This document describes cutaneous urinary diversion, which involves creating an artificial opening in the skin for urinary elimination when the bladder has been removed or damaged. It defines urinary diversion and lists indications. It describes types of diversions based on elevation from the skin surface and shape. It discusses incontinent diversions like ileal conduits and continent diversions using techniques like Mitrofanoff appendicovesicostomy. Early and late complications of stomas are outlined, including ischemia, hemorrhage, stenosis, prolapse, hernia, and skin issues. Management strategies are provided for various complications that may arise.

1. Cutaneous urinary diversion
By
Mohamed Elgendy
Assistant lecturer of urology
Assuit University

2. Definition
• Artifictial orifice for urinary diversion.

3. Indication of urinary diversion
• When the bladder has to be removed either due to malignant
tumour or post tramatic.
• When the sphincters of the bladder & the detrusor muscle
have been damaged or have lost their normal neurological
control.
• When there is irremovable obstruction in the bladder &
distal to that.
• neglected Ectopic vesicae or failure of repair
• Incurable vesico- vagina fistula.

4. Types/Classification
(1) According to elevation from surrounding
surface: Two types of stomas may be made on
the anterior abdominal wall:
• The flush stoma is preferable for the continent
type of diversion.
• The stoma that protrudes is preferable for
incontinent type of diversion.

5. Types/Classification Cont.
2) According to Shape:
1. Nipple Stoma:
“Rosebud”
• the stoma is grasped and
brought out for a
distance of 5 to 6 cm
through the abdominal
wall.
• it is preferred in the
incontinent stoma

6. 2) Loop End Ileostomy
• It is preferred in obese
patients that have a
thick abdominal wall
and often a thick, short
ileal mesentery
• the distal end of the
loop is closed and the
bowel is drawn through
the rent in the
abdominal wall.

7. 3) Flush Stoma
 It is preferred in the continent
types of urinary diversion.
 It can be done by appendix or
tapered ileum.
 It can be placed in umbilicus or
away from umbilicus.
 To avoid stomal stenosis a skin
flap should be incorporated in the
stoma.
 It has different shape V shaped
and VQZ stomaplasty.

8. Flush Stoma

9. The site of the stoma should be
selected preoperatively
 done by marking the stomal site with the patient in the
sitting position, as well as in the supine position.
 at least 5 cm away from the planned incision line.
 well away from skin creases, scars, belt lines, and bone
prominences.
• placed through the belly of the rectus muscle.
 be brought through a circular incision made at the
predetermined site.

10. Types of Incontinent Cutaneous
urinary diversion
Ileal Conduit
• the most common method of
urinary diversion in the United
States
• a segment of ileum 18–20 cm
long and located approximately
15–20 cm proximal to the
ileocecal valve

11. Ureterocutaneous shunt
• Ureter is implantened
direct to the skin
• Common in developing
country

12.  Loop ureterostomy
• Anterior part of the
ureter is implanted to
skin with maintenance
of posterior wall
continuity.

13. Incontinent vesicostomy
• Bladder opened directly
to the the skin

14. CONTINENT CUTANEOUS URINARY
DIVERSION
• Continent urinary diversion differs according to types of
channels.
• The creation of a reliable continence mechanism that is
easily catheterizable is considered the final and most
important principle of continent urinary reservoir
construction.
• the catheterizable channel should be brought up to reach
the skin without tension. It should be short and secured to
the peritoneum beneath anterior abdominal wall fascia to
prevent kinking and problems with catheterization.

15. 1) Nipple valves
• created by
intussuscepting an
intestinal segment to
create a sphincteric
compression
mechanism.

16. 2) Mitrofanoff
• using the vermiform appendix
• Its opened distal end was implanted submucosally, and
the base was brought to the abdominal wall.
• His principle was that any supple tube implanted
submucosally with sufficient muscle backing acts as a
flap valve and results in a reliable continent
cutaneous catheterizable channel.
• As the reservoir fills, the rise in intravesical pressure is
transmitted through the epithelium and to the
implanted conduit, clothing its lumen.

