Zachary L. Smith, MD
S. Bruce Malkowicz, MD, FACS
BASICS
DESCRIPTION
• Catheterizable stomas (CSs) are utilized in all age groups and provide a means of emptying the native bladder or neobladder.
• Most common indications for CS vary with age groups:
– Pediatrics: Incontinence related to neurologic or congenital conditions
– Adults: Urinary diversion following extirpative surgery for malignancy
• Location of CS can vary, but is most often located in the umbilicus or right lower quadrant.
• Catheterizable channels are commonly constructed from a segment of small bowel or the appendix.
• Mechanism of CS continence depends on the type of urinary reservoir.
• Patients with CS often have routine catheterization schedules.
• CS problems can be related to the stoma, catheterizable channel, or urinary reservoir.
EPIDEMIOLOGY
Incidence
• Complications are reported in 10–50% of patients with CSs:
– Stomal stenosis has been reported in up to 40% of CS
– Most stomal-related complications are reported within the 1st yr following surgery (1)[C].
– Incontinence is reported in 1–20% of cases and is associated with the mechanism of continence.
– Parastomal hernias have been noted in 0–5% of patients.
Prevalence
N/A
RISK FACTORS
• Improper stomal positioning
• Infrequent use of CS
• Multiple prior abdominal procedures
• Obesity
• Surgical technique
• Wound infections
Genetics
N/A
PATHOPHYSIOLOGY
• Stomal stenosis can be attributed to infrequent catheterization, scar formation, ischemia secondary to compromised vascular supply to catheterizable channel, or a nontension-free mucocutaneous anastomosis.
• Difficulty catheterizing the CS channel can be attributed to angulation of a mobile and/or redundant channel.
• Significant weight loss or gain
• Improper creation of continence mechanism
• Incomplete detubularization or augmentation of the urinary reservoir can lead to incontinence secondary to low compliance and small reservoir capacity.
• Pouchitis (lower urinary tract infection) can cause temporary failure of the continence mechanism because of the hypercontractility of the bowel segment; can be caused by inflammation of the mucosa.
ASSOCIATED CONDITIONS
• Urologic, gynecologic, and colorectal malignancies
• Spinal dysraphisms
• Traumatic spinal cord injuries
GENERAL PREVENTION
• Maintenance of a regular catheterization regimen
• Several complications can be prevented at the time of surgery when creating the catheterizable channel:
– Maintenance of vascular supply to catheterizable channel
– Minimized redundancy catheterizable channel with fixation and stabilization of the continence mechanism
– Adequate construction of continence mechanism
– Tension-free mucocutaneous anastomosis
– Use of V-flap of skin to prevent stomal stenosis
DIAGNOSIS
HISTORY
• Date of surgery
• Indication for CS:
– Incontinence (urinary vs. fecal)
– Malignancy
• Attempt to obtain operative reports
• Type of bowel utilized
• History of CS complications
• Catheterization details:
– Typical catheterization regimen
– Type and size of catheter used
– Technique utilized (direction, amount of pressure, etc.)
– Normal catheterization volumes
– Time of last normal catheterization
– Character of urine at the time of last successful catheterization (color, odor, presence of debris, etc.)
• Status of the bladder neck in patients with native bladder intact:
– Urethral catheterization can be attempted in patients whose native urethra is intact and who have an open bladder neck.
• Review of systems should focus on abdominal symptomatology.
PHYSICAL EXAM
• Vital signs may reveal tachycardia, hypotension, and fever in patients with peritonitis secondary to perforation of the catheterizable channel or urinary reservoir.
• Abdominal exam evaluating signs of peritonitis
• Inspection of the stoma, evaluating for:
– Stenosis
– Mucosal ischemia
– Abdominal wall deformity suggestive of parastomal hernia
• Catheterization of CS to:
– Evaluate patency of stoma
– Determine capacity of urinary reservoir
– Evaluate continence mechanism
– Obtain urine sample
– Instill contrast for imaging.
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Serum electrolytes:
– Elevated serum creatinine may be noted in patients with urinary retention from the inability to catheterize.
– Several metabolic abnormalities may be present in patients with urinary reservoirs, depending on bowel segment utilized:
Stomach: Hypochloremic, hypokalemic alkalosis
Jejunum: Hyponatremic, hypochloremic, hyperkalemic acidosis
Ileum: Hyperchloremic acidosis
Colon: Hyperchloremic acidosis
• CBC:
– Leukocytosis suggestive of infection
• Blood and urine cultures in patients presenting with abdominal pain and fever
Imaging
• Contrast study of catheterizable channel and urinary reservoir to evaluate for perforation
• Cross-sectional imaging of the kidneys assessing for the presence of hydronephrosis
ALERT
Have a low threshold for obtaining a cross-sectional imaging study (CT/MRI) with contrast when a perforation of the CS or urinary reservoir is suspected, especially in patients with neurologic deficits.
