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Cutaneous Ureterostomy

Cutaneous Ureterostomy. Gary P. Kearney MD FACS. # Patients. 30 Patients 13F 17M Age Range = 20-79 Mean age = 66 yrs Excluding 3 patients < 40 yrs Mean age = 70 yrs. Surgical options. Cutaneous ureterostomy Bilateral Cutaneous ureterostomy

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Cutaneous Ureterostomy

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  1. Cutaneous Ureterostomy Gary P. Kearney MD FACS

  2. # Patients 30 Patients 13F 17M Age Range = 20-79 Mean age = 66 yrs Excluding 3 patients < 40 yrs Mean age = 70 yrs

  3. Surgical options Cutaneous ureterostomy Bilateral Cutaneous ureterostomy Cutaneous ureterostomy with contralateral nephrectomy Cutaneous ureterostomy with contralateral renal embolism Cutaneous ureterostomy with transureteroureterostomy

  4. Renal Function No Deterioration Renal pelvis dilates – 20-30cc Low pressure system Cultures+/- +No Rx Uses 5-8F. Feeding tub to assist Serum creatinine & creatinine clearance to follow Ultrasound not useful

  5. Complications Acute tubular necrosis -1 Stomal stenosis -1 Loss of solitary kidney Dialysis -1 Operative mortality Stroke -1 Obstructed stent -1

  6. Primary Diseases Primary diagnosis of patients with Cutaneous Ureterostomy Tumor # Patients Cervical Carcinoma 7 Carcinoma of Bladder 13 Rectal Carcinoma 4 Carcinoma of Prostate 4 Carcinoma of Testes 1 Carcinoma of Ovary 1

  7. Operative Technique Surgical options Preoperative preparations Stomal site selection Nephropexy Ureteral Stoma Stomal appliance Intraoperative considerations

  8. Preoperative preparation Percutaneous nephrostomy Hyperalimentation Trial of ureteral stent Cutaneous Ureterostomy is an elective procedure

  9. Stomal site selection Patient selected sitting Right or Left upper quadrant Skin devoid of wrinkles of scars Site easily managed by appropriate patient

  10. J. B. (Postop)

  11. Past problems Retraction of ureter Abcess Urinoma

  12. Surgical technique One inch subcoastal incision Rib resection not required Extraperitoneal procedure (take care anteriorly) Dissect Gerota’s fascia completed but not vascular pedicle Rotate lower pole to lie directly anteriorly Make sure ureter assumes a short straight course to skin Renal capsulotomy 2-3 inches on inferior surface Complete nephropexy to anterior or lateral abdominal wall (6-8 sutures) Fashion skin pedicle & incise ureter 2cm Suture skin flap to apex of spatulated ureter with 5-0 Dexon/Vicryl Use diversion stent - 7F

  13. Nephropexy Method of George Prather MD Importance of procedure can not be over emphasized Provides fixation of kidney and prevents retraction of ureter and stomal stenosis Renal capsule is stripped back where possible to promote adherence to abdominal wall

  14. Ureteral Stoma Turned back ureter is brought through anteriorly, spreading rectus muscle, anterior rectus fascia large enough to admit the index finger Ureter should extend 1.5-2cm beyond skin surface Using skin flap technique increases surface area of stoma & helps prevent stomal retraction and stenosis

  15. Stomal appliance Base of skin pedicle arises from 12 o'clock position when patient is viewed standing. Conduit collection devise has small diameter opening. Single belt can be used for bilateral ureterostomies Single stomas are to be encouraged where possible

  16. Intra-op considerations Historically Mannitol 12.5gms used to promote diuresis Minimize manipulation of kidney to avoid injury to vasculature Stage diversion where necessary in bilateral cases Sacrifice contralateral kidney by nephrectomy to gain single stoma when renal function is adequate Embolization has been effective when patient condition precludes a second operation

  17. Expanded Indications Solitary kidney Extended life expectancy in high risk patients

  18. Palliative Diversion Classic indication Poor surgical risk Limited life expectancy

  19. Types In-Situ (ISU) Loop (LCU) End Cutaneous

  20. Recent Considerations Newer antegrade and retrograde catheters frequently allow placement of indwelling ureteral stents. Percuatenous nephrostomy drainage allow elective consideration of permanent diversion Current patients represent a subset who are healthy enough to survive past above diversionary techniques with long-term complications of sepsis, obstructed stents, dislocation of nephrostomy tubes etc.

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