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Colon Shuffle

The Colon Shuffle is a modified incontinent colon conduit urinary diversion developed at the Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital (NKI-AVL) in Amsterdam, formally described by Meijer, Mertens, Meinhardt, et al. in 2015.[1] The technique is designed for patients who already have a colostomy or who simultaneously require a colon/rectum resection along with urinary diversion. The core concept uses the distal (defunctionalized) segment of the transected colon as a urinary conduit while creating a new colostomy from the proximal colon on the contralateral side of the abdomen.

Clinical Rationale​

A significant subset of patients requiring urinary diversion present with complex pelvic pathology that also requires fecal diversion — most commonly:

  • Locally advanced or recurrent rectal cancer requiring pelvic exenteration
  • Locally advanced bladder cancer with rectal involvement
  • Radiation-induced pelvic damage (fistulae, cystitis, proctitis) after treatment for cervical, rectal, or bladder cancer
  • Patients who already have a colostomy from prior surgery and now require urinary diversion

In these patients, the standard ileal conduit (Bricker) requires an additional ileo-ileal anastomosis to restore small-bowel continuity, which adds operative time, morbidity, and the risk of anastomotic leak — particularly problematic in irradiated patients.[1][2][3]

The Colon Shuffle addresses this problem by repurposing the distal colon — which would otherwise be discarded or defunctionalized after colonic resection — as a urinary conduit. The term "shuffle" refers to the rearrangement of stoma function: the existing or planned colostomy site is converted to a urostomy, and a new colostomy is created from the proximal colon on the opposite side of the abdomen.[1]

The Colon Shuffle is conceptually related to several earlier techniques for managing simultaneous urinary and fecal diversion.

  • Davis and Noble (1992) — used a preexisting or newly created colostomy as the urinary stoma for a colon conduit, with a proximal colostomy for fecal diversion, avoiding any bowel anastomosis (n = 14).[4]
  • Carter, Dalton, and Garnett (1989, 1994) — described the double-barreled wet colostomy: a single abdominal stoma for both urinary and fecal diversion, with a loop colostomy divided 10–15 cm distal to the stoma (n = 11; follow-up to 80 mo).[5][6]
  • Alemozaffar et al. (2019) — 41 patients with distal colon (sigmoid/descending) urinary conduit during pelvic exenteration, specifically to avoid small-bowel anastomosis.[3]

The Colon Shuffle differs from the double-barreled wet colostomy in that it creates two separate stomas (one for urine, one for feces) rather than a single combined stoma — simplifying stoma care and avoiding mixing of urinary and fecal streams.[1]

Indications​

The Colon Shuffle is indicated in two primary clinical scenarios:[1]

  1. Patients with a preexisting colostomy who subsequently require urinary diversion (e.g., progressive bladder dysfunction, fistula, or new bladder malignancy after prior rectal surgery).
  2. Patients who simultaneously require colon/rectum resection and urinary diversion (e.g., pelvic exenteration for locally advanced rectal cancer invading the bladder; locally advanced bladder cancer requiring en bloc rectosigmoid resection).

The technique is particularly advantageous in patients with prior pelvic radiation — comprising 90.4% of the NKI-AVL series — because it avoids the need for an ileal conduit and its associated ileo-ileal anastomosis in irradiated tissue.[1]

Surgical Technique​

Scenario 1 — Preexisting Colostomy​

  1. The existing colostomy is taken down.
  2. The distal (defunctionalized) colon segment — between the colostomy site and the rectal stump — is mobilized and assessed for viability and adequate length to reach the ureters.
  3. The ureters are mobilized and anastomosed to the distal colon segment (ureterocolonic anastomosis), creating a colon conduit.
  4. The distal end is brought to the abdominal wall as a urostomy (typically at the previous colostomy site or a new site).
  5. A new colostomy is created from the proximal colon on the contralateral side for fecal diversion.

The colostomy has been "shuffled" — the old colostomy site becomes the urostomy, and a new colostomy is created on the opposite side.

