Ileal conduit - short case in surgery

What it is

Examination of an ileal conduit

1. Introduction

• Wash hands, introduce yourself, confirm identity and obtain consent.
• Ask if the patient has pain or any problem with the stoma or bag.
• Ensure adequate exposure from xiphisternum to pubis while preserving dignity.
• Position patient supine with knees slightly flexed.
• Inspect the bag first. Do not remove it unless necessary and with a stoma nurse/chaperone available.

2. General examination

• Pallor, cachexia, dehydration.
• Features of chronic kidney disease.
• Surgical scars.
• Supraclavicular lymph nodes, if malignancy is relevant.

3. Inspection of the stoma and appliance

Site

• Usually right lower abdomen/right iliac fossa.
• Ideally placed through rectus muscle and away from skin folds, bony prominences and previous scars.

Stoma

• Pink or red
• Moist
• Well perfused
• Protruding slightly above skin level
• Continuously draining clear yellow urine, sometimes with mucus

• Pallor, dusky discoloration, black stoma: ischaemia/necrosis
• Retraction
• Stenosis
• Prolapse
• Bleeding or ulceration
• Excessive mucus, pus, malodorous or cloudy urine
• Poorly fitting appliance or urine leakage

Peristomal skin

• Excoriation and erythema from urine leakage
• Fungal rash
• Ulceration
• Contact dermatitis

Bag and urine

• Amount of urine
• Colour: clear yellow normally
• Cloudiness, offensive smell, debris: consider urinary infection
• Haematuria
• Leakage around bag
• Integrity and fit of appliance

4. Palpation

• Ask permission before palpating.
• Gently palpate around the stoma for tenderness, induration, mass, or a parastomal hernia.
• Ask the patient to cough or raise head/shoulders to demonstrate a parastomal hernia.
• Palpate the abdomen for:
  • Masses
  • Organomegaly
  • Fullness in renal angles
  • Incisional hernia
• Check for renal angle tenderness, which may suggest upper urinary tract infection or obstruction.

5. Complete with

• Urine microscopy, culture and sensitivity
• Renal function and electrolytes, including bicarbonate
• Ultrasound KUB for hydronephrosis
• CT urogram/CT abdomen and pelvis if obstruction, recurrence or a complication is suspected.”

Short-case presentation

“This patient has an ileal conduit urinary diversion, with a urostomy in the right iliac fossa and a urine-collecting appliance. An ileal conduit is an incontinent urinary diversion in which both ureters are implanted into an isolated segment of ileum, whose distal end is brought out as a stoma. It is most commonly formed after radical cystectomy for bladder cancer.

The stoma appears healthy if it is pink, moist and well perfused, with continuous urinary drainage. I would specifically assess for leakage, peristomal skin excoriation, stomal stenosis, prolapse, retraction, parastomal hernia, urinary infection, upper-tract obstruction and renal impairment.”

Viva voce questions and answers

1. What is an ileal conduit?

2. What is the commonest indication?

3. Why is it called an incontinent diversion?

4. Which segment of bowel is used?

5. Where is the stoma usually placed?

6. Why must the stoma be marked preoperatively?

7. Describe the principle of construction.

1. Isolate a short vascularised ileal segment.
2. Restore small-bowel continuity.
3. Implant the ureters into the proximal end of the isolated bowel segment.
4. Bring its distal end to the skin as a spouted stoma.

8. What are the advantages of an ileal conduit?

• Technically relatively simple
• Reliable drainage
• No need for self-catheterisation
• Suitable for frail patients or those unable to manage continent diversions
• Usually fewer immediate complications than more complex continent urinary diversions

9. What are the disadvantages?

• Permanent external appliance
• Continuous urine drainage
• Body-image concerns
• Stomal and skin complications
• Risk of infection, ureteroileal stricture, renal deterioration and metabolic abnormalities

10. What is normal output from an ileal conduit?

11. What early complications can occur?

• Haemorrhage
• Ileus or bowel obstruction
• Urinary leak
• Ureteroileal anastomotic leak
• Stomal ischaemia/necrosis
• Wound infection
• Urinary tract infection
• Electrolyte disturbance

12. What late complications can occur?

• Stomal stenosis, retraction or prolapse
• Parastomal hernia
• Peristomal dermatitis
• Ureteroileal anastomotic stricture
• Hydroureteronephrosis/hydronephrosis
• Recurrent pyelonephritis or UTI
• Renal impairment
• Calculi
• Hyperchloraemic metabolic acidosis

13. Why can metabolic acidosis occur?

14. How would you investigate recurrent UTI or declining renal function?

• Urinalysis and urine culture
• Serum creatinine, urea, electrolytes and bicarbonate
• Ultrasound KUB for hydronephrosis
• CT urogram or contrast study through conduit if obstruction/stricture is suspected
• Functional renal imaging when indicated

15. What advice will you give the patient?

• Maintain good oral fluid intake unless restricted for another reason.
• Empty the bag before it becomes too full.
• Ensure the appliance fits well and change it as advised.
• Expect some mucus in the urine.
• Seek urgent help for fever, flank pain, falling urine output, persistent haematuria, leakage, a dusky/black stoma, severe skin irritation, or a new painful swelling around the stoma.

