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.
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.

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291
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