The stoma of the ileal conduit

Pelvic exenteration: experience from a rural cancer center in developing world

Background. Pelvic exenteration (PE) is a morbid procedure. Ours is a rural based cancer center limited trained surgical oncology staff. Hence, this audit was planned to evaluate morbidity and outcomes of all patients undergoing PE at our center. Methods. This is a IRB approved retrospective audit of all patients who underwent PE at our center from January 2010 to August 2013. The toxicity grades were retrospectively assigned according to the CTCAE version 4.02 criteria. Chi-square test was done to identify factors affecting grades 3–5 morbidity. Kaplan Meier survival analysis has been used for estimation of median PFS and OS. Results. 34 patients were identified, with the median age of 52 years (28–73 years). Total, anterior, posterior, and modified posterior exenterations were performed in 4 (11.8%), 5 (14.7%), 14 (41.2%), and 11 (32.4%) patients, respectively. The median time for surgery was 5.5 hours (3–8 hours). The median blood loss was 500 mL (200–4000 mL). CTCAE version 4.02 grades 3-4 toxicity was seen in nine patients (25.7%). The median estimated progression free survival was 31.76 months (25.13–38.40 months). The 2-year overall survival was 97.14%. Conclusion. PE related grades 3–5 morbidity of 25.7% and mortality of 2.9% at our resource limited center are encouraging.

Human papillomavirus-negative ileostomal chronic papillomatous dermatitis

BACKGROUND

Papillomatous stoma-related skin lesions may result from irritant reactions or infection with epidermodysplasia verruciformis human papillomavirus (HPV) types.

METHODS

We report upon a papillomatous lesion at the ileostoma of a 63-year-old male with familial adenomatous polyposis and colorectal adenocarcinoma. We thoroughly tested the lesion for HPV using immunohistochemistry, transmission electron microscopy, and polymerase chain reaction analyses.

RESULTS

The lesion was a fleshy, multilobulated, and verrucous plaque, with hyperkeratosis, hypergranulosis, acanthosis and marked papillomatosis. The clinical and light microscopic features were suggestive of a condyloma. However, no HPV was detected.

CONCLUSIONS

We suggest that the lesion most likely represents chronic papillomatous dermatitis, a reaction to mechanical and/or chemical irritation usually associated with urostomies and only rarely observed with ileostomies. This case highlights the clinical, diagnostic and therapeutic aspects of an unusual cutaneous morbidity associated with ileostomies.

Round Table: “Urinary diversion” - Prevention of complications

— The Authors take into consideration the different techniques of urinary diversion; in the light of their findings, they reviewed the most important complications following urinary diversion and the possibilities of their prevention.

Local status of the urinary stoma--the relation to peristomal skin complications

Sixty-six patients with uretero-ileostomy were investigated with special regards to local status of the urinary stoma, i.e. stomal site, length, size/shape, and peristomal skin. Each variable was defined. In reports from other centres there has been a lack of definitions making it difficult to compare results from different studies. One fifth of our patients had inadequately located stomas and 85% had stomas shorter than 1 cm. The peristomal skin status was assessed according to CPS, Classification of Peristomal Skin. Eight per cent of the patients exhibited severe erythematous/erosive lesions and one fifth pseudoverrucose lesions. The relation between skin lesions and local status of the urinary stoma was analyzed. Patients with inadequately located stomas were more likely to show severe erythematous/erosive lesions and there was a tendency towards patients with stomas shorter than 1 cm, more frequently exhibiting pseudoverrucose lesions.

Urodynamic investigation of the ileal conduit: upper tract dilatation and the effects of revision of the conduit

Urodynamic studies of the ileal conduit were performed in 36 patients with normal upper urinary tracts (controls) and in 32 who had progressive upper tract dilatation within 6 years preceding the study. In controls the conduit emptied mainly by means of low pressure, to-and-fro activity. In contrast, high frequency, high amplitude peristaltic activity was found commonly in patients with upper tract dilatation, such activity being consistent with obstruction of the distal conduit. Of the 32 patients with upper tract dilatation 17 underwent reoperation on the conduit as well as postoperative urodynamic studies. Among these 17 patients a decrease was observed in basal pressure in the conduit postoperatively compared to preoperatively (5 +/- 4 and 12 +/- 6 cm. water, p less than 0.001). A decrease also was found postoperatively in the frequency (4 +/- 6 and 36 +/- 28 per hour, p less than 0.001) and amplitude (34 +/- 47 and 61 +/- 28 cm. water, p less than 0.001) of peristaltic activity. Radiological improvement in the appearance of the upper urinary tracts was found in 9 patients (53 per cent) postoperatively. These findings support the hypothesis that upper tract dilatation in certain patients with an ileal conduit may be caused by high pressure activity in the presence of free ureteral reflux. Such abnormalities, which are probably the result of obstruction of the distal conduit, may be detected by means of urodynamic evaluation and may be corrected by revision of the conduit.

