Integrated Treatment by an Ostomy Care Team of a Complicated Mucocutaneous Separation After Radical Cystectomy With Ileal Conduit Urinary Diversion: A Case Report

The gold standard treatment of muscle-invasive bladder cancer is radical cystectomy, and the ileal conduit technique is considered to be the most commonly used urinary diversion method.¹ Despite the widespread use of ileal conduits in urinary diversion, stoma-related complications are still common. Mucocutaneous separation is one of the more serious complications that can lead to sepsis and even death.² 

The reported incidence rate of mucocutaneous separation varies from 3.7% to 19.5%.^3-6 It is an interruption of the junction between the conduit and peristomal skin, which usually occurs within 1 month after surgery.⁷ The causative factors are complicated, and the etiology includes malnutrition, infection, a large skin opening (ie, a skin opening that is larger than the conduit), poor surgical technique, and excessive tension at the mucocutaneous junction.^2,8 Management consists of filling the defect with an absorptive powder or dressing and covering it with the pouch’s skin barrier.^5,9 Although mucocutaneous separation is most often resolved with appropriate wound management, the treatment process may be relatively complicated and often requires multidisciplinary management. To the authors’ knowledge, literature on the integrated treatment of mucocutaneous separation in the postoperative care of an ileal conduit remains scant.

In this article, the authors present the case of a patient with mucocutaneous separation that was managed conservatively with a combination of systemic therapy and stomal skin management by an ostomy care team.

Ethical considerations. The study was carried out according to the principles of the Declaration of Helsinki. Informed consent of the patient was obtained for the use of his stomal photographs. 

History. A 46-year-old man was admitted to our hospital with the complaint of frequent dysuria. Bladder leiomyosarcoma was diagnosed by computed tomography urography and cystoscopy after routine urinary examination. An ileal conduit diversion following radical cystectomy was performed successfully, and the stoma was placed on the lower right abdominal wall. However, abdominal distension and fever developed on postoperative day 6, and the patient’s body temperature ranged from 37.0˚C to 39.0˚C  for 10 days. Accompanying symptoms were nausea, vomiting, and progressive oliguria. Laboratory test results revealed high levels of C-reactive protein (118.85 mg/L), serum creatinine (788 mmol/L), and leukocytosis (23.35 × 109/L) as well as low levels of hemoglobin (86 g/L) and albumin (25 g/L). Abdominal radiographs showed severe enterectasis. The patient’s condition was managed medically using gastrointestinal decompression, parenteral nutrition, urinary diversion, and an antibiotic (vancomycin). Despite this treatment strategy, some secondary changes appeared in the ileal conduit and peristomal skin. On postoperative day 15 some effluent was observed to overflow around the conduit, scattered peristomal ulcers appeared on the peristomal skin (Figure 1), and mucocutaneous separation was observed from 3 o’clock to 5 o’clock (Figure 2). 

The pouching system was opened to expose the wound, and necrotic tissue around the wound was resected to encourage wound drainage. Hydrocolloid powder was applied to absorb exudate in the fissures of the lesion (Figure 3A), and a silver-containing hydrophilic fiber dressing was applied for the first 7 days when fresh granulation tissue appeared(Figure 3B). Skin barrier strips were applied around the stoma followed by a convex pouching system (Figure 3C). 

The dressing was initially changed every 24 hours. After 72 hours of daily changes, the amount of exudate decreased and the frequency of dressing changes was extended to every 2 to 3 days. On treatment day 12, the mucocutaneous separation and scattered ulcers were completely granulated. No additional surgical procedures, such as suturing of the skin or stomal relocation, were required (Figure 4). The defect healed completely on treatment day 16 (Figure 5). A urologist and 2 enterostomal therapy nurses were in charge of the patient’s treatment. The urologist assessed the general condition of the patient, discussed treatment measures with a gastroenterologist and a dermatologist, and developed a holistic treatment plan. The enterostomal therapy nurses assessed and treated the peristomal complications.   