Scenario 2 — Simultaneous Colon Resection + Urinary Diversion​

  1. The colon/rectum resection is performed (e.g., low anterior, abdominoperineal, or pelvic exenteration).
  2. The colon is transected at the appropriate level.
  3. The distal segment (which would otherwise be discarded or left as a Hartmann stump) is used as the urinary conduit.
  4. The ureters are anastomosed to this distal colon segment.
  5. The distal end is brought out as a urostomy.
  6. The proximal colon is brought out as a colostomy on the contralateral side.

No bowel anastomosis is required; both fecal and urinary streams exit through separate stomas.

Advantages​

The Colon Shuffle offers several advantages over standard ileal conduit in this patient population.[1][2][3][7]

  1. Avoids bowel anastomosis — no ileo-ileal anastomosis, eliminating leak risk in irradiated tissue. In Cotter et al. (2017), the no-bowel-anastomosis (NBA) approach had lower intraoperative (p = 0.04) and early postoperative (p = 0.02) complication rates vs the bowel-anastomosis group.[7]
  2. Uses otherwise discarded bowel — the distal segment that would be defunctionalized is repurposed.
  3. Avoids ileal harvest — preserves the terminal ileum, reducing bile-salt malabsorption, B12 deficiency, and diarrhea risk.
  4. Colon is radiation-resistant relative to ileum — the transverse and descending colon usually lie outside the pelvic radiation field; the thick colonic wall facilitates reliable ureteral reimplantation.[3][8][9]
  5. Reduced operative time — no ileal harvest, no ileo-ileal anastomosis, no mesenteric closure.
  6. Stomal advantages — colon conduit stomas have less stenosis and a larger caliber than ileal-conduit stomas.[9]

Clinical Outcomes — NKI-AVL Series (Meijer 2015)​

ParameterResult
Patients21 (14 male, 7 female)
Mean age61.5 years
Prior pelvic radiotherapy90.4% (19/21)
IndicationsLocally advanced/recurrent rectal cancer, bladder cancer, cervical cancer, radiation damage
Short-term complications (30 d)52.4% (11/21)
Major complications (anastomotic leak, fecal peritonitis)0%

Source: Meijer 2015.[1] Despite the 52.4% complication rate (reflecting the high-risk population), no major complications such as bowel anastomotic leakage or fecal peritonitis occurred — a notable achievement in a cohort where > 90% had prior pelvic radiation.

Supporting Evidence — Colon Conduit Outcomes​

Multi-Institutional Colon Conduit Study (Hebert 2026, n = 179)​

The largest contemporary CCUD series (Reconstruction and Diversion: Improving Outcomes Group):[2]

ParameterResult
Patients179 (median age 61)
Prior radiation therapy63.7%
Prior abdominal surgery72%
30-day high-grade complications28.5%
30–90-day high-grade complications14.5%
90-day mortality4.5%
90-day reintervention30.2%
Most common late complicationUreteral stent / nephrostomy tube (16.8%)
Colonic anastomosis associated with worse 30-day outcomesNo
Hypoalbuminemia (< 3.2 g/dL) associated with 30–90-day high-grade complicationsYes (HR 0.18 protective for albumin ≥ 3.2)

This study substratified into three groups: CCUD with colonic anastomosis, CCUD with colostomy, and colostomy switch (essentially the Colon Shuffle concept). The presence of a colonic anastomosis was not associated with worse 30-day outcomes; hypoalbuminemia was the dominant predictor of complications.[2]

Colon vs Ileal Conduit in Pelvic Exenteration (Hagemans 2020)​

In 214 ileal vs 45 colon conduits after exenteration for rectal cancer:[10]

  • Ileal conduit: higher postoperative ileus (21% vs 7%, p = 0.024).
  • Ileo-ileal anastomotic leak in 4% of ileal conduits — entirely avoided with colon conduit.
  • No difference in uretero-enteric anastomotic leak, urological complications, mortality, major complications, or hospital stay.

