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Stoma Site Marking

Preoperative marking and education are recommended whenever a stoma may be needed. The joint WOCN Society/AUA/ASCRS position statement includes urinary diversions and emphasizes individualized assessment by a trained clinician. An appropriate skin site must also be compatible with bowel perfusion, mesenteric reach and the planned reconstruction.[1]

See also: Ileal Conduit, Cutaneous Ureterostomy, Principles of Urinary Diversion, Continent Catheterizable Channels, and Incisions & Closure.

What the Evidence Supports​

Marking is associated with fewer complications and better self-care. A 2021 systematic review included 20 studies, with 19 contributing to quantitative synthesis: pooled odds ratios were 0.47 (95% CI 0.36–0.62) for complications and 0.34 (0.18–0.64) for self-care deficits.[2] The complication analysis had substantial heterogeneity (I² 70.6%).[2] The pooled data combine ostomy types.[2] A separate meta-analysis reported an inconclusive urostomy subgroup estimate for stoma and peristomal complications (OR 0.53, 95% CI 0.23–1.21; p = 0.132); it neither establishes a urinary-specific reduction nor rules one out.[6]

The ASCRS 2022 ostomy guideline recommends that potential stoma sites be marked preoperatively by a trained provider when possible (statement 2; strong recommendation, moderate-quality evidence, 1B, upgraded from 1C in 2015).[3] It states that urostomies are beyond its scope, so it is fecal-stoma guidance. The joint statement is the multidisciplinary guidance that includes urinary stomas.[1][3]

The ASCRS guideline also cites a systematic review of 10 studies (2109 patients) in which marking was associated with fewer stoma and peristomal complications across ostomy types (OR 0.52, 95% CI 0.42–0.64); the lower hernia odds were reported for fecal stomas (OR 0.25, 95% CI 0.09–0.71).[3]

A historical 137-patient ileal-conduit cohort found stoma complications in 20 patients (14.6%), predominantly parastomal hernia. Higher BMI was associated with complications. The 2001–2005 single cohort reports complication frequency without estimating marking's effect.[4]

Who and When​

Arrange assessment by a certified ostomy nurse and the operating team during preoperative planning. Other appropriately trained clinicians can mark a site when specialist nursing is unavailable. In the end-colostomy siting study ASCRS cites, sites chosen by surgeons were a median of 2 cm from those chosen by ostomy nurses, most badly sited locations were too low, and no difference by surgeon seniority was detected; surgeons with a colorectal subspecialty interest were more concordant with the nurses than general surgeons were.[3] There is no requirement to wait until the day before surgery. The mark is preserved with indelible ink or a waterproof cover, and backup sites are documented when the intraoperative choice is uncertain.[1]

Education and marking should occur together when feasible. For fecal stomas, ASCRS recommends preoperative and postoperative education by a specialized provider such as a wound, ostomy and continence nurse when creation is elective (statement 1; strong recommendation, moderate-quality evidence, 1B) and follow-up for teaching, care and support (statement 3; strong recommendation, low-quality evidence, 1C).[3] The guideline cites a 42-patient randomized trial of fecal-stoma education with a shorter hospital stay (8 versus 10 days, p = 0.02) and faster stoma-care proficiency (5.5 versus 9 days, p < 0.001).[3] Two nonrandomized studies in the 2025 colorectal-stoma education meta-analysis reported fewer peristomal skin complications with education (31/328 [9.5%] versus 31/160 [19.4%]; pooled RR 0.45, 95% CI 0.29–0.72).[7] The review found no significant pooled difference in length of stay; its GRADE table rated both outcomes very low certainty, and it did not evaluate urinary diversion.[7]

Assessment Checklist​

  • Examine standing, sitting and supine, adapted to the patient's mobility. Identify folds that appear only on sitting or bending.
  • Assess visibility and reach, hand function, vision, clothing and beltline, occupation, braces and habitual activities.
  • Identify the rectus muscle and a flat pouching surface. For a site requiring a pouch, use the intended skin barrier as a guide; choose a location at least 2 inches (about 5 cm) from the midline, umbilicus, scars, folds, creases and bony prominences.[8] Test appliance fit against the abdominal contour in sitting, standing and bending, and lightly mark folds or creases to avoid.[1][8]
  • Confirm the planned incontinent pouching system versus continent catheterizable channel. Their access and construction requirements differ. For a planned Indiana pouch or neobladder, the Canadian urinary-diversion task force advises marking an ileal-conduit backup site if the preferred diversion is not feasible (expert opinion).[9]
  • Mark the preferred site and, when needed, clearly ranked alternatives. Discuss these with the operating surgeon.[1]

