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Cutaneous Ureterostomy

Cutaneous ureterostomy (CU) is the simplest form of incontinent urinary diversion — one or both ureters are brought directly through the abdominal wall to the skin surface, creating a stoma without using any bowel segment.[1][2] It is primarily used in elderly, frail, and highly comorbid patients undergoing radical cystectomy who may not tolerate the additional operative time and bowel manipulation of an ileal conduit.[1][3][4]

CU was one of the earliest urinary diversions but fell out of favor due to high stomal-stenosis rates. It has experienced a resurgence as tubeless techniques have matured and the elderly bladder-cancer population has grown.[4][8]

Configurations​

ConfigurationDescription
Single-stoma (SSCU)Both ureters brought to one abdominal stoma — typically left ureter transposed across the midline (transureteroureterostomy) before exteriorization[2][3]
Bilateral-stoma (BSCU)Each ureter brought to its own stoma on each side of the abdomen[5]
UnilateralSingle ureter exteriorized — solitary functioning kidney or palliative[6][7]

Urine drains continuously into an external collection device, similar to an ileal conduit, but no intestinal segment is interposed.

Indications​

CU is considered in:[1][2][3][4][7][6]

  • Elderly patients (≥ 75 yr) with high comorbidity burden (ASA ≥ 3)
  • Limited life expectancy where minimizing operative time is paramount
  • Prior extensive abdominal surgery / radiation precluding safe bowel mobilization
  • Palliative urinary diversion for ureteral obstruction from pelvic malignancy
  • Inflammatory bowel disease or short-bowel syndrome (bowel-diversion contraindications)
  • Unfit for general anesthesia — CU can be performed under spinal/epidural via extraperitoneal approach[6]
  • Pediatric: end CU as temporizing measure for severe megaureter / hydronephrosis awaiting reimplant[9]

Surgical Technique​

The unifying goal across techniques is a tubeless (catheter-free) stoma that drains freely without chronic indwelling stents.

Rodríguez technique (largest adult series, n = 310)[10]​

  1. Transposition of the left ureter above the inferior mesenteric artery
  2. Mobilization of the ileocecal segment with repositioning above each terminal ureter
  3. Abdominal-wall hiatus fixation with 4 angle sutures
  4. Y-V plasty of the ureters with edge-to-edge anastomosis for stomal creation
  5. Double-J stents postoperatively — prolonged stenting (> 3 mo) recommended for the left ureter (significantly reduces left obstruction: 4.5% vs 13.7%, p = 0.01)

Toyoda technique (Japanese origin, widely used)[11][12]​

  • Tubeless stoma created by everting ureteral mucosa and suturing to skin
  • Tubeless condition in 89% of renal units; 51% with no hydronephrosis at long-term follow-up

Modified tubeless techniques​

Modifications including abdominal-wall tunnel stabilization with rectus-sheath fixation sutures improved catheter-free rates from ~ 72% (Toyoda) to ~ 91%.[12][13]

Extraperitoneal approach for the very frail[6]​

Total extraperitoneal radical cystectomy with CU under combined spinal-epidural anesthesia — flatus passage POD 1, median LOS 7 days.

Perioperative Outcomes — Advantages over Ileal Conduit​

CU consistently demonstrates perioperative advantages despite older / more comorbid CU populations:

ParameterCutaneous UreterostomyIleal Conduitp
Operative timeSignificantly shorterLonger0.001[1][2]
EBLSignificantly lessMore0.001[1]
LOS4 days medianLonger0.001[1][3][4]
Time to regular diet3 days medianLonger0.01[3][4]
ICU requirementLowerHigher0.01–0.03[1][2]
Intraoperative complications13.7%40%0.035[2]
Early postoperative complications24.1%60%0.012[2]
Wound infectionOR 0.33OR 3.020.004[5]
Early pyelonephritisOR 0.33OR 3.040.02[5]

Despite CU patients being significantly older and more comorbid, 90-day and 365-day mortality are comparable to ileal conduit.[2] SEER analysis of patients ≥ 80 yr found no difference in overall or cancer-specific survival (median OS 19 mo in both groups).[15]

Complications​

Stomal stenosis — the hallmark concern​

  • Ureteral obstruction in ~ 13.2%, predominantly affecting the left ureter (9.9%) because of the longer transposition course[10]
  • Management: restenting (55%) → stomal revision (33%) → conversion to ileal conduit (11%)[10]
  • Prolonged stenting > 3 mo significantly reduces left obstruction (4.5% vs 13.7%, p = 0.01)[10]
  • Mayo Clinic series: higher obstruction rates can be pre-emptively addressed with chronic stenting[1]
  • Preoperative stoma site marking by a WOC nurse — in supine, sitting, and standing positions — addresses the soft-tissue contribution to stomal failure (skin folds, beltline, pannus geometry) that aggravates the underlying ureteral-stenosis tendency.

