External Stoma and Peristomal Complications following Radical Cystectomy and Ileal Conduit Diversion: A Systematic Review

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Konrad M. Szymanski, MD, MPH; Diane St-Cyr, RN, ET, BSc, MEd; Tarik Alam, RN, ET; and Wassim Kassouf, MD, CM, FRCSC

Abstract: An ileal conduit is the most common urinary diversion following radical cystectomy for invasive bladder cancer. Unlike internal complications commonly described in urological literature, reports about the incidence of external complications are sparse. A Medline database review (1996–2008) of English-language literature was conducted to: 1) describe and compare external stoma and peristomal complications and complication rates among outpatients with ileal conduit diversion following radical cystectomy, and 2) summarize commonly used prevention and management strategies. Fourteen publications (mostly retrospective, single-center studies) met inclusion criteria. The reported incidence of complications ranged from 15% to 65%. Divided according to pathogenesis, the most commonly reported complications are 1) stoma or abdominal wall-related changes — parastomal hernia, stoma prolapse, stenosis, and retraction; and 2) peristomal skin changes — chemical injury: irritant contact dermatitis, pseudoverrucous lesions, and alkaline crustations; mechanical injury: pressure ulcers, skin stripping injuries, mucocutaneous separation; infection: candidiasis, folliculitis; immunologic disorders: allergic contact dermatitis; and disease-related lesions: varices, pyoderma gangrenosum, malignancy. Peristomal complications also appear to be under-recognized and under-reported. Research to establish the validity and reliability of assessment tools and long-term follow-up studies are needed to improve the evidence-base of prevention and care.



Potential Conflicts of Interest: Dr. Kassouf, Dr. Szymanski, and Ms. St-Cyr have nothing to disclose. Mr. Alam is an employee of Hollister Ltd., Aurora, Ontario, Canada.



Please address correspondence to: Wassim Kassouf, MD, CM, FRCSC, Montreal General Hospital, 1650 Cedar Avenue, L8-315, Montreal, Quebec H3G 1A4 Canada; email: wassim.kassouf@muhc.mcgill.ca.

     External stoma complications are the most frequent indication for reoperation after cystectomy.1 They represent the most common reason for outpatient ostomy service visits and are important predictors of patient quality of life.2 In addition, although the majority of peristomal skin disorders are mild and can be easily managed on an outpatient basis, they can progress in severity when unattended.3 Evidence-based approaches are sparse for primary and secondary prevention of complications.

     There appears to be a certain disconnect between the prevalence of cystectomy with ileal conduit creation and the knowledge regarding long-term stoma complications in the literature and among patients and urologists. In a cross-sectional study (N = 202),3 62% of participants with a peristomal skin disorder did not believe they had a disorder and more than 80% of participants did not seek professional attention.

     Following radical cystectomy and ileal conduit creation at the authors’ institution, patients are followed-up by an interdisciplinary team, which includes experienced enterostomal therapy nurses (ETNs) and urologists. The high frequency of external stoma and peristomal complications observed in these patients, along with questions about evidence-based management principles, were motivating factors for conducting and synthesizing a literature review to describe and compare epidemiology, management, and assessment of long-term external stoma and peristomal complications among patients with ileal conduit diversion following radical cystectomy.

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