The role of the ileal conduit in the development of upper tract dilatation

The purpose of this study was to clarify the role of the conduit in the development of upper tract dilatation after ileal conduit urinary diversion. Twenty-seven patients with a normal upper tract were compared with 17 who had developed upper tract dilatation. Patients were studied by means of a technique to measure pressure and flow under "steady-state" conditions. Pressure activity was classified into two types. Type I pressure activity (frequency 6.2 +/- 3/min; amplitude 4.7 +/- 3 cm H2O) resulted in to-and-fro movement of contrast and the escape into the appliance of small volumes of contrast. In controls, most of the output from the conduit occurred during type I activity (73 +/- 14%). Type III/IV pressure activity resulted in vigorous aboral peristalsis and occurred infrequently in controls (frequency 5 +/- 4/h). In patients with upper tract dilatation, in contrast, type III/IV peristaltic activity occurred frequently (frequency 37 +/- 30/h; P less than 0.001: amplitude 72 +/- 34 cm H2O) and was responsible for most of the output (70 +/- 17%; P less than 0.001). The findings support the hypothesis that high pressure activity in the conduit is an important factor in the aetiology of upper tract dilatation, and they are compatible with the presence in such patients of functionally important obstructions of the distal conduit.

Complications of ileal conduit diversion in adults with cancer followed up for at least five years

A total of 111 adults with malignant disease of the bladder were studied to determine the long term complications of ileal conduit diversion. Each patient had survived at least five years (mean 10 years) after cystectomy. At final follow up the radiological appearance of one or both kidneys had deteriorated in 50 (47%) of 107 patients: deterioration worsened significantly (p less than 0.01) with increasing duration of follow up. Eighteen patients (16%) developed biochemical evidence of impaired renal function, of whom four died of complications of renal failure. Bilateral upper tract dilatation was noted in 30 patients (28%), and in 21 its cause was obscure. Ten patients formed renal stones, and an additional 12 required further operations on the conduit or stoma. Despite the age of patients with bladder cancer and the poor prognosis of those with invasive tumours clinically important side effects were observed in a significant proportion of the long term survivors. Further efforts to determine the aetiology of upper tract dilatation in patients with an ileal conduit diversion are justified.

Isolated ileal loop augmentation of existing ileal conduit

A new method of stomal revision in an existing ileal conduit is described. Two cases are reported in which the procedure was a success. It is suggested that ileal loop augmentation of an existing ileal loop may serve, in selected cases, as a useful alternative to complete conduit reconstruction.

Funneled ureteroileal anastomosis

We analyzed the functional results of urinary diversion in 21 patients who had a funneled ureteroileal anastomosis to avoid stricture and stenosis. No attempt was made to avoid reflux from the conduit to the ureter but special care was taken to construct a cutaneous stoma to prevent reflux from the appliance. The results of the procedure were satisfactory. No urinary leakage, or stricture of the ureters or ureteroileal anastomosis was observed in any patient and kidney function was preserved. One of the main advantages of this technique is simplicity in construction, which means increased safety when used by surgeons not extensively trained in urinary diversion operations.

End-to-end ureteroileal anastomosis for ileal conduits

In the "Y" anastomosis, both ureters are spatulated and joined together to form a single tube which is anastomosed to the proximal end of the ileum. This technique has several theoretical advantages which appear to be borne out in practice when the results of its use in 101 patients followed for up to 12 years are reviewed. Only 2 anastomotic leaks needed operative treatment and only 4 patients developed ureteroileal stenosis. Renal function remained unchanged or improved in 84% of the patients, and definite hydronephorsis or pyelonephritis developed in only 4% of the kidneys. These results show that this method of ureteroileal anastomosis is at least as good as, and possibly better than, other techniques.

Chronic papillomatous dermatitis as a peristomal complication in conduit urinary diversion

In 76 patients with conduit urinary diversion, the skin in the stomal area was studied with regard to complications. No such complications had occurred in 39 cases. Superficial erosive dermatitis was present or had been a transient episode in 27 cases. The immediate peristomal area was found in ten cases to show a different type of complication. This was characterized by hyperplastic, papillomatous skin lesions of a chronic nature. A rubber urinary collecting device for long-term use had been fitted in nine of the ten patients, and none of them had a protruding nipple stoma. The clinical, microbiologic and histologic features of these hyperplastic lesions are described and aetiologic factors are discussed. Change to another type of collecting device was followed within three to six weeks by healing of the lesions.

Back-flow from urinary collecting devices into the ileal conduit

The occurrence of back-flow from urinary collecting devices into the ileal conduit was observed in 9 out of 46 patients. In 6 of them back-flow to the upper urinary tract also occurred. Nipple stomas of at least 2 cm height were found to resist back-flow into the conduit better than any flat stoma.