Cotter (2017) — No-Bowel-Anastomosis Approach​

In 43 patients with preexisting colostomy undergoing urinary diversion, the NBA group (n = 10, analogous to the Colon Shuffle) had:[7]

  • Lower intraoperative complications (p = 0.04)
  • Lower early postoperative complications (p = 0.02)
  • Similar stomal complications, ureteral obstruction, and reoperation rates

Complications​

Short-Term​

The 52.4% short-term complication rate in the NKI-AVL series reflects the high-risk patient population (90% prior radiation, complex pelvic surgery) rather than an inherent flaw of the technique. Importantly, no anastomotic leaks or fecal peritonitis occurred.[1]

Colon-Conduit-Specific​

ComplicationIncidence
Uretero-enteric stricture5–16.8%
Pyelonephritis / UTI7–24%
Hyperchloremic metabolic acidosis24–34%
Hypokalemia39%
Stomal complications (stenosis, hernia)4–12%
Postoperative ileus7–20%
Conduit stones5–7%

Sources: Hebert 2026; Alemozaffar 2019; Hagemans 2020; Dagen 1980.[2][3][10][11]

Metabolic Considerations​

Colon conduits are associated with hyperchloremic metabolic acidosis due to chloride-bicarbonate exchange across the colonic mucosa. In Alemozaffar 2019, 34.1% developed metabolic acidosis and 24.4% developed hyperchloremia at ≥ 90 days. Monitoring and oral alkali supplementation may be required.[3] See Urinary Acidifiers & Alkalinizers.

Limitations of the Colon Shuffle Specifically​

  • Limited published data — only the NKI-AVL series of 21 patients has been published under the "Colon Shuffle" name; no long-term follow-up.[1]
  • Dependent on adequate distal colon — the technique requires a viable, non-irradiated distal colon segment of sufficient length to reach the ureters and abdominal wall.
  • Two stomas — unlike the double-barreled wet colostomy (single stoma), the Colon Shuffle requires two separate stomas, which may impact body image and QoL.
  • Not continent — the Colon Shuffle is an incontinent conduit requiring an external appliance, not a continent reservoir.
FeatureColon ShuffleDouble-Barreled Wet ColostomyDavis/NobleStandard Ileal Conduit + Colostomy
Number of stomas2 (separate urostomy + colostomy)1 (combined)2 (separate)2 (separate)
Bowel anastomosis requiredNoNoNoYes (ileo-ileal)
Urinary-fecal stream separationCompletePartial (internal at stoma)CompleteComplete
Ileal harvest requiredNoNoNoYes
Stoma care complexityModerate (2 appliances)Low (1 appliance)ModerateModerate
Risk of ascending UTI from fecal contaminationLowHigher (shared stoma)LowLow
Published series size21 (NKI-AVL)11–4114Standard of care

Current Status​

The Colon Shuffle occupies a niche but important role in the armamentarium of urinary diversion. It is best suited for patients requiring simultaneous urinary and fecal diversion — particularly those with prior pelvic radiation — where avoiding an ileal conduit and its associated bowel anastomosis can reduce morbidity.[1][2][7]

The Hebert 2026 multi-institutional study reinforces that colon conduit urinary diversion remains an important option when ileum is not clinically feasible, and that the presence of a colonic anastomosis does not worsen short-term outcomes; hypoalbuminemia is the dominant modifiable predictor of complications.[2]

The Colon Shuffle's primary contribution is its elegant simplicity — repurposing bowel that would otherwise be discarded, avoiding additional anastomoses, and preserving the ileum — making it a pragmatic solution for a challenging clinical problem.[1]