16. Differentiate ileal conduit from an ileostomy.

• Ileal conduit: urinary diversion; urine exits through the stoma into a urostomy bag.
• Ileostomy: faecal diversion; liquid intestinal contents exit into a stoma bag.

17. What alternatives to ileal conduit can be offered after cystectomy?

• Orthotopic neobladder
• Continent cutaneous urinary reservoir
• Cutaneous ureterostomy in selected patients
• Ureterosigmoidostomy, rarely used because of infection, metabolic and malignancy risks

18. What must you say if you find a parastomal hernia?

“There is a reducible swelling around the ileal-conduit stoma that becomes prominent on coughing, consistent with a parastomal hernia. I would assess for pain, irreducibility, obstruction and appliance difficulties.”

One-line examiner summary

“This is a right iliac fossa ileal-conduit urostomy, most likely following radical cystectomy, and I would assess the stoma, appliance, peristomal skin, parastomal hernia, urine quality, renal function and evidence of infection or upper-tract obstruction.”

Hemangioma over right arm - short case

Introduction

• Infantile hemangioma: often appears in the first weeks of life, proliferates in infancy, then gradually involutes.
• Vascular malformation: usually present at birth, grows proportionately with the child, does not spontaneously involute, and may enlarge with trauma, infection, puberty, or pregnancy.

Examination

1. Preparation

• Wash hands, introduce yourself, confirm patient identity and obtain consent.
• Ask about pain, bleeding, ulceration, increase in size, and restriction of movement.
• Expose both upper limbs fully and compare sides.
• Position patient sitting comfortably, with the right arm supported.

2. General examination

• Pallor, especially if there has been recurrent bleeding
• Other skin lesions or syndromic features
• Evidence of high-output cardiac failure in a very large, high-flow vascular lesion: tachycardia, tachypnoea, cardiomegaly

3. Local examination

Inspection

• Over the right arm: specify anterior/posterior and upper/middle/lower third.
• Note whether it lies close to a joint, neurovascular bundle, or axilla.

• Solitary or multiple.

• Measure in centimetres in two dimensions.
• Note whether it is well-defined, lobulated, diffuse, or segmental.

• Superficial hemangioma: bright red, raised, “strawberry” appearance.
• Deep lesion: bluish or skin-coloured swelling.
• Mixed lesion: both red superficial and bluish deep components.
• Look for ulceration, crusting, bleeding, infection, scars or areas of spontaneous involution.

• Dilated veins
• Skin warmth or discolouration
• Limb asymmetry, hypertrophy, muscle wasting, or distal swelling
• Functional impairment around elbow, shoulder, or wrist

• Ask the patient to move shoulder, elbow, wrist and fingers.
• Observe whether the swelling becomes prominent with dependency, muscle contraction, Valsalva manoeuvre or limb elevation.

Palpation

• Local temperature
• Tenderness
• Consistency: soft, compressible, firm, cystic
• Compressibility
• Reducibility
• Fluctuation
• Pulsatility
• Whether it refills after compression
• Plane: skin, subcutaneous tissue, muscle or deeper structures
• Mobility over deeper tissues
• Skin pinchability

Special tests

• Diascopy: press a glass slide over the lesion. Blanching supports a vascular lesion.
• Emptying test: elevate the arm and gently compress the swelling. Venous lesions may empty and refill on dependency.
• Cough impulse: usually absent.
• Pulsatility and bruit: palpate for thrill and auscultate for bruit. Their presence suggests an arteriovenous malformation rather than a simple hemangioma.
• Examine distal pulses, capillary refill, temperature, sensation and motor function.
• Palpate regional lymph nodes, especially axillary nodes if ulcerated/infected or if diagnosis is uncertain.

4. Completion

“I would complete the examination with ultrasound and colour Doppler to assess the flow characteristics and extent of the lesion. MRI is useful for a deep, extensive, intramuscular or anatomically complex lesion. I would assess the need for specialist vascular-anomalies, dermatology or plastic-surgery review.”