Other[1][16][17][18]​

  • Sepsis — most common 30-day complication (13% in Mayo series)
  • Late UTI / pyelonephritis — more common with CU than IC long-term
  • Nephrolithiasis — increased risk, particularly with chronic stenting
  • Stomal ischemia / necrosis — rare but may require revision
  • Anxiety / depression — higher rates reported with ureterostomy than other diversions
  • Tube dependence — at 12 mo, ~ 70–76% remain tube-free, similar to ileal conduit[19]

Renal function​

In a series of 70 elderly patients (median age 78), median GFR declined from 74.3 → 54.6 mL/min at 6 mo (p < 0.001).[20] Patients requiring chronic catheter / stent placement had significantly higher rates of renal deterioration, pyelonephritis, and urolithiasis.[12]

Metabolic Advantages over Bowel-Based Diversions​

Because no intestinal segment is used:[21]

  • No hyperchloremic metabolic acidosis
  • No vitamin B12 malabsorption
  • No bowel anastomotic complications (leak, obstruction, fistula)
  • No prolonged postoperative ileus

Quality of Life​

  • Tjiaman 2025 SR/meta — IC may offer better physical QoL (FACT scores) than bilateral-stoma CU, but single-stoma CU shows no significant QoL difference vs IC.[14]
  • Single-institution Bladder Cancer Index (BCI) studies — overlapping QoL scores between CU and IC in elderly patients.[3][5]
  • Minimally invasive RC with single-stoma CU — comparable Stoma-QoL to IC at 6 mo with fewer complications (37.4% vs 57.6%).[22]
  • Single-stoma CU has lower ostomy-related costs than bilateral-stoma CU and IC.[5]

Single-stoma vs bilateral-stoma CU[14][5]​

Single-stoma is generally preferred — better physical QoL on meta-analysis, shorter operative time, higher first-catheter-removal success, lower ostomy costs, simpler stoma management.

CU vs Ileal Conduit — Summary​

FeatureCutaneous UreterostomyIleal Conduit
Bowel segment usedNone15–20 cm ileum
Operative timeShorterLonger
Metabolic complicationsNoneAcidosis, B12 deficiency
Bowel complications (ileus, obstruction)None20–29%
Stomal stenosis riskHigher (~ 13%)Lower (5–24%)
Late UTI / pyelonephritisHigherLower
Wound infectionLowerHigher
Overall survival (≥ 80 yr)EquivalentEquivalent
QoL (single-stoma)ComparableComparable
Ideal candidateElderly, frail, high ASABroader population

Long-Term Surveillance​

Lifelong monitoring given stenosis, renal-deterioration, and recurrent-infection risks:[20][12][17]

  • Renal function — GFR at discharge, 6 mo, then annually
  • Upper-tract imaging — ultrasound or CT for hydronephrosis and stones
  • Stoma assessment — regular evaluation for stenosis; early stenting / revision
  • Urine cultures — monitor for recurrent UTI / pyelonephritis
  • Cancer surveillance — per primary-disease protocol
  • Psychological screening — given higher rates of anxiety / depression reported[17]

See Also​

References​

1. Nabavizadeh R, Rodrigues Pessoa R, Dumbrava MG, et al. "Cutaneous ureterostomy following radical cystectomy for bladder cancer: a contemporary series." Urology. 2023;181:162–166. doi:10.1016/j.urology.2023.08.018

2. da Costa RMM, Pereira do Nascimento LA, Silva TA, Panhoca R, Sadi MV. "Comparison between cutaneous ureterostomy and the ileal conduit in patients with urothelial bladder carcinoma undergoing radical cystectomy: expanding eligibility for the gold standard treatment." Urol Oncol. 2026;44(5):111031. doi:10.1016/j.urolonc.2026.111031

3. Longo N, Imbimbo C, Fusco F, et al. "Complications and quality of life in elderly patients with several comorbidities undergoing cutaneous ureterostomy with single stoma or ileal conduit after radical cystectomy." BJU Int. 2016;118(4):521–526. doi:10.1111/bju.13462

4. Deliveliotis C, Papatsoris A, Chrisofos M, et al. "Urinary diversion in high-risk elderly patients: modified cutaneous ureterostomy or ileal conduit?" Urology. 2005;66(2):299–304. doi:10.1016/j.urology.2005.03.031