Key Takeaways​

  1. The Colon Shuffle (Meijer/NKI-AVL 2015) repurposes the distal colon as an incontinent urinary conduit while creating a new proximal colostomy on the contralateral side — no ileal harvest, no ileo-ileal anastomosis, two separate stomas.[1]
  2. Specifically valuable in patients with preexisting colostomy or who simultaneously require colon/rectum resection — particularly after prior pelvic radiation (90.4% of the NKI-AVL cohort).[1]
  3. NKI-AVL outcomes: 52.4% short-term complications but no anastomotic leaks or fecal peritonitis — strong safety signal in a high-risk population.[1]
  4. Supported by broader colon-conduit evidence (Hebert 2026 n = 179; Hagemans 2020 lower ileus; Cotter 2017 NBA-favorable outcomes) — colon conduit is a legitimate option when ileum is suboptimal.[2][7][10]
  5. Hypoalbuminemia is the dominant modifiable predictor of complications across the colon-conduit literature; nutritional optimization is critical.[2]
  6. Hyperchloremic metabolic acidosis (24–34%) and hypokalemia (39%) require lifelong monitoring and possible alkali supplementation.[3]
  7. Distinct from the double-barreled wet colostomy (single shared stoma), which has higher ascending-UTI risk; the Colon Shuffle's two-stoma configuration separates urinary and fecal streams.[5][6][12]

See Also​

References​

1. Meijer RP, Mertens LS, Meinhardt W, et al. "The Colon Shuffle: A Modified Urinary Diversion." Eur J Surg Oncol. 2015;41(9):1264–8. doi:10.1016/j.ejso.2015.02.007

2. Hebert KJ, Swinney S, Johnson R, et al. "Outcomes After Colon Conduit Urinary Diversion: A Multi-Institutional Retrospective Study From the Reconstruction and Diversion: Improving Outcomes Group." J Urol. 2026;215(5):621–32. doi:10.1097/JU.0000000000004935

3. Alemozaffar M, Nam CS, Said MA, et al. "Avoiding the Need for Bowel Anastomosis During Pelvic Exenteration — Urinary Sigmoid or Descending Colon Conduit — Short and Long Term Complications." Urology. 2019;129:228–33. doi:10.1016/j.urology.2019.03.015

4. Davis BE, Noble MJ. "Simplified Urinary Diversion in Patients With Preexisting or Imminent Colostomy." J Urol. 1992;147(5):1245–7. doi:10.1016/s0022-5347(17)37529-8

5. Carter MF, Dalton DP, Garnett JE. "Simultaneous Diversion of the Urinary and Fecal Streams Utilizing a Single Abdominal Stoma: The Double-Barreled Wet Colostomy." J Urol. 1989;141(5):1189–91. doi:10.1016/s0022-5347(17)41210-9

6. Carter MF, Dalton DP, Garnett JE. "The Double-Barreled Wet Colostomy: Long-Term Experience With the First 11 Patients." J Urol. 1994;152(6 Pt 2):2312–5. doi:10.1016/s0022-5347(17)31665-8

7. Cotter KJ, Gor RA, Kwaan MR, et al. "Urinary Diversion With vs Without Bowel Anastomosis in Patients With an Existing Colostomy: A Multi-Institutional Study." Urology. 2017;109:190–4. doi:10.1016/j.urology.2017.06.036

8. Hagen-Cook K, Althausen AF. "Early Observations on 31 Adults With Non-Refluxing Colon Conduits." J Urol. 1979;121(1):13–6. doi:10.1016/s0022-5347(17)56642-2

9. Morales P, Golimbu M. "Colonic Urinary Diversion: 10 Years of Experience." J Urol. 1975;113(3):302–7. doi:10.1016/s0022-5347(17)59468-9

10. Hagemans JAW, Voogt ELK, Rothbarth J, et al. "Outcomes of Urinary Diversion After Surgery for Locally Advanced or Locally Recurrent Rectal Cancer With Complete Cystectomy; Ileal and Colon Conduit." Eur J Surg Oncol. 2020;46(6):1160–6. doi:10.1016/j.ejso.2020.02.021

11. Dagen JE, Sanford EJ, Rohner TJ. "Complications of the Non-Refluxing Colon Conduit." J Urol. 1980;123(4):585–7. doi:10.1016/s0022-5347(17)56031-0

12. Golda T, Biondo S, Kreisler E, et al. "Follow-Up of Double-Barreled Wet Colostomy After Pelvic Exenteration at a Single Institution." Dis Colon Rectum. 2010;53(5):822–9. doi:10.1007/DCR.0b013e3181cf6cb2