© 2009 THE AUTHORS 1586 JOURNAL COMPILATION © 2 0 0 9 B J U I N T E R N A T I O N A L | 1 0 5 , 1 5 8 6 – 1 5 8 9 | doi:10.1111/j.1464-410X.2009.08988.x 2009 THE AUTHORS. JOURNAL COMPILATION 2009 BJU INTERNATIONAL Reconstructive and Paediatric Urology PANNICULECTOMY AND STOMAL REVISION IN OBESE PATIENTS KATKOORI et al. Synchronous panniculectomy with stomal revision for obese patients with stomal stenosis and retraction Devendar Katkoori, Srinivas Samavedi, Bruce Kava, Mark S. Soloway and Murugesan Manoharan Department of Urology, Miller School of Medicine, University of Miami, Miami, FL, USA Accepted for publication 14 July 2009 PATIENTS AND METHODS In all, 302 RCs with UD were done by one surgical team between 2002 and 2008, with ileal conduit diversion in 182 (60%); 18 had a body mass index (BMI) of >35 kg/m 2 , and among them four had severe stomal stenosis with retraction. We report the technique we used for managing stomal stenosis in these patients. RESULTS The mean (range) BMI of the patients was 42 (38–46) kg/m 2 ; all were women. The mean (SD) operative duration was 2 (0.5)h. The drain was removed once the drainage was <25 mL in 24 h. The mean (SD) hospital stay was 3 (1) days; there were no significant complications. After a mean follow-up of 3 years there was no recurrent stomal stenosis or retraction. CONCLUSIONS The unique advantage of this procedure is that it avoids laparotomy in a morbidly obese patient, and it provides excellent cosmesis while correcting the stomal complication. KEYWORDS panniculectomy, stomal stenosis, obese, revision, ileal conduit Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To report our experience of synchronous panniculectomy with stomal revision in morbidly obese patients after radical cystectomy (RC) and ileal conduit urinary diversion (UD). Abnormal skin folds with an uneven surface, stomal retraction and stomal stenosis result in a poorly fitting appliance which leads to urinary leakage, need for frequent change of appliances and skin excoriation. INTRODUCTION Bladder cancer is the fourth most commonly diagnosed malignancy in the USA; it is estimated that 70 980 new cases will be diagnosed with bladder cancer in 2009 in the USA [1]. About a fifth of these patients will have a radical cystectomy (RC) and urinary diversion (UD). Several types of UD have been described and their relative advantages and complications have been extensively discussed. The ileal conduit (IC) is still a predominant form of UD, accounting for 20–55% of all UDs worldwide [2]. The overall complication rate for IC can be 18–66% [3–5]. Stoma-related complications are one of the most common and account for 18–34% of the complications after IC UD [3–5]. Stomal complications frequently require re- admission and repeat surgical procedures. The stomal complications include bleeding, necrosis, retraction, obstruction, parastomal hernia, prolapse and stenosis [6]. The incidence of stomal stenosis in individuals with an IC is 2–19% [7]. Stomal stenosis results in increased conduit length and volume, renal failure, pyelonephritis, hydronephrosis and stones. Ischaemia, retraction, constriction of fascia, local skin changes and a poorly fitting appliance can increase the risk of a stomal stenosis. Obesity increases the risk of stoma-related complications of ileostomies, colostomies or ICs [8]. Significantly many patients undergoing RC with UD are overweight. Lee et al. [9] studied the effect of body mass index (BMI) on morbidity after RC. In their analysis the mean BMI was 28 kg/m 2 ; 70% of the study group had above-normal BMI, with 20% obese and 10% morbidly obese. Obesity causes stomal retraction, stomal stenosis, poor appliance application and need for frequent change of appliance. Several procedures have been described for managing stomal complications in the obese individual. Panniculectomy is a good option for managing obese patients with stomal complications. We describe our experience with four patients who had panniculectomy for revision and repositioning of the stoma. PATIENTS AND METHODS In all, 302 RCs with UD were done by one surgical team between 2002 and September 2008, with IC in 182 (60%) patients, among whom 18 had a BMI of >35 kg/m 2 . There was severe stomal stenosis with retraction in four patients. We report the technique we used for managing stomal stenosis in these patients. The steps of the procedure were: Step 1: A circum-stomal incision is made incising the skin and subcutaneous tissue, and mobilizing the conduit up to the rectus sheath. Adequate care is taken to maintain the conduit’s vascularity. A circum-umbilical BJUI BJU INTERNATIONAL