Surgical Revision of Closed Cutaneous Ureterostomy
The definitive treatment for a cutaneous ureterostomy that has closed due to skin coverage is surgical revision through local stomal revision, which involves excising the overlying skin, mobilizing the ureteral segment, and re-maturing the stoma with proper technical modifications to prevent recurrence. 1
Immediate Surgical Approach
Excise the skin covering the stomal opening and mobilize the ureteral segment to bring it back to skin level. 1 The key is to create adequate stomal protrusion of at least 1-2 cm above the skin surface to prevent recurrence. 1
Critical Technical Modifications to Prevent Re-stenosis
The surgical technique must incorporate specific modifications that have dramatically improved outcomes:
Perform YV plasty of the ureter with edge-to-edge anastomosis for stomal creation rather than simple puncture technique, as the puncture method leads to restenosis. 2, 3
Fix the abdominal wall hiatus with 4 interrupted sutures between the anterior and posterior rectus sheath to maintain stability of the abdominal wall tunnel. 4, 2 This modification improved catheter-free rates from 60.5% to 89.8% in one series. 4
Create a fish-mouth opening by cutting the distal ureter longitudinally and suture each separated ureteral segment to the corresponding skin area (with epidermis and dermis removed) to ensure firm fixation and healing by first intention. 5
Ensure the stoma passes through the rectus muscle to provide fascial support and reduce risk of retraction and hernia. 1
Additional Technical Considerations
Mobilize the ileocecal segment and reposition it above the terminal ureter to provide additional support and prevent kinking. 2
If bilateral cutaneous ureterostomy, transpose the left ureter above the inferior mesenteric artery to reduce the higher risk of left-sided obstruction. 2
Consider preserving the parietal peritoneum and fixing ureteral orifices to one another in single-site bilateral ureterostomies, which achieved 76.9% catheter-free rates versus 42.3% with standard technique. 6
Perioperative Stenting Strategy
Place ureteral stents at the time of revision and maintain them for greater than 3 months. 2 Long-term stenting (>3 months) significantly reduced left ureteral obstruction compared to early removal (<3 months): 4.5% versus 13.7% obstruction rates. 2 This is particularly critical for the left ureter, which has a 9.9% obstruction rate overall. 2
Common Pitfalls to Avoid
Never attempt conservative management with catheterization or dilation alone when skin completely covers the opening - this will fail and only delay definitive surgical treatment. 1
Avoid inadequate mobilization of the ureteral segment - insufficient length will lead to tension and recurrent stenosis. 1
Do not place the stoma outside the rectus muscle during revision, as this increases risk of retraction and parastomal hernia. 1
Never use a simple puncture technique for the ureterostomy - this consistently leads to stomal stenosis and requires the flap-based technique described above. 3
Preoperative Planning
Consult wound ostomy continence (WOC) nursing for preoperative stoma site marking if relocation is planned. 1
Ensure any existing ureteral stents are functioning if present in the system. 1
Assess for concurrent complications (such as parastomal hernia or contralateral ureteral obstruction) that may require simultaneous repair. 1