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Le urostomie: prima parte

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Le urostomie: prima parte

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Le urostomie: prima parte

  1. 1. LE UROSTOMIE: QUANDO, DOVE, PERCHE’ ? Giancarlo Comeri Castellanza 8 ottobre 2011
  2. 2. DEFINIZIONE • Lurostomia o derivazione urinaria, è lesclusione del reservoir vescicale e/o dell’uretra con deviazione del flusso urinario verso la cute o il lume intestinale14/03/12
  3. 3. LE UROSTOMIE: QUANDO? INDICAZIONI • Neoplasie vescicali e prostatiche avanzate • Carcinosi diffusa della pelvi • Infiammazioni croniche della vescica • Cistite interstiziale • Cistite attinica • Malformazioni congenite (estrofia vescicale) • Vescica neurologica • Traumi vescicali e uretrali14/03/12
  4. 4. bambino bambina ESTROFIA CLASSICA
  5. 5. FISIOPATOLOGIA DELLE UROSTOMIE Lurostomia è caratterizzata da un deflusso costante di urina Lurina ha un pH leggermente acido (tra 5 e 6) ma lurina fresca di solito non ha effetti dannosi Lurina stagnante può invece essere alcalina ed avere effetti dannosi sulla cute14/03/12
  6. 6. TIPI DI UROSTOMIE UROSTOMIECONTINENTI INCONTINENTIINTERNE TEMPORANEE ESTERNE DEFINITIVE
  7. 7. CLASSIFICAZIONE UROSTOMIE INCONTINENTI TEMPORANEE DEFINITIVE CISTOSTOMIE  U.C.S. NEFROSTOMIE  U.I.C.S.
  8. 8. UROSTOMIE UROSTOMIE CONTINENTI INCONTINENTIINTERNE TEMPORANEE ESTERNE DEFINITIVE
  9. 9. UROSTOMIE INCONTINENTI TEMPORANEE Cistostomia percutanea
  10. 10. UROSTOMIE INCONTINENTITEMPORANEECistostomia percutanea Catetere di Bracci Punta “Pigtail” Punta “Malecot” Foley siliconato forato in punta
  11. 11. CISTOSTOMIA PERCUTANEA
  12. 12. UROSTOMIE INCONTINENTI TEMPORANEENefrostomia percutanea
  13. 13. UROSTOMIE INCONTINENTI TEMPORANEE Nefrostomia Raccordo Estremità
  14. 14. UROSTOMIE INCONTINENTI DEFINITIVE (con stoma cutaneo)- Uretero-cutaneostomia- Condotto gastrico- Condotto digiunale- Condotto ileale- Condotto ileo-cecale- Condotto trasverso-colico- Condotto sigmoideo- Uretrostomia perineale
  15. 15. LE UROSTOMIE INCONTINENTI DEFINITIVE COLLOCAZIONE STOMIA CUTANEA Ombelico ( condotto gastrico) Centrali sotto-ombelicali (UCS bilaterali con stoma unico) Fossa iliaca destra (condotti e tasche ileali e ileo-coliche) Fossa iliaca sinistra (condotti e tasche sigmoidee) Fossa iliaca dx e sin. (UCS bilaterali)
  16. 16. URETEROCUTANEOSTOMIA Anastomosi diretta alla cute dei due ureteri (modello di derivazione urinaria esterna più utilizzato fino agli anni ’50) Oggi realizzata raramente per:-Stenosi stomia cutanea-Infezione ascendente-Ineluttabile deterioramento funzione renale
  17. 17. URETEROCUTANEOSTOMIA INDICAZIONI RESIDUE Soluzione palliativa se breve aspettativa di vita Insorgenza imprevista di problemi intraoperatori ( ripiego eventualmente temporaneo) Nell’infanzia come derivazione temporanea protettiva del rene in attesa di chirurgia ricostruttiva
  18. 18. URETEROCUTANEOSTOMIA FISIOPATOLOGIA URETERALEUreteri appena dilatati = ottimali per UCS (migliore vascolarizzazione collaterale per muscolare ispessita)Ureteri molto dilatati = UCS scadenti (ischemia e adinamia per assottigliamento della tonaca muscolare)
  19. 19. URETEROCUTANEOSTOMIE CLASSIFICAZIONE Monolaterali Bilaterali con stoma separato Bilaterali con stoma unicoDirette Con lembo cutaneoAmin - AbeshouseCukier o semplice - a “nipple””Swenson e Smith - MalamentChute - Straffon 2
  20. 20. URETEROCUTANEOSTOMIA BILATERALE Stoma separato Stoma unico14/03/12
  21. 21. URETEROCUTANEOSTOMIA Bilaterale con stoma separato14/03/12
  22. 22. URETEROCUTANEOSTOMIA Bilaterale con stoma unico14/03/12
  23. 23. URETEROCUTANEOSTOMIA TECNICHE DI ABBOCCAMENTO DIRETTO CUKIER o semplice
  24. 24. URETEROCUTANEOSTOMIA TECNICHE DI ABBOCCAMENTO DIRETTO a “loop” : nei bambini
  25. 25. URETEROCUTANEOSTOMIA TECNICHE DI ABBOCCAMENTO DIRETTO Straffon 2
  26. 26. URETEROCUTANEOSTOMIA TECNICHE DI ABBOCCAMENTO DIRETTO Chute
  27. 27. URETEROCUTANEOSTOMIA ABBOCCAMENTO CON LEMBO CUTANEO Abeshouse
  28. 28. URETEROCUTANEOSTOMIA ABBOCCAMENTO CON LEMBO CUTANEO a “nipple”
  29. 29. URETEROCUTANEOSTOMIAABBOCCAMENTO CON LEMBO CUTANEO Malament
  30. 30. URETEROCUTANEOSTOMIA ABBOCCAMENTO CON LEMBO CUTANEO Swenson e Smith
  31. 31. URETEROCUTANEOSTOMIA COMPLICANZE STOMIA CUTANEA Necrosi Deiscenze Fistole Stenosi Ernie Prolassi Dermatiti Infezioni Squilibri metabolici secondari
  32. 32. RETRAZIONE Retrazione ureterocutaneostomia
  33. 33. URETEROCUTANEOSTOMIA CAUSA DELLE COMPLICANZE Compromissione vascolare nel mobilizzare l’uretere Angolature ischemizzanti ed ostruenti Torsione e trazione sul moncone Scorretto allineamento del tunnel muscolo- fasciale Scelte incongrue delle sedi stomali

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