Diagnostic Procedures/Surgery
Urodynamics in patients with incontinence may reveal uninhibited contractions or a poorly compliant high-pressure reservoir.
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Perforation of CS channel or urinary reservoir
• Stomal stenosis
• Incontinence
• False passage
• Parastomal hernia
• Fistula
• Inability to catheterize due to redundancy of catheterizable channel
TREATMENT
ALERT
Perforation of CS conduit or urinary reservoir mandates emergent exploratory laparotomy, drainage of urinary extravasation, and repair of urinary reservoir.
GENERAL MEASURES
• Good hygiene
• Routine catheterization of CS
• Early intervention with difficulty
MEDICATION
First Line
• Incontinence related to uninhibited pouch contractions:
– Anticholinergics (oxybutynin, tolterodine, etc.) (2)[C]
• Pouchitis may sometimes be due to infection and can be treated with appropriate antibiotics.
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Stomal stenosis:
– Elective surgical revision with V-flap of skin (3)[C]
• Incontinence:
– Elective surgical revision of continence mechanism
– Injection of bulking agent into CS
– Augmentation of urinary reservoir with intestinal patch in cases of high pressures and poor compliance (2)[C]
• Parastomal hernia:
– Elective hernia repair with or without repositioning stoma site on abdominal wall
– Surveillance in asymptomatic patients
• Fistula:
– Elective revision
• Inability to catheterize secondary to false passage or redundancy of CS channel:
– Elective revision
– Occasionally, minor false passages can be treated with an indwelling catheter for a short period to allow healing of channel.
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Stomal stenosis:
– Routine catheterization schedule
– Dilatation of stenosis
• Inability to catheterize secondary to false passage or redundancy of CS channel:
– Change type of catheter
– Change method of catheterization
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
Success following stomal revisions for stenosis ranges from 80–95% (1)[C].
COMPLICATIONS
Recurrence of prior complication
FOLLOW-UP
Patient Monitoring
• Maintenance of routine catheterization schedule
• Additional follow-up with enterostomal therapist
Patient Resources
• United Ostomy Associations of America, Inc. www.ostomy.org
• Bladder Cancer Advocacy Network. www.bcan.org
REFERENCES
1. Thomas JC, Dietrich MS, Trusler L, et al. Continent catheterizable channels and the timing of their complications. J Urol. 2006;176:1816–1820.
2. Farnham SB, Cookson MS. Surgical complications of urinary diversion. World J Urol. 2004;22:157–167.
3. Hellenthal NJ, Eandi JA, DeLair SM, et al. Umbilical stomal stenosis: A simple surgical revision technique. Urology. 2007;69:771–772.
ADDITIONAL READING
• Benson MC, McKiernan JM, Olsson CA. Cutaneous continent urinary diversion. In: Wein AJ, Kavoussi LR, Novick AC, et al., eds., Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Elsevier; 2012.
• Skinner E, et al. Complications of continent cutaneous urinary diversion. In: Taneja SS, Smith RB, Ehrlich RM, eds. Complications of Urologic Surgery, Prevention and Management. 4th ed. Philadelphia, PA: WB Saunders; 2010.
See Also (Topic, Algorithm, Media)
• Bladder Cancer, Urothelial, Muscle Invasive (Clinical and Pathologic T2/T3/T4) (MIBC)
• Bladder Cancer, Squamous Cell Carcinoma
• Catheterizable Stoma Problems Image 
• Parastomal Hernia
• Pouchitis
• Urostomy Problems
CODES
ICD9
• 596.82 Mechanical complication of cystostomy
• 596.83 Other complication of cystostomy
• V55.5 Attention to cystostomy
ICD10
• N99.512 Cystostomy malfunction
• N99.518 Other cystostomy complication
• Z43.5 Encounter for attention to cystostomy
CLINICAL/SURGICAL PEARLS
• Cathterizable stomas are used for varying reasons throughout one’s life. Benign/neurogenic causes most common in children, malignant causes most common in adults.
• Stomal stenosis is by far the most common complication of cathterizable stomas.
• Surgical revision is often required for most cathterizable stomas complications.
• Good technique and cathterizable stomas maintenance with a routine catheterization schedule can prevent most complications.