17. Mitrofanoff

18. 3) Yang-Monti technique
• In this procedure, a 2
cm segment of small
bowel is opened
longitudinally along the
antimesenteric border
and then closed
transversely.
• its problem is the
relatively short length of
the channel.

19. 4) Casale
• modification of Yang-
Monti technique
• Increase length of the
tube
• Two segment open
opposite each other
Paramesentric
• But its blood supply is
irreliable.

20. 5) In situ ileocecal valve
• used as continence
mechanism in
reservoirs formed by
the cecum
• A short segment of
terminal ileum, whether
tailored or not, is used
as catheterizable
channel.

21. 6) Continent Vesicostomy
• Parallel incisions 3 cm
apart are made into the
anterior bladder and used
to form a long rectangular
flap.
• The full-thickness strip is
tubularized down to the
bladder.
• The bladder mucosa from
either side of the tube is
then mobilized and closed
over the mucosal tube to
create a flap valve.

22. Complication of cutaneous urinary
stoma
Early complications
–Ischemia
–hemorrhage
–stenosis
–fistula
–retraction.
Late complications
– Prolapse
– obstruction
– para stomal
hernia
– skin irritation

23. Stoma Ischemia/Necrosis
Causes
–Aggressive
stripping of
mesentery
–Stenotic fascia
defect
–Extensive tension

24. Hemorrhage
• Mild hemorrhage common and self limiting.
– Usually mucosal.
– Apply pressure
• Active bleeding
– Implies failure to ligate a mesenteric vessel
– Identify and ligate.

25. Stomal Stenosis/Stricture
• Could manifest early or
late
• Ischemia is usual
underlying factor
• May leads to upper-tract
obstruction.
• Other causes: -Infection
and retraction
• Treat initially with dilation
• Definitive Stoma revision

26. Edema
• TTT mainly medical.

27. Mucocutaneous Separation
• Separation along
mucocutaneous border
• Caused by underlying
tension or separation of
sutures
• Usually treated
medically.
• Could lead to stricture.

28. Peristomal abscess and fistula
• Caused mainly by
infected
hematoma
• May lead to fistula

29. Stoma Retraction
• Causes
– Tension
– Obesity
– Steroids use. Poor
wound healing
• Can lead to leakage and
severe skin problem.
• Most eventually need
revision

30. Prolapse

31. Parastomal Hernia
• Predisposing factors
– Stoma placement lateral to rectus
(common)
– Large stoma
– Obesity
– Prior abdominal incisions
– Malnutrition
– Wound infection
• May present with
intestinal obstruction
• Minor cases ttt by
Abdominal binder
• Major cases – Repair
with mesh.

32. Peristomal Skin Complication
causes
• Due to prolonged contact of the skin with
urine.
• Pressure trauma from belt
• Allergic reaction in sensitive patient.

33. Skin Complications
• Fungal infections
• Ttt by Antifungal
powder
(Nystatin) or
systemic therapy
with fluconozole

34. Skin Complications
(Pyoderma Gangrenosum)
• Treatment conflicting
–Wound
debridement
–Steroids
injection
–Systemic
therapy

35. Skin Complications
• Allergic contact
dermatitis
• Ttt by Identify irritant
(skin patch test) and
discontinue products.
• Apply hydrocortisone
cream for short period
• Topical antihistamines

36. Skin Complications(Granulomas)
May be due to
– Granulation
tissue (poor
wound healing
and infection)
–Bowel
metaplasia

37. Skin Complications(Stoma warts)
• Warty raised
macerated
lesions around
the stoma.
• May cause
bleeding and
pain.

38. Pyelonephritis & Renal Deterioration
• Pyelonephritis occurs in approximately 10% of
patients who have undergone urinary diversion.
• Obstruction and stasis of urine within the
reconstructed urinary tract are risk factors for the
development of infection
• The presence of hydronephrosis, particularly in
patients with a conduit diversion, may indicate
the presence of ureteric reflux or obstruction at
the ureterovesical junction.

39. finally
• “care and expertise are important in
creating urinary stomas because
some patients must live with the
technical result for the rest of their
lives”

40. Thank you