creation of an ileal urostomy

Preoperative diagnosis: Gross hematuria via ileal conduit.

Postoperative diagnosis: Same.

Procedures performed: Exploratory laparotomy, lysis of adhesions, takedown
of urostomy, partial resection of urostomy, and complete left ureterectomy
with creation of an ileal urostomy to the left renal pelvis.

indications: The patient is a 60-year-old white male who is initially
status post a cystectomy for advanced bladder cancer followed by creation
of an ileal conduit, followed several years later by a nephroureterectomy
that revealed nodes positive. With these findings and the recurrent
hematuria, we decided to decrease the risk of his TCC by resecting his left
ureter and removing his ileal conduit from the right side and placing it on
the left-hand side directly to the renal pelvis. As well, a cystoscopy was
performed to evaluate his urethra and it was found to be without any
abnormalities.

Description of procedure: The patient was taken to the operating room and
placed on the operating table.

Once on the table, a midline incision was carried out. An extensive lysis
of adhesions was then carried out. The loop was then identified. The
right ureteral stump was appreciated and appeared to have a cavity around
it, and this was then resected down to the psoas muscle. Once this was
completely resected, attention was then turned toward the left ureter.
This could not be fully appreciated due to its adherence to the
vasculature. Attention was then turned toward reflecting the sigmoid
colon, and the ureter was then appreciated on the opposite side of the
sigmoid colon, and then traced back through the sigmoid mesentery to the
other side where it could then be dissected sharply off the bifurcation on
the common iliac. Once this was accomplished, the urostomy was taken down.
Of note, it was shortened about midway to allow for removal of the portion
that was attached to the ureters. At that time attention was turned toward
cutting off this staple line and tagging it so we could use a series of 4-0
PDS sutures to sew this down to the renal pelvis, which had been
spatulated.

A thorough cystoscopy of the renal pelvis was carried out and this
demonstrated no abnormalities. Of note, the sigmoid was then brought back
and the conduit was then placed through this. The butt end of the conduit
was then placed through the sigmoid mesentery, then brought up to the skin,
at which time a new urostomy was fashioned. At the end of this procedure,
once the ______ was secured, attention was turned toward performing a
cystoscopy, which revealed no abnormalities of the urethra. It was decided
to leave the urethra at this point and he may require a urethrectomy at
some subsequent point. He will be brought back to the office in three
months for urethroscopy, looposcopy, and pyeloscopy. The patient was
awakened from anesthesia and taken to the recovery room in stable
condition. Of note, he had a JP drain placed and a bander stent placed
without any significant troubles.