Short-case presentation

“This patient has a solitary vascular lesion over the right arm, measuring approximately ___ × ___ cm. It is ___ in colour, ___ in consistency, and is [compressible/non-compressible], with [no/positive] pulsatility, thrill or bruit. The overlying skin shows [no ulceration/ulceration]. Distal neurovascular status is normal and there is [no/any] functional limitation.

My provisional diagnosis is a hemangioma of the right arm. However, I would differentiate it from a venous or arteriovenous malformation. Colour Doppler ultrasonography, and MRI if deep or extensive, would help define the lesion and its flow characteristics.”

Viva voce questions and answers

1. What is a hemangioma?

2. What is the natural history of infantile hemangioma?

1. Is absent or minimally visible at birth.
2. Appears in the first few weeks of life.
3. Has rapid growth during early infancy, especially from 1 to 3 months.
4. Usually completes most growth by around 5 months.
5. Then slowly involutes over years, often leaving normal skin or residual fibrofatty tissue, telangiectasia or skin redundancy.

3. What is a strawberry hemangioma?

4. What is a cavernous hemangioma?

5. Differentiate hemangioma from vascular malformation.

6. What are the differential diagnoses of a vascular swelling on the arm?

• Venous malformation
• Arteriovenous malformation or arteriovenous fistula
• Lymphatic malformation
• Lymphangioma
• Pyogenic granuloma
• Varix
• Soft-tissue tumour with prominent vascularity
• Angiosarcoma, rarely, particularly if a rapidly enlarging destructive lesion in an adult

7. What features suggest an arteriovenous malformation?

• Warmth
• Pulsatility
• Thrill
• Bruit
• Dilated superficial veins
• Rapid enlargement
• Pain, bleeding, ulceration or distal ischaemia
• Possible high-output cardiac failure in a large lesion

8. What are the complications of hemangioma?

• Ulceration
• Pain
• Bleeding
• Secondary infection
• Scarring or residual skin deformity
• Functional impairment if near a joint or if extensive
• Cosmetic disfigurement
• Rarely, high-output cardiac failure with large high-flow lesions, although this suggests an arteriovenous lesion rather than an ordinary infantile hemangioma

9. Which hemangiomas require urgent referral or active treatment?

• Threat to function or limb movement
• Rapid growth
• Ulceration, pain, recurrent bleeding or infection
• Large, deep, segmental or cosmetically disfiguring lesions
• Uncertain diagnosis
• Features of high-flow lesion
• Possible associated anomalies or syndromes

10. What investigations will you order?

• Ultrasound with colour Doppler: first-line for flow, depth and vascularity.
• MRI with contrast: for deep, extensive, intramuscular or complex lesions, and to define relation to nerves, muscles, vessels and joints.
• CBC if recurrent bleeding or severe ulceration.
• Coagulation profile if a large vascular lesion or consumptive coagulopathy is suspected.
• Echocardiography if there is concern for high-output cardiac failure.

11. Is biopsy routinely done?

12. What is the management of a small, uncomplicated infantile hemangioma?

• Reassure parents.
• Clinical photographs and serial measurement.
• Regular review during the proliferative phase.
• Educate about warning symptoms: rapid growth, ulceration, bleeding, infection or impaired limb movement.

13. What is the first-line treatment for a problematic infantile hemangioma?

14. What precautions are needed with propranolol?

• Bradycardia
• Hypotension
• Hypoglycaemia
• Bronchospasm, especially in reactive airway disease
• Poor feeding or intercurrent illness

15. What other treatment options exist?

• Topical timolol for small, thin superficial lesions
• Wound care and pain relief for ulcerated lesions
• Laser therapy in selected superficial or residual lesions
• Corticosteroids when beta-blockers cannot be used or fail
• Surgical excision for selected residual, ulcerated, function-threatening, or diagnostically uncertain lesions

16. When is surgery considered?

• Persistent lesion after involution with significant cosmetic or functional deformity
• Recurrent ulceration or bleeding
• A well-localised lesion that can be removed safely
• Diagnostic doubt
• Failure or contraindication to medical therapy

17. What is Kasabach-Merritt phenomenon?

18. What advice will you give to parents?

• Most infantile hemangiomas improve with time.
• Take photographs at regular intervals to document change.
• Avoid trauma and scratching.
• Seek early review if there is ulceration, bleeding, pain, rapid enlargement, colour change, fever, reduced limb movement, or a cold/pale hand.
• Keep follow-up appointments during the period of rapid growth.

One-line exam summary

“This is a vascular lesion over the right arm, clinically consistent with a hemangioma. I would assess its extent, skin complications, compressibility, flow characteristics, effect on limb function and distal neurovascular status, and confirm the nature of the lesion with colour Doppler, with MRI for a deep or extensive lesion.”