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Stoma Site Marking

Preoperative stoma site marking is the strongest single intervention available before a urinary diversion — ileal conduit, cutaneous ureterostomy, or continent cutaneous reservoir — for reducing stoma-related morbidity and protecting quality of life. Marking is associated with lower complication rates (OR 0.47), improved self-care (OR 0.34), and better health-related quality of life across pooled cohorts, and is endorsed by a joint position statement from the ASCRS, WOCN Society, and the AUA.[1][2][3]

See also: Ileal Conduit, Cutaneous Ureterostomy, Principles of Urinary Diversion, Bowel Anastomosis, Incisions & Closure.

Why Preoperative Marking Matters​

A systematic review and meta-analysis of 2,109 patients found that preoperative marking reduced stoma and peristomal complications across the board — including prolapse, retraction, necrosis, peristomal skin breakdown (OR 0.52), and parastomal hernia (OR 0.25).[1] Burgess-Stocks et al. (2022), validating the WOCN Patient Bill of Rights against the literature, confirmed that preoperative marking — regardless of ostomy type (fecal or urinary) — produces better quality of life, greater patient confidence and independence, and lower complication rates.[3]

The baseline matters: stomal complications occur in approximately 15% of ileal-conduit patients, with parastomal hernia the most common single complication.[4] Marking does not eliminate these events, but it shifts the curve meaningfully — particularly for the soft-tissue-failure endpoints (skin breakdown, leakage, hernia) that drive long-term morbidity after the immediate postoperative period.

Who Should Perform the Marking​

Marking by a certified Wound, Ostomy, and Continence (WOC) nurse is the gold standard.[1][3] When surgeons and trainees were evaluated against WOC-nurse-selected sites, their chosen locations were a median 2 cm away from the nurse's preferred site, and most "badly sited" stomas were placed too low on the abdominal wall. Surgeon seniority did not improve accuracy.[1] Surgical training in stoma site selection has been described as haphazard and infrequently involving WOC nurse specialists.[1]

When a WOC nurse is genuinely unavailable — emergent cases, low-resource settings, off-hours — other trained providers (surgeon, surgical resident with explicit training, advanced practice provider) may perform the marking. The marker should still apply the same checklist below; "no WOC nurse available" is not a license to mark from memory at the operating table.[1]

Principles of Stoma Site Selection​

For an ileal conduit, the standard location is the right lower quadrant, typically at approximately one-third of the distance from the right anterior superior iliac spine to the umbilicus, brought through the rectus abdominis muscle.[5][6][7]

The site-selection checklist:

  • Evaluate in supine, sitting, and standing positions to identify how skin folds and body contours shift between resting and weight-bearing.[1][8]
  • Place within the rectus abdominis muscle to reduce parastomal hernia risk.[1][7]
  • Avoid skin folds, creases, scars, bony prominences (iliac crest, costal margin), the umbilicus, and the beltline / waistline.[7][8]
  • Confirm the patient can visualize and access the stoma for self-care, accounting for age, vision, dexterity, and any disability that affects reach.[3][8]
  • Ensure ≥ 5 cm (≈ 2 in) of flat peristomal skin around the planned site to allow secure pouching-system adhesion.[7]
  • Mark the day before surgery with an indelible marker (small "X" or dot); consider marking a backup site on the contralateral side in case intraoperative findings dictate a change.[6]

Special Populations​

Obese Patients (BMI > 25 kg/m²)​

Obesity is a strong independent risk factor for stomal complications, particularly parastomal hernia.[4] In obese patients an upper abdominal site may be preferable to avoid the deep lower-abdominal panniculus, and intraoperative techniques to gain conduit length (selective mesenteric vessel ligation, transverse vs distal ileal harvest) may be required to reach a more cephalad stoma. Convex pouching systems and ostomy belts are frequently needed postoperatively.[1][5][7]

Wheelchair-Bound or Neurologically Impaired Patients​

The stoma site must be assessed with the patient seated in their own wheelchair to ensure it is accessible and not obscured by the chair, a lap tray, or an abdominal pannus in the seated position. The 5th International Consultation on Incontinence specifically recommends a preoperative wheelchair test for neurogenic-bladder patients undergoing ileal conduit; failure to do this is a recurrent cause of stoma-care failure in long-term NLUTD patients.[9]

Patients With Prior Abdominal Surgery​

Previous scars, drain sites, and existing stomas must be avoided. When the standard right lower quadrant site is unavailable because of prior surgery, the contralateral side or an upper quadrant site is considered; the constraints on rectus placement and peristomal skin quality apply equally.

