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Colon Shuffle

The colon shuffle is an incontinent colon-conduit strategy for patients who already have a colostomy or need both urinary and fecal diversion. A suitable segment provides the urinary conduit, while proximal bowel provides a separate fecal stoma, contralateral if necessary. The term was used at the Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, where Meijer and colleagues reported 21 patients in 2015. Davis and Noble described a related colostomy-conversion approach in 14 patients in 1992.[1][2]

The technique avoids an additional bowel-to-bowel anastomosis when a fecal stoma is already needed, and it avoids ileal harvest.

Clinical setting​

Patients who need urinary diversion together with fecal diversion include those with locally advanced or recurrent rectal cancer requiring pelvic exenteration, locally advanced bladder cancer with rectal involvement, and radiation-induced pelvic damage such as fistula, cystitis or proctitis. Others already have a colostomy from prior surgery and later need urinary diversion. An ileal conduit in these patients requires an ileo-ileal anastomosis, which adds a site of potential leak (ileo-ileal anastomotic leakage occurred in 4% of ileal conduits after exenteration in Hagemans's series).[5] In the Meijer series 90.4% of patients (19/21) had prior pelvic radiotherapy.[1][2][3]

Anatomy and planning​

Review the existing operation, remaining bowel, vascular pedicles, ureteral reach, radiation field and proposed appliance sites with colorectal expertise. The urinary and fecal segments both need adequate perfusion and tension-free reach.[3] An irradiated sigmoid segment or damaged mesentery may make this strategy unsuitable.[3]

SettingReconstruction concept
Existing end colostomyThe distal portion of the functioning, stoma-bearing colon can be isolated for urinary drainage; the more proximal fecal bowel is redirected to another stoma
Concurrent colorectal resectionAfter determining the required resection, select viable remaining colon for the urinary conduit and a proximal segment for fecal diversion
Limited abdominal stoma spacePlan both appliance sites together; contralateral stomas are common, but same-side placement may be feasible

The stoma-bearing segment in an end colostomy is not the disconnected bowel between the stoma and a Hartmann rectal stump. Nor should tumor-bearing or otherwise unsuitable distal bowel be repurposed because it would otherwise be discarded.[3] Theva's technical report describes these reconstruction principles and includes five patients, with operative times of 5 to 11 hours and one Clavien III complication.[3]

Operative sequence​

  1. Confirm the extent of any required resection and the viability of the colon proposed for reconstruction.
  2. Map and preserve the arterial supply to both planned diversions before making mesenteric divisions. In Theva's sigmoid-conduit configuration, identify the left colic and superior hemorrhoidal branches of the inferior mesenteric artery; if the left colic artery is divided for descending-colon reach to the fecal stoma, the descending colon depends on middle colic supply through the marginal artery. Confirm perfusion of both segments.[3]
  3. Isolate the urinary-conduit segment while ensuring that proximal bowel can reach its fecal stoma without tension.
  4. Mobilize the ureters with their blood supply preserved; construct unobstructed, tension-free ureterocolonic anastomoses.
  5. Mature the urinary and fecal stomas at accessible sites, checking perfusion, orientation, drainage and appliance fit.

In the colostomy-switch approach, the existing stoma is retained as the urinary outlet and a new proximal fecal stoma is created. No bowel anastomosis is required, and the urinary and fecal streams leave through separate stomas. Bowel length, vessel divisions and stoma location depend on the actual anatomy. See Colon Conduit for implantation and follow-up principles.[2][3]

Evidence and its limits​

Meijer 2015: named colon-shuffle cohort​

The retrospective NKI-AVL series (2003–2013) included 21 patients (14 men, 7 women; mean age 61.5 years), 19 with previous pelvic radiation. Within 30 days, 52.4% (11/21) had complications. No bowel-anastomotic leakage or fecal peritonitis occurred. Only this series has been published under the colon-shuffle name.[1]

Comparative observational evidence​

StudyPopulation and findingInterpretation
Cotter 201743 patients with an existing colostomy: 10 without and 33 with bowel anastomosis. Intraoperative and early overall complications were lower in the former groupRetrospective selection; no significant difference in operative time, hospital stay or several specific complications.
Hagemans 2020Rectal-cancer exenteration: 214 ileal and 45 colon conduits. Ileus was 21% versus 7%; wound infection 14% versus 31%, with the wound association not persisting after adjustment[5]—
Hebert 2026Four-center retrospective cohort of 179 colon conduits, including colostomy-switch patients; concurrent colonic anastomosis was not associated with worse 30-day outcomes[6]—

Sources: Cotter, Hagemans and Hebert.[4][5][6] In Cotter, operative time (550 versus 480 minutes) and length of stay (10 versus 25 days) did not differ significantly between the groups.[4] In Hebert, the cohort was divided into colon conduit with colonic anastomosis, with colostomy, and colostomy switch. Albumin ≥3.2 g/dL was associated with fewer 30–90-day high-grade complications (HR 0.18) in Hebert's observational cohort.[6] See the colon-conduit outcome table for the cohort's time-specific results.

Difference from double-barreled wet colostomy​

The colon shuffle uses separate urinary and fecal stomas. The double-barreled wet colostomy uses separate urinary and fecal limbs exiting through one abdominal stoma and appliance. Carter's design is a diverting loop colostomy with the colon divided 10 to 15 cm distal to the stoma, so that the distal segment acts as the urine limb. It provides internal stream separation and differs from the earlier wet colostomy, which mixes urine and feces upstream.[7][8]

Carter's first 11-patient series reported no clinical pyelonephritis during 0.5–80 months of follow-up, but one patient developed late bilateral ureterocolonic strictures.[8] Golda's 41-patient cohort reported pyelonephritis in 4/41 (9.8%), including renal deterioration from chronic pyelonephritis in 1/41 (2.4%); ureterocolonic stenosis in 1/41 (2.4%); and lithiasis in the urine reservoir in 3/41 (7.3%), and concluded that the risk of ascending infection must be considered.[9] Follow-up was discontinued for 14 referred patients after a mean of 18.6 months, while 27 were followed locally for a mean of 32.2 months.[9] No study compares the double-barreled wet colostomy directly with the colon shuffle.[8][9]

FeatureColon shuffleDouble-barreled wