Ureteral ostomies

Ureterocutaneostomy
Ureteroileostomy
Ureterosigmoidostomy
Trans Uretero Anastomosis

Definition:
Ureteral ostomy is an intervention planned in the pelvic demolition surgery for bladder cancer (cystectomy) or for other pathologies that contemplate the necessity of ureter connections to the skin, to the intestine or to the contralateral ureter.

Indications:
The four surgeries above constitute the derivative reconstructive phase after demolition, generally pelvic interventions for infiltrating bladder neoplasms or other urogenital pathologies.

• Ureterocutaneostomy and Trans Uretero Anastomosis: direct ureteral derivation to the skin. Interventions in patients with high generic risk for whom necessary demolition interventions are programmed (non controllable bladder bleeding, debulking (mass reduction), symptomatic, post-attinic oncology or intestinal unreliability for previous interventions or radiotherapy). The type of derivation involves the permanent tutoring of urocutaneous ostomies (Bracci catheters, Gilvernet stents, pielocutaneous stents), with periodic substitutions to prevent cicatricial stenosis.
• Ureteroileostomy: an ever-present derivation that is practiced when continental urinary tract interventions are not possible or when due to pelvic or lymph node secondary localization a complement radiotherapy of the pelvic cavity is required.
• Ureterosigmoidostomy: ureteral derivations in the rectus sigma, with particular indications in female patients, basically linked to the need to avoid using external tutors (sticker bags) of difficult personal handling or nursing.

Technical Description:

• Ureterocutaneostomy and Trans Uretero Anastomosis: involves the anastomosis of the ureters directly into the skin of the abdomen. Depending on the availability of the ureteral tissue, a single anastomosis may be performed (Trans Uretero Anastomosis), otherwise an anastomosis will be performed on the two opposing sides of the abdomen (ureterocutaneostomy). A ureteral tutor will be constantly kept in place and replaced periodically in order to overcome any cicatricial stenosis. The patient will be instructed in managing the external collection systems for urine and any stomach complications. In the case of Trans Uretero Anastomosis, the replacement of the ureteral tutors involves the use of radiological maneuvers.
• Ureteroileostomy: This type of anastomosis is used after cystectomy when an ileal conduit is being wound up. In this case, a segment of 15 to 20 cm of ileum is cut off, one end of which will be anastomosed to the skin of the abdomen (left or right wall), the other will be anastomosed to the ureters. Two ureteral tutors will be kept in place for 1-2 weeks. This type of derivation involves an external collection system for urine for which the patient will be adequately instructed.

Preparation for intervention:

• Intestinal fiber-free diet (two days before surgery), purgatives and enemas the day before surgery (only for interventions involving the use of intestinal tracts).
• Skin reparation (trichotomy) and identification of preferred ostomies points, compatible with the patient’s somatic trim.
• Antibiotic prophylaxis.
• Antithrombotic prophylaxis.

Duration of intervention:
The duration of the intervention varies from a minimum of 2 hours to a maximum of 5 (including the demolition time).

Type and duration of hospitalization:
The hospitalization is ordinary with an average stay of 7-14 days.

Results:
Ureterocutaneostomy, Ureteroileostomy, Ureterosigmoidostomy, Trans Uretero Anastomosis: good when compared to the underlying disease, often neoplastic and as such related to malign stage and degree.

Advantages:

• Ureterocutaneostomy, Trans Uretero Anastomosis: does not require intestinal resection, it is the fastest-performing technique especially in patients with poor clinical situations.
• Ureteroileostomy: Preserves renal function.
• Ureterosigmoidostomy: preservation of urinary continence, absence of external collection chambers.

Disadvantages:

• Ureterocutaneostomy, Trans Uretero Anastomosis: the need for an external urine collection system (bags attached to the abdominal wall) that can be single or double and which may lie apart, detach, etc., need for specific nursing even in the case of contact dermatitis (urine, plaque). Need for periodic replacement of tutors, more careful replacement of tutors in the Trans Uretero Anastomosis.
• Ureteroileostomy: the need for an external urine collection system (bags attached to the abdominal wall) that can be dislocated, detached, etc. Necessity of specific nursing even in the case of contact dermatitis (urine, plaque).
• Ureterosigmoidostomy: the need to continue antibiotic therapy at full dosage for 2-4 weeks, a low-dose bacteriostatic therapy would also be indicated. Regular oral intake of sodium and potassium citrate is also required for acid-base balance control. Possible ascending pyelonephritis.

Side effects:

• For Ureterocutaneostomy, Trans Uretero Anastomosis and Ureteroileostomy: no significant side effects are reported.
• Ureterosigmoidostomy: consistently liquid feces (rarely incoercible diarrhea), possible onset of hyperchloremic acidosis in the event of inadequate correction with bicarbonates.

Complications:

• Ureterocutaneostomy: acute necrosis, dehiscence and late stenosis of the stoma are the most common complications: for this reason, it is advisable to have permanent tutoring. Infections or encrustations on tutors in case of corpuscular urine or failure to observe the replacement in due course. Peristomal contact dermatitis by the chemical characteristics of urine and urostomal plaques.
• Ureteroileostomy: dehiscence of the ostomy with urinary fistula with partial or total detachment. In the first case, a tutoring can be re-attempted by percutaneous antegrade maneuver. In the event of failure of the previous maneuver or total detachment another surgery is required. Another complication is the stenosis of the ureteroileal joint with partial or total obstruction of the upper excretory pathway. In this case, it is necessary to restore the upstream renal function with percutaneous nephrostomy and subsequent endourological recovery attempt of anastomotic patency. Intestinal occlusion or enteric fistula in the terminal ileal anastomosis, which needs immediate correction.
• Ureterosigmoidostomy: dehiscence and stenosis of ureterocolic anastomosis (major postoperative complication). The resolution of these complications is difficult. It is preferred, in most cases, to resort to surgical revision. In addition, recurrent kidney infections with possible kidney stones. Intestinal occlusion and hyperchloremic metabolic acidosis. Colic tumors (benign and malignant) have been described in 40% of cases near anastomoses. This tendency to intestinal carcinogenesis has not been observed in other forms of urinary tract (apparently induced by feces and urine mixing).
• Trans Uretero Anastomosis: In addition to skin complications (already described), the possibility of dehiscence or stenosis at the level of ureteral anastomosis involves almost constant surgical revision.

At discharge:
The patient should be advised to have a morigerized period of time (reduced physical stress, low activity, moderate diet, antiseptic urinary therapy) for a variable period depending on post-operative disorders.
For stomach carcinomas it is advisable to have a good stomach hygiene and periodic replacement of the collection systems and strict observation of the replacement time of the tutors (if present).
For patients with ureterosigmoidostomy, periodic acid-base balance control is recommended.
The abundant hydration (1-1.5 l / day) is a dietary diet recommended to everyone.

How to behave in case of complications arising after discharge:
In the case of colic pain, reduced or missed urine output (in the case of Ureterocutaneostomy, Ureteroileostomy) and in case of irregularities in the alvus, contact the urologist.

Checks:
The first postoperative check will be performed within 30-45 days.