Parastomal Hernia as a Risk Factor for Ileal Conduit Fistulae

doi:10.4236/ijcm.2011.23048

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International Journal of Clinical Medicine, 2011, 2, 289-291

doi:10.4236/ijcm.2011.23048 Published Online July 2011 (http://www.SciRP.org/journal/ijcm)

289

Parastomal Hernia as a Risk Factor for Ileal

Conduit Fistulae

Thomas Andrew Alexander Skinnner, Richard Watson Norman

Department of Urology, Dalhousie University, Halifax, Canada.

Email: [email protected]

Received January 29th, 2011; revised April 16th, 2011; accepted May 11th, 2011.

ABSTRACT

Purpose: to review potential risk factors for the development of ileal conduit fistulae. Methods: two patients were iden-

tified who had a remote history of an ileal conduit and who formed a fistula from the conduit—one to the small bowel

and one to the skin. Their presentation, management and outcomes are described. Results: Both patients had paras-

tomal hernias as th e likely cause of their fistula forma tion. Discussion: parastomal h erniation may con tribute to fistula

formation due to a strangulated ischemic pressure necrosis of the ad jacent ileal conduit and/or bowel.

Keywords: Fistula, Ileal Conduit, Parastomal Hernia, Urinary Diversion

1. Introduction

Advancements in surgical procedures can lead to new

and complex problems. Over the past 40 years, radical

cystectomy has become the treatment of choice for inva-

sive or aggressive bladder cancers, as well as for other

bladder disorders. The development of this procedure has

lead to a variety of urine management systems designed

to replace the bladder’s storage and voiding functions.

Bladder substitution with an ileal conduit was pioneered

by Eugene M. Bricker over half a century ago and re-

mains a popular technique today [1,2]. This method of

urinary diversion requires a relatively simple surgical

procedure, has low complications rates and is associated

with good patient quality of life [2,3]. It does, however,

open the door to a number of potential problems.

Complications following the creation of a Bricker

conduit may be separated into early and late events.

Early complications are most commonly visceral, in-

cluding gastrointestinal or urinary fistulae and intestinal

ileus. Delayed complications tend to consist of urological

or parietal issues including acute pyelonephritis, uret-

eroileal stricturing, urolithiasis, incisional hernias, paras-

tomal hernias and stricturing of the stoma [4]. Stomal

complications are generally regarded as the commonest

problem associated with ileal conduits with parastomal

hernia occurring most frequently [4-6]. Identified risk

factors for the development of parastomal hernia include

advanced age, obesity, steroid use, chronic cough and

malnutrition [4]. Less common is the occurrence of ileal

conduit fistulae, which can cause serious morbidity often

requiring surgical intervention [7]. Risk factors for de-

velopment of fist ul ae are not wel l unde rst o o d.

We report two patients with a remote history of an

ileal conduit who developed parastomal hernias and went

on to form a fistula from the conduit—one to the small

bowel and one to the skin. We suggest that both devel-

oped as secondary complications of parastomal hernia

formation, which may explain their late presen tation.

2. Case # 1

Forty-five years earlier, this 77 year old woman had

marked ureteric dilatation and renal scarring and under-

went partial cystectomy and bilateral ureteric re-im-

plantation. Three years later she was converted to an ileal

conduit urinary diversion due to voiding dysfunction,

intolerance of a urethral catheter and upper tract deterio-

ration. Five years after she developed stomal stenosis

treated by dilatation and then revision. In the same year,

she had small bowel resection for obstruction secondary

to adhesions with gangrenous bowel. Four years subse-

quently she had an elective cholecystectomy and further

revision of her stoma because of re-stenosis and recurrent

symptomatic urinary tract infections. She continued to

have intermittent problems with stomal stenosis managed

by daily finger/catheter dilatation and eventually the

stoma was revised again 38 and 39 years after her origi-

nal diversion. She was first noted to have parastomal

hernia 1 year later. A year after that she developed a

Parastomal Hernia as a Risk Factor for Ileal Conduit Fistulae

290

spontaneous mid-left ureteric leak which healed with

percutaneous nephrostomy drainage and antegrade stent-

ing and 1 year after that an asymptomatic parastomal

hernia was noted to contain incarcerated small bowel

(Figure 1). She was reviewed by general surgery and it

was decided to watch her expectantly. One year later she

developed a small bowel to conduit fistula confirmed by

computerized tomography. Serum creatinine varied be-

tween 200 - 300 umol/L. A trial of TPN was unsuccess-

ful. She underwent a complicated laparotomy, lysis of

numerous small bowel adhesions, excision of the scarred

ileal loop and resection of several segments of small

bowel. It was felt folly to attempt to reconstruct a new

conduit in view of the state of the bow el and ureters, and

both ureters were clipped off. The hernia was repaired a

with a large Surgisis mesh. Bilateral percutaneous

nephrostomy drainage was established post-operatively.

She has never felt better and her recent serum creatinine

is 136 umol/L.

3. Case #2

This 70 year old diabetic woman had an ileal conduit

urinary diversion 12 years earlier because of progressive

bilateral hydronephrosis, impaired bladder emptying and

recurrent funguria. One year later she was noted to have

a parastomal hernia which was watched expectantly.

Three years later she developed a partial small bowel

obstruction, urosepsis and bilateral hydronephrosis re-

quiring bilateral nephrostomy tubes and ICU support.

She formed an enterocutaneous fistula that closed spon-

taneously after total parenteral nutrition. She did well

although her parastomal hernia continued to enlarge and

was seen on a computerized tomographic scan (CT) 5

years later. After another 2 years, she developed a small

Figure 1. Parastomal herniation of incarcerated bowel is

seen in this CT scan of case #1.

subcutaneous abscess that started putting out urine. Loo-

pogram showed the connection to the skin. A foley

catheter was inserted into the ileal loop and the fistula

dried up in 10 days. She is doing well 2 year later but the

parastomal hernia continues to grow and it is regularly

evaluated by general surgery (Figure 2). The current

feelings are that the risks of surgery outweigh the poten-

tial benefits.

4. Discussion

Ileal conduit fistulae are largely restricted to old case

reports [8]. These fistulae may present in a variety of

ways—transcutaneous urine leakage, passage of gas or

gastrointestinal contents through the ileal stoma, severe

intractable diarrhea, and refractory pyelonephritis [9,10].

Although some suggest that fistula formation is pre-

dominantly an early complication following urinary di-

version surgery, we and others report examples of ileal

conduit fistulae occurring many years after they were

created [8,9]. These include both conduit-cutaneous and

conduit-enteric fistulae [9,10]. Although the mechanism

of fistula formation in unclear potential risk factors in-

clude prior radiation, urinary stones, chronic inflamma-

tion, diabetes mellitus and stomal structuring [10]. Spe-

cific case reports have also provided evidence that local

tumors or abscess formation may play a role [9]. We

propose that parastomal herniation contributed to fistula

formation in both of our patients due to a strangulated

ischemic pressure necrosis of the adjacent conduit and/or

bowel.

5. Acknowledgements

Neither author has any industrial link or affiliation re-

lated to the subject matter in this manuscript.

Figure 2. The patient described as case #2 points to the site

of her previous conduit-cutaneous fistula. The large paras-

tomal hernia is seen adjacent to the appliance.

Parastomal Hernia as a Risk Factor for Ileal Conduit Fistulae

291

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