A right-sided site is common for an ileal conduit, but a fixed ASIS-to-umbilicus fraction should not replace this assessment. Rectus placement is a recommended siting principle; it is not a guarantee against parastomal hernia.[1][3]

Adaptation to the Patient​

SituationPractical adjustment
Protuberant abdomen or substantial pannusAn upper abdominal site may improve visibility and shorten the passage through a thick abdominal wall; verify conduit reach.
Wheelchair use, contractures or limited reachAssess in the patient's usual seated position and equipment; demonstrate access with the patient or their chosen caregiver.
Prior surgery or existing stomasConsider scars, hernias, pouch footprints and the proposed incision together; a contralateral or higher site may be preferable.
Two separate stomasPlan enough room for both appliances and consider different horizontal levels if belts will be used.

The joint statement presents these as individualized planning considerations, not fixed geometric rules.[1]

Connect Marking With Construction and Follow-up​

For an incontinent ileal conduit, adequate protrusion, perfusion and a tension-free passage help appliance fitting. A flush or retracted conduit warrants assessment for leakage and skin injury; it does not automatically mean the diversion has failed. A continent catheterizable outlet, such as an Indiana-pouch stoma, may intentionally sit flush with the skin and must remain accessible for catheterization.[11] For fecal stomas, ASCRS recommends protrusion above the skin when possible (statement 6; strong recommendation, low-quality evidence, 1C), usually at least 2 cm for an ileostomy and 1 cm for a colostomy.[3] It lists selective mesenteric vessel ligation, end-loop stomas and an upper abdominal site in obese patients as ways to gain length, and it excludes urostomies.[3]

Taneja and Godoy described preparing the ileal-conduit stoma before abdominal-wall transposition in 45 consecutive cases. This uncontrolled series describes a technical option and has no comparison with conventional maturation.[5]

Before discharge, confirm appliance or catheter skills, access to supplies and a contact for problems. For a new urinary stoma, arrange follow-up by an ostomy nurse specialist within 2 weeks after discharge, with ongoing assessment of leakage, peristomal skin, changing body contour and self-management.[10]

References​

1. WOCN Society, AUA, and ASCRS. Position statement on preoperative stoma site marking for patients undergoing ostomy surgery. J Wound Ostomy Continence Nurs. 2021;48(6):533–536. doi:10.1097/WON.0000000000000820. Society statement and illustrated guide.

2. Kim YM, Jang HJ, Lee YJ. The effectiveness of preoperative stoma site marking on patient outcomes: a systematic review and meta-analysis. J Adv Nurs. 2021;77(11):4332–4346. doi:10.1111/jan.14915.

3. Davis BR, Valente MA, Goldberg JE, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for ostomy surgery. Dis Colon Rectum. 2022;65(10):1173–1190. doi:10.1097/DCR.0000000000002498.

4. Kouba E, Sands M, Lentz A, Wallen E, Pruthi RS. Incidence and risk factors of stomal complications in patients undergoing cystectomy with ileal conduit urinary diversion for bladder cancer. J Urol. 2007;178(3 Pt 1):950–954. doi:10.1016/j.juro.2007.05.028.

5. Taneja SS, Godoy G. Creation of urinary stoma before abdominal wall transposition of ileal conduit improves stomal protrusion, eversion, and symmetry. Urology. 2009;73(4):893–895. doi:10.1016/j.urology.2008.10.051.

6. Hsu MY, Lin JP, Hsu HH, Lai HL, Wu YL. "Preoperative stoma site marking decreases stoma and peristomal complications: a meta-analysis." J Wound Ostomy Continence Nurs. 2020;47(3):249-256. doi:10.1097/WON.0000000000000634

7. Shi V, McKechnie T, Anant S, et al. "The impact of preoperative stoma education on postoperative outcomes for patients with new stomas after colorectal surgery: a systematic review and meta-analysis." Tech Coloproctol. 2025;29(1):183. doi:10.1007/s10151-025-03213-4

8. Wound, Ostomy and Continence Nurses Society. "Stoma Site Marking Procedure: Quick Reference." 2021. PDF

9. Canadian Urological Association, Nurses Specialized in Wound, Ostomy and Continence Canada, and Urology Nurses of Canada. "Canadian Urinary Diversions Position Statement." 1st ed. 2022. PDF

10. Colwell JC, Stoia Davis J, Emodi K, et al. "Use of a convex pouching system in the postoperative period: A national consensus." J Wound Ostomy Continence Nurs. 2022;49(3):240–246. doi:10.1097/WON.0000000000000874

11. Bladder Cancer Canada. "Indiana Pouch." Patient guide. Accessed October 7, 2026.