Cystectomy and urinary diversion is a complicated procedure. Postoperative complications, such as peristomal skin problems, have been reported in 10% to 70% of patients with a urostomy.¹⁰ Although most complications can be managed in outpatient clinics, higher costs of postsurgical care and higher hospital readmission rates have been reported in patients with peristomal skin problems.¹¹ Mucocutaneous separation is an early peristomal skin complication that usually occurs within 1 month after surgery and commonly results in late-term stoma retraction and stenosis. However, to the authors’ knowledge, there are few studies reporting the treatment of mucocutaneous separation in detail.

In this case, mucocutaneous separation occurred secondary to high abdominal pressure and concomitant hypoproteinemia. Although gastrointestinal decompression was performed immediately after the appearance of abdominal symptoms, excessive tension at the mucocutaneous junction had occurred. Mucocutaneous tension is considered to be one of the risk factors for mucocutaneous separation.¹² Another risk factor present in this case, hypoproteinemia, has previously been reported in an observational study.¹³ In this case, the ostomy care team developed a systematic treatment scheme to relieve bowel stasis and reverse nutritional imbalance as well as manage the stoma, urinary output, peristomal wounds, and surrounding skin. Preventing further skin irritation from irritating effluent was paramount.¹⁴ Although progressive oliguria was found after intestinal tympanites, a small amount of urine (about 10 mL per day) might still hinder epidermal resurfacing and restoration of an intact seal. A temporary percutaneous renal microfistulation was performed not only to recover renal function, but also to decrease the risk of additional peristomal skin problems. Coordination of care and information-sharing across all team members is considered crucial for improving stoma-related treatment efficiency¹⁵ and enhancing patients’ health-related quality of life.¹⁶ In this case, all peristomal wounds were healed after 16 days of coordinated care.

Peristomal skin protection is the cornerstone of ostomy management. Creating dry surfaces, filling irregular contours, and treating infections are the main means of wound management.⁷ Hydrocolloid powder, in which the main ingredient is carboxymethyl cellulose, was used to absorb moisture in the wound and provide a dry adhesion surface. Following guidance from the Wound, Ostomy and Continence Nurses Society,¹⁷ the authors also filled the wound with a silver-containing hydrophilic fiber dressing. Guidance on how to use these antimicrobial dressings is limited. We used the silver dressing until the exudate decreased (about 1 week) and fresh granulation appeared on the defect. Based on the team’s experience, these dressings work well in infected wounds but may impede later reepithelialization. Neither skin care products triggered irritant or allergic contact dermatitis.

Limitations of this study include the inherent exclusiveness of a case study and associated bias. Further research is needed to increase the understanding of the outcomes of, and optimal wound treatment criteria for, these complications in persons with a urostomy. 

This case study illustrated the outcome of integrated treatment by an ostomy care team of a patient with complex mucocutaneous separation following urostomy surgery and high abdominal pressure and hypoproteinemia. The wound was fully granulated after 12 days. Assessment, treatment, and follow-up by an ostomy care team should play a vital role in the management of peristomal skin complications including mucocutaneous separation. 

Ms. Zhang is a urology nurse and a member of the Ostomy Care Team in the Department of Urology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Dr. Cen and Dr. Li are urologic surgeons in training, Department of Urology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Ms. Shao is a urology nurse and a member of the Ostomy Care Team, Department of Urology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Dr. Wei, Dr. Z. Chen, Dr. Luo, Dr. W. Chen, and Dr. Huang are urologic surgeons in the Department of Urology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China. Address all correspondence to: Yong Huang, MD, Department of Urology and Emergency, the First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Rd., Guangzhou 510080, China; tel: +86-020-8775-5766; fax: +86-20-87333300; email: huangy79@mail.sysu.edu.cn and to Wei Chen, MD, Department of Urology, the First Affiliated Hospital, Sun Yat-sen University. No. 58, Zhongshan 2nd Rd., Guangzhou 510080, China; tel: +86-020-8775-5766; fax: +86-20-87333300; email: chenwei3sysu@163.com. DZ, JC, and PL all contributed equally to this article.

This work was supported by the Guangdong Basic and Applied Basic Research Foundation (Grant/Award Number 2020A1515010086) and the Guangdong Medical Science and Technology Research Foundation (Grant/Award Numbers A2018040 and A2018051).