4%)
– More commonly occur with loop stomas (4–20%)
• Nearly all patients will have a stomal-related complication at some point.
Prevalence
N/A
RISK FACTORS
• Obesity
• Chronic cough
• Wound infection
• Abdominal distension
• Malnutrition
• Immunosuppression/steroid use
• Poor surgical technique
• Lack of proper stomal care
• Warm weather, excessive sweating, oily skin may cause the skin barrier adhesive to loosen
• Weight gain or loss can alter the topography of the stoma itself and the surrounding skin that may affect the security of the face plate adherence
Genetics
N/A
PATHOPHYSIOLOGY
• A pouching system (also called an appliance) collects the urine that exits from the stoma:
– 2 styles of pouching systems are available:
Both include an adhesive faceplate, flange, skin barrier, or wafer (the part that sticks to the skin), and a urine collection pouch.
1-piece pouches fused to skin barrier.
2-piece systems have a face plate and a pouch that can be removed from the barrier.
• Patients should be encouraged to empty the pouch as needed but at least every 2–4 hr.
• The faceplate and system should be changed if there is leakage or every 4–7 days depending on individual patient characteristics.
• A properly constructed stoma usually protrudes ∼1.5 cm from the abdominal wall:
– Initially, a properly constructed stoma will be somewhat edematous. It will reduce slightly in size over several weeks following surgery. This means that the initial hole in the faceplate may change as the edema resolves.
– The stoma is ideally not placed near a skin fold and is sufficiently far from the incision that the appliance will adhere and not leak.
• Early complications usually relate to impaired vascular supply (1):
– Stomal necrosis can result in retraction, with a flush ostomy that is difficult to apply an appliance to.
• Early stomal retraction can be caused by an insufficient length of bowel segment or improper technique in securing and eversion of the stoma.
• Stomas stenosis: with or without obstruction:
– Reported in 2.8–19%
– May be asymptomatic, painful, or cause appliance fit problems
– Stomal stenosis is less for loop stoma than end stomas.
– Multifactorial causes: Fascial or muscular constriction, ischemia, and retraction allowing skin edges to overgrow opening (hyperkeratosis)
• Parastomal Hernia:
– Gap between the intestinal segment forming the stoma and the surrounding fascia
– Factors include obesity, malnutrition, chronic cough, wound infection.
– Placement of the intestinal segment through the rectus fascia minimizes the risk of herniation.
– Stomas placed lateral to the rectus fascia are more likely to develop a parastomal hernia (2.8% in rectus fascia vs. 21% lateral to rectus fascia).
– Most parastomal hernias worsen with time.
• Poorly fitting appliances can cause social embarrassment and skin irritation and breakdown:
– Urine contact (alkaline) with the skin can cause stomal encrustation, stomal epithelization, and eventual stenosis due to hyperkeratosis.
– Unless contraindicated, maintaining the urine in an acid state is more protective of the skin (see below).
– Peristomal skin problems can occur frequently and early after surgery.
• Irritative adhesives
• Fungal infections: redness and pruritus.
• Bleeding from portal HTN
• Urine pH:
– Most fruits and vegetables: alkalinized urine.
– Meats and cereals: acidic urine.
– Unless contraindicated, keep urine in acidic pH range; protects skin, limits the deposition of urine crystals in and around the stoma.
• Calcifications and small stones due to exposed staples usually pass spontaneously
ASSOCIATED CONDITIONS
• Congenital anomalies such as exstrophy or myelodysplasia
• Urothelial carcinoma
• Urethral carcinoma
GENERAL PREVENTION
• Parastomal skin care can reduce bleeding, stomal stenosis, and dermatitis.
• Surgical technique ensuring a properly formed stoma in an appropriate location based on the abdominal wall contours
• Proper site location by an experienced stoma nurse preoperatively takes into account many variables, including the contour of the abdomen in the sitting and standing positions and the type of belts and garments worn by the patient.
• Proper selection of pouching system:
– Compatibility with abdominal contours
– Proper sizing of the pouch opening to minimize urine exposure on the skin
– The opening on the adhesive skin barrier should be no more than 1/8-inch larger than the stoma to help keep urine off the skin.
• Emptying pouch appropriately such that excessive weight of the pouch will not disrupt the skin adhesion (usually when about 1/3 full)
• When changing the faceplate, the patient should learn to gently push the skin away from the sticky barrier rather than pulling the barrier off the skin.
• An acidic urine will be more protective of the peristomal skin than alkaline urine.
DIAGNOSIS
HISTORY
• Timing of diversion
• Weight change; may alter the fit of the faceplate
• Review the care of the stoma and appliance:
– Frequency of face plate change
– Frequency of emptying the collection pouch
• Complaints of parastomal skin lesions, bleeding, or dermatitis
• Problems with the adhesives, paste, tape, or pouch material
PHYSICAL EXAM
• Peristomal skin lesions:
– Irritative parastomal lesions that are manifested by hypopigmentation, hyperpigmentation, and skin atrophy
– Erythematous erosive lesions that are macular, scaling with loss of epidermis
– Pseudo-verrucous appear wartlike
• Minor bleeding from the exposed mucosa is common. Significant bleeding can be seen in cases of ileal conduit varices.
• Examine for evidence of parastomal herniation: Defect along fascial region of urostomy usually redicible
• Stomal stenosis or hyperkeratosis:
– Calibrate ostomy with a sterile catheter if stomal stenosis present.
• Note presence of urinary crystals on the skin.
