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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][5]

Configurations​

ConfigurationDescription
Single-stoma (SSCU)Both ureters drain through one skin opening. They may be joined side-to-side at the stoma; transposition across the midline does not itself mean transureteroureterostomy. Configuration depends on reach and perfusion.[6]
Bilateral-stoma (BSCU)Each ureter brought to its own stoma on each side of the abdomen[6]
UnilateralSingle ureter exteriorized — solitary functioning kidney or palliative[7][8]

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][8][7]

  • Frail or highly comorbid patients; chronological age and ASA score alone are not universal eligibility thresholds
  • Limited life expectancy where minimizing operative time is paramount
  • Prior extensive abdominal surgery / radiation precluding safe bowel mobilization
  • Selected palliative diversion when appropriate; percutaneous nephrostomy or ureteral stenting may impose less initial burden than surgery
  • Inflammatory bowel disease or short-bowel syndrome (bowel-diversion contraindications)
  • Exceptional anesthesia constraints: an extraperitoneal regional-anesthesia approach has been described in selected frail patients with a single functioning kidney after nephroureterectomy; this is not an established option for every patient unfit for general anesthesia.[7]
  • Pediatric: end CU as temporizing measure for severe megaureter / hydronephrosis awaiting reimplant[9]

Surgical Technique​

The aim is reliable low-resistance drainage while preserving ureteral perfusion. A tubeless stoma is desirable, but some patients require long-term stents and exchanges; this possibility belongs in preoperative counseling.

Rodríguez technique (reported 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. Postoperative Double-J stenting. In the 272-patient stent-duration analysis, left obstruction was 4.5% with >3 months versus 13.7% with shorter stenting. This nonrandom comparison supports individualized drainage planning, not mandatory prolonged stenting for every patient.

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

  • Tubeless stoma created by everting ureteral mucosa and suturing to skin
  • Yoshimura reported 92/103 renal units (89%) achieving a tubeless condition in 61 patients; 53/103 had no hydronephrosis, while 14 renal units were not evaluated during follow-up. These are renal-unit outcomes, not an 89% patient-level guarantee.

Modified tubeless techniques​

Separate retrospective studies describe different modifications: Li 2023 reported catheter-free renal units of 56/78 (71.8%) versus 89/98 (90.8%); Kim 2005 reported 26/43 (60.5%) versus 53/59 (89.8%) after adding tunnel stabilization. These are not interchangeable before/after estimates or randomized evidence.[12][13]

Extraperitoneal approach for the very frail[7]​

A selected unilateral diversion series reported early bowel recovery and a seven-day hospital stay under combined spinal/epidural anesthesia. The authors explicitly called for further study before extrapolating to bilateral drainage.

Comparative Outcomes​

Most comparisons are observational and vulnerable to selection differences. CU often shortens surgery and avoids an intestinal anastomosis; it does not eliminate major complications.

  • Longo 2016: 35 CU versus 35 ileal-conduit patients, all over 75 with substantial comorbidity; CU had shorter surgery/hospitalization and fewer early complications, with overlapping BCI scores.[3]
  • Deliveliotis 2005: 29 CU versus 25 conduit patients; intraoperative complications were 13.7% versus 40%, and early surgical complications 24.1% versus 60%. These rates describe a small historical cohort.[4]
  • Da Costa 2026: 57 CU versus 70 conduit patients, with older and less fit CU patients; recovery favored CU on several measures, but complication/mortality comparisons did not demonstrate a significant difference. This was a study combining prospective and retrospective data, not proof of equivalence.[2]
  • Tjiaman 2025 systematic review (11 studies): ileal conduit was associated with more wound infection (OR 3.02) and early pyelonephritis (OR 3.04), especially versus single-stoma CU. Ileus and wound dehiscence did not differ significantly.[14]

A SEER study matched 285 patients per group aged ≥80 and detected no significant overall or cancer-specific survival difference. This does not establish equal survival or eliminate selection bias.[15]

Complications​

Stomal stenosis — the hallmark concern​

  • In Rodríguez’s 272 evaluable patients, obstruction occurred in 36 (13.2%), including left-only obstruction in 27 (9.9%)[10]
  • Among those 36 obstruction cases, treatment was restenting in 20, revision in 12, and conduit conversion in four. This describes treatment distribution, not a mandatory sequential ladder.[10]
  • Stent duration must balance obstruction risk, infection, encrustation, and the burden of repeated exchanges; the reported duration association was nonrandomized[10]
  • Chronic stenting may be needed when a tubeless trial fails or is unsuitable[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 Complications​

  • Major perioperative morbidity: the Mayo cohort had 14/31 patients with Clavien ≥3 complications within 30 days. Sepsis affected four patients; 90-day readmission was 10/31. A short median stay in that study does not imply a low-risk operation.[1]
  • Late infection, stones, ischemia, and renal decline remain concerns. Chronic catheter insertion is associated with these outcomes, but may also mark patients who already have worse drainage.[12]
  • Tube dependence: in a 56-patient retrospective comparison, a tube-free trial was performed in 86%; estimated 12-month tube-free survival was 70% for CU versus 76% for conduit, without a significant difference. This is a conditional study result, not a guaranteed tubeless success rate for everyone undergoing CU.[16]

Renal function​

In a series of 70 elderly patients (median age 78), median GFR declined from 74.3 → 54.6 mL/min/1.73 m² at 6 mo (p < 0.001).[17] Patients requiring chronic catheter / stent placement had significantly higher rates of renal deterioration, pyelonephritis, and urolithiasis.[12]

What Avoiding Bowel Changes​

CU avoids urine contact with bowel and the associated diversion-induced intestinal acid absorption, as well as loss of ileal absorptive surface and an intestinal anastomosis. However, patients can still develop acidosis from CKD or illness, nutritional deficiency from other causes, and postoperative ileus or bowel obstruction from cystectomy/abdominal surgery. The comparative meta-analysis did not show a significant ileus reduction.[14][17]

Quality of Life and Stoma Choice​

The 2025 review found better physical QoL with ileal conduit than bilateral-stoma CU, while the comparison with single-stoma CU did not show a significant difference. That indirect pattern does not prove single-stoma CU is superior to bilateral CU for every patient.[14]

A single appliance can simplify care, but safe reach and perfusion take priority. In Fu’s retrospective study, single-stoma CU had better first stent-removal success and lower costs than bilateral-stoma CU; the groups differed in age and ASA score. Costs and results depend on local protocols and cannot be generalized as guaranteed savings.[6]

Offer realistic counseling about appliance fit, leakage, body image, possible permanent stents, exchanges, and caregiver support. Neither CU nor ileal conduit guarantees better global QoL or renal preservation.

Long-Term Surveillance​

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

  • Renal function — establish a postoperative baseline and repeat according to renal/drainage risk; annual long-term review is commonly used when stable
  • Upper-tract imaging — ultrasound or CT for hydronephrosis and stones
  • Stoma assessment — regular evaluation for stenosis; early stenting / revision
  • Urine cultures — obtain for suspected infection or another specific indication; routine cultures of an asymptomatic, colonized diversion should not trigger antibiotics. Follow procedure-specific infection prevention for stent exchanges or mucosa-breaching interventions[18]
  • Cancer surveillance — per primary-disease protocol
  • Psychological and practical support — review adaptation, stoma care, and access to supplies

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

6. 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

7. 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

8. 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

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;165:785–788. PubMed.

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. 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

17. 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

18. European Association of Urology. EAU Guidelines on Urological Infections. 2026. Asymptomatic bacteriuria in reconstructed tracts, stents and before urological interventions. Guideline.