5. Fu Z, Tian Z, Chen Y, et al. "Analysis of the efficacy of a single subumbilical stoma for bilateral cutaneous ureterostomy after radical cystectomy." Eur J Med Res. 2023;28(1):273. doi:10.1186/s40001-023-01250-z

6. Murali A, Philips MR, Patidar S, et al. "Total extra-peritoneal approach to radical cystectomy with ureterostomy: a novel technique for the elderly and frail." Urol Oncol. 2025;43(1):61.e19–61.e28. doi:10.1016/j.urolonc.2024.10.008

7. Kearney GP, Docimo SG, Doyle CJ, Mahoney EM. "Cutaneous ureterostomy in adults." Urology. 1992;40(1):1–6. doi:10.1016/0090-4295(92)90426-w

8. Zingg EJ, Bornet B, Bishop MC. "Urinary diversion in the elderly patient." Eur Urol. 1980;6(6):347–351. doi:10.1159/000473370

9. Kitchens DM, DeFoor W, Minevich E, et al. "End cutaneous ureterostomy for the management of severe hydronephrosis." J Urol. 2007;177(4):1501–1504. doi:10.1016/j.juro.2006.11.076

10. Rodríguez AR, Lockhart A, King J, et al. "Cutaneous ureterostomy technique for adults and effects of ureteral stenting: an alternative to the ileal conduit." J Urol. 2011;186(5):1939–1943. doi:10.1016/j.juro.2011.07.032

11. Yoshimura K, Maekawa S, Ichioka K, et al. "Tubeless cutaneous ureterostomy: the Toyoda method revisited." J Urol. 2001;165(3):785–788.

12. Li M, Fu X, Zu X, Chen J, Chen M. "Modified tubeless ureterocutaneostomy in high-risk patients after radical cystectomy and its long-term clinical outcomes." Technol Cancer Res Treat. 2023;22:15330338231192906. doi:10.1177/15330338231192906

13. Kim CJ, Wakabayashi Y, Sakano Y, et al. "Simple technique for improving tubeless cutaneous ureterostomy." Urology. 2005;65(6):1221–1225. doi:10.1016/j.urology.2004.12.009

14. Tjiaman MP, Zaidan MZ, Ausath ZF, et al. "Quality of life and postoperative complications of single- or bilateral-stoma cutaneous ureterostomy compared to ileal conduit after radical cystectomy: a systematic review and meta-analysis." Urology. 2025. doi:10.1016/j.urology.2025.09.034

15. Huang S, Chen H, Li T, et al. "Comparison of survival in elderly patients treated with uretero-cutaneostomy or ileal conduit after radical cystectomy." BMC Geriatr. 2021;21(1):49. doi:10.1186/s12877-020-01861-9

16. Liu Z, Tian Q, Xia S, et al. "Evaluation of the improved tubeless cutaneous ureterostomy technique following radical cystectomy in cases of invasive bladder cancer complicated by peritoneal metastasis." Oncol Lett. 2016;11(2):1401–1405. doi:10.3892/ol.2015.4045

17. Hu X, Miao J, Huang Y, et al. "Urinary diversion-specific morbidity after radical cystectomy: a ten-year institutional experience." Cancer Med. 2026;15(3):e71684. doi:10.1002/cam4.71684

18. Swierzewski SJ, Fitzpatrick CC, McGuire EJ. "Intermittent self-catheterization of the renal pelvis: report of 2 cases." J Urol. 1993;149(2):369–370. doi:10.1016/s0022-5347(17)36086-x

19. Thakker PU, Refugia JM, Wolff D, et al. "Ileal conduit versus cutaneous ureterostomy after open radical cystectomy: comparison of 90-day morbidity and tube dependence at intermediate term follow-up." J Clin Med. 2024;13(3):911. doi:10.3390/jcm13030911

20. Creta M, Fusco F, La Rocca R, et al. "Short- and long-term evaluation of renal function after radical cystectomy and cutaneous ureterostomy in high-risk patients." J Clin Med. 2020;9(7):E2191. doi:10.3390/jcm9072191

21. Lenis AT, Lec PM, Chamie K, Mshs MD. "Bladder cancer: a review." JAMA. 2020;324(19):1980–1991. doi:10.1001/jama.2020.17598

22. Fuschi A, Al Salhi Y, Sequi MB, et al. "Evaluation of functional outcomes and quality of life in elderly patients (> 75 yo) undergoing minimally invasive radical cystectomy with single-stoma ureterocutaneostomy vs Bricker intracorporeal ileal conduit urinary diversion." J Clin Med. 2021;11(1):136. doi:10.3390/jcm11010136