Construction Linkages — Marking Is Half the Equation​

Even an optimally marked site fails if the stoma is constructed flush with the skin. A multicenter analysis confirmed a direct correlation between stoma protrusion and patient success in self-care.[3] Flush stomas should be avoided whenever technically feasible — they predispose to leakage and peristomal skin complications.[3][7] For ileal conduit, the stoma is typically matured as an everted "rosebud" approximately 2–3 cm above the skin.[10]

Intracorporeal stomal preparation before abdominal-wall transposition — described by Taneja and Godoy — improves symmetry and reduces retraction and stenosis compared with traditional skin-side maturation.[10]

Preoperative Education​

Site marking should be accompanied by comprehensive preoperative ostomy education, which is itself a standard of care. Education should cover anatomy, the planned procedure, lifestyle expectations, an introduction to the pouching system, and psychological preparation.[1][3] Preoperative education has been associated with shorter length of stay (8 vs 10 days, p = 0.02) and faster time to ostomy-care proficiency (5.5 vs 9 days) in pooled data summarized by the ASCRS guideline.[1]

Summary Checklist​

  1. Consult a WOC nurse preoperatively (ideally the day before surgery).
  2. Assess the abdomen in supine, sitting, and standing positions.
  3. Identify the rectus abdominis muscle — right side for ileal conduit by default.
  4. Select a flat area with ≥ 5 cm of smooth peristomal skin.
  5. Avoid scars, folds, bony prominences, umbilicus, and beltline.
  6. Confirm the patient can see and reach the site.
  7. Perform a wheelchair-seated assessment when applicable.
  8. Mark with indelible ink the day before surgery; consider a backup contralateral site.
  9. Deliver preoperative ostomy education concurrently with marking.

References​

1. Davis BR, Valente MA, Goldberg JE, et al. "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Ostomy Surgery." Dis Colon Rectum. 2022;65(10):1173–1190. doi:10.1097/DCR.0000000000002498

2. Kim YM, Jang HJ, Lee YJ. "The Effectiveness of Preoperative Stoma Site Marking on Patient Outcomes: A Systematic Review and Meta-Analysis." J Adv Nurs. 2021;77(11):4332–4346. doi:10.1111/jan.14915

3. Burgess-Stocks J, Gleba J, Lawrence K, Mueller S. "Ostomy and Continent Diversion Patient Bill of Rights: Research Validation of Standards of Care." J Wound Ostomy Continence Nurs. 2022;49(3):251–260. doi:10.1097/WON.0000000000000876

4. Kouba E, Sands M, Lentz A, Wallen E, Pruthi RS. "Incidence and Risk Factors of Stomal Complications in Patients Undergoing Cystectomy With Ileal Conduit Urinary Diversion for Bladder Cancer." J Urol. 2007;178(3 Pt 1):950–4. doi:10.1016/j.juro.2007.05.028

5. Zhang WJ, Huang XY, Lin B, et al. "The Effect of Body Mass Index on Quality of Life in Modified Single Stoma Cutaneous Ureterostomy or Ileal Conduit After Radical Cystectomy." Cancer Med. 2023;12(22):20930–20939. doi:10.1002/cam4.6638

6. Akakpo W, Chartier-Kastler E, Joussain C, et al. "Outcomes of Ileal Conduit Urinary Diversion in Patients With Multiple Sclerosis." Neurourol Urodyn. 2020;39(2):771–777. doi:10.1002/nau.24279

7. Hedrick TL, Sherman A, Cohen-Mekelburg S, Gaidos JKJ. "AGA Clinical Practice Update on Management of Ostomies: Commentary." Clin Gastroenterol Hepatol. 2023;21(10):2473–2477. doi:10.1016/j.cgh.2023.04.035

8. Panattoni N, Mariani R, Spano A, et al. "Nurse Specialist and Ostomy Patient: Competence and Skills in the Care Pathway. A Scoping Review." J Clin Nurs. 2023;32(17-18):5959–5973. doi:10.1111/jocn.16722

9. Drake MJ, Apostolidis A, Cocci A, et al. "Neurogenic Lower Urinary Tract Dysfunction: Clinical Management Recommendations of the Neurologic Incontinence Committee of the Fifth International Consultation on Incontinence 2013." Neurourol Urodyn. 2016;35(6):657–65. doi:10.1002/nau.23027

10. Taneja SS, Godoy G. "Creation of Urinary Stoma Before Abdominal Wall Transposition of Ileal Conduit Improves Stomal Protrusion, Eversion, and Symmetry." Urology. 2009;73(4):893–5. doi:10.1016/j.urology.2008.10.051