How to revise a urostomy opening that is covered with skin?

Surgical Revision of Skin-Covered Urostomy Opening

A skin-covered urostomy opening requires surgical revision with excision of the overlying skin and re-maturation of the stoma to restore proper urinary drainage and prevent complications including infection, hydronephrosis, and renal damage.

Immediate Assessment and Planning

The first priority is to assess whether this represents:

• Complete stomal retraction with skin overgrowth covering the opening
• Stomal stenosis with progressive narrowing and skin encroachment
• Partial coverage requiring urgent versus semi-urgent intervention 1

Evaluate for signs of urinary obstruction including decreased output, flank pain, fever, or signs of upper tract compromise, as these indicate urgent surgical need 2, 3.

Surgical Approach

The definitive treatment is surgical revision through local stomal revision or formal stomal relocation:

Local Stomal Revision (First-Line)

• Excise the overlying skin circumferentially around the stoma site
• Mobilize the bowel segment (typically ileal conduit) to bring it back to skin level
• Re-mature the stoma by suturing the mucosal edge to the skin with interrupted absorbable sutures, ensuring adequate protrusion (typically 1-2 cm above skin level) 1
• Place the stoma through the rectus muscle if not already positioned there to minimize future complications 1

Stomal Relocation (If Local Revision Fails)

• Consider formal relocation to a new site if:
  • Multiple previous revisions have failed
  • Significant scarring prevents adequate mobilization
  • Concurrent parastomal hernia requiring repair 1
• However, note that moving the stoma carries significant risk of parastomal hernia at the new location (up to 50% within 5 years), so this should be reserved for cases where local revision is not feasible 1

Critical Technical Considerations

Key surgical principles to prevent recurrence:

• Ensure adequate stomal protrusion of at least 1-2 cm above the skin surface to prevent urine contact with peristomal skin 4, 5
• Create appropriate stomal diameter - the opening should fit snugly around the stoma without constriction but without excessive space that allows urine leakage onto skin 5
• Position through rectus muscle to provide fascial support and reduce risk of retraction and hernia 1
• Avoid tension on the bowel segment during maturation as this predisposes to retraction 1

Perioperative Management

Preoperative considerations:

• Consult wound ostomy continence (WOC) nursing for preoperative stoma site marking if relocation is planned 1
• Assess for concurrent complications requiring simultaneous repair (parastomal hernia, stenosis) 1
• Ensure ureteral stents are functioning if present in the ileal conduit 1

Postoperative care:

• Immediate pouching with transparent appliance to monitor stoma viability 2
• Monitor for adequate urinary output (should be continuous from urostomy) 2, 3
• Assess stoma color (should be pink/red; dusky or black indicates ischemia requiring urgent re-exploration) 1

Common Pitfalls to Avoid

• Do not attempt conservative management with catheterization or dilation alone when skin completely covers the opening - this will fail and delay definitive treatment 1
• Avoid inadequate mobilization of the bowel segment, which leads to tension and recurrent retraction 1
• Do not create excessive stomal opening in the appliance faceplate, as chronic urine exposure causes pseudoverrucose skin lesions and further complications 5
• Avoid placing stoma outside the rectus muscle during revision, as this significantly increases parastomal hernia risk 1

Long-Term Follow-Up

Patients require ongoing monitoring by WOC specialists or urologic nursing for:

• Proper appliance fit and changing technique (typically every 4-7 days for urostomy) 1, 2
• Peristomal skin assessment for complications 4, 3
• Stomal assessment for recurrent stenosis or retraction 2, 3
• Education on signs of complications requiring urgent evaluation 6, 2