DIAGNOSTIC TESTS & INTERPRETATION
Lab
Usually not necessary
Imaging
• Not usually necessary. However, in the setting of severe stomal stenosis or prolapse, CT or US may identify dilation of the intestinal segment or evidence of hydronephrosis.
• Loopogram to identify if there is reflux or obstruction of the ureters with prolapse or parastomal herniation.
Diagnostic Procedures/Surgery
Calibration of the stoma with a red rubber catheter and determination if there is retained urine may be useful.
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Cutaneous allergic reaction or fungal infection
• Parastomal hernia
• Peristomal skin breakdown
• Stomal bleeding, prolapse, retraction, stenosis
TREATMENT
GENERAL MEASURES
• Proper initial surgical technique will minimize short- and long-term stomal problems.
• Proper stomal care and problem-solving is often accomplished by consultation with a certified ostomy care health provider:
– Wound, Ostomy and Continence Nursing Certification Board (WOCNCB) provides certification in ostomy nursing
• A proper pouching system should have the following characteristics:
– Secure, leak-proof seal that lasts 3–7 days
– Protective of the skin around the stoma
– Nearly invisible when covered with clothing
– Easy to put on and take off
• Convex-style appliances can sometimes compensate for a retracted or flush stoma:
– Many styles and adhesive types may offer options to correct many fit problems.
• A 1-piece urostomy system tends to be more flexible that a 2-piece unit; may help with stomas that are near a deep abdominal fold or crease.
• Ostomy belts can sometimes help with securing the appliance in place and minimize mechanical disruption of the system.
• Gently trimming peristomal hair may help with face plate adherence.
• Allergic reaction to adhesive or other components can be addressed by switching to another product.
• Urine crystals on the skin or stoma (whitish gritty particles) are caused by alkaline urine:
– Cranberry juice in place of citrus juices (citrus juices make the urine more alkaline)
– Consider vitamin C daily
– Some acid ash foods (make urine acidic) include: Most meats, breads and cereals, cheese, corn, cranberries, eggs, macaroni, nuts, pasta, prunes, fish, and poultry.
– A 1:1 dilution of water and white vinegar applied with a cloth moistened with the mixture will dissolve the crystals.
• A pouch cover can help keep the skin beyond the skin barrier dry and reduce the incidence of superficial fungal infections where the pouch hangs down and contacts the skin.
MEDICATION
First Line
• Antifungal agents: Nystatin or miconazole powder lightly applied twice a day in cases of superficial fungal infection
• Severe allergic reactions to adhesive or appliance may require topical steroids short-term.
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Surgical repair for parastomal hernias:
– High likelihood of recurrence with or without relocation of the fascial opening. Suprafascial synthetic mesh wrap may decrease recurrence.
– Period of conservative management appropriate; Laparoscopic repair reported
• Surgical revision for stomal stenosis
• Surgical revision of retracted stoma
• Liposuction reported to correct inverted stoma in obese patients
• Looposcopy to remove calculi
ADDITIONAL TREATMENT
Radiation Therapy
Some limited reports of radiation to treat stomal stenosis–related hyperkeratosis
Additional Therapies
Formally trained wound and ostomy care nurses or a nure with extensive experience can often help resolve many issues.
Complementary & Alternative Therapies
Asparagus and seafood may cause increased odor. Hydration helps limit odors in general.
ONGOING CARE
PROGNOSIS
Very good when intervention is applied in a timely fashion to prevent irreversible upper tract deterioration from stomal stenosis.
COMPLICATIONS
• Recurrent stomal stenosis
• Recurrent parastomal hernia
• Recurrent skin irritation from poor ostomy care
• Appliance leakage
FOLLOW-UP
Patient Monitoring
• Stomal wound care
• Cancer surveillance as per protocol
Patient Resources
• Wound, Ostomy and Continence Nursing Society. http://www.wocn.org/?page=patients
• Urostomy And Continent Urinary Diversion. http://kidney.niddk.nih.gov/kudiseases/pubs/urostomy/
REFERENCE
1. Salvadalena GD. The incidence of stoma and peristomal complications during the first 3 months after ostomy creation. J Wound Ostomy Continence Nurs. 2013;40(4):400–406.
ADDITIONAL READING
• American Cancer Society Urostomy Guide: http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/ostomies/urostomyguide/index. Accessed August 2013.
• Gitlin J, Taneja SS. Complications of conduit urinary diversion. In: Taneja SS, et al., eds. Complications of Urologic Surgery, 4th ed. Philadelphia, PA: Saunders, 2010.
• Khalil el-SA. Long term complications following ileal conduit urinary diversion after radical cystectomy. J Egypt Natl Canc Inst. 2010;22(1):13–18.
See Also (Topic, Algorithm, Media)
• Catheterizable Stoma Problems
• Ureteroenteric Anastomotic Stricture
• Urostomy Problems Image 
CODES
ICD9
• 553.29 Other ventral hernia without mention of obstruction or gangrene
• 997.5 Urinary complications, not elsewhere classified
ICD10
• K43.5 Parastomal hernia without obstruction or gangrene
• N99.531 Infection of other stoma of urinary tract
• N99.538 Other complication of other stoma of urinary tract
CLINICAL/SURGICAL PEARLS
• Urostomy difficulties are common.
• A urostomy that is flush with the skin causes significant skin excoriation and complications, so attempt to have the stoma protrude at least 1–2 cm above the skin when creating it in the OR.
• A convex stoma appliance can be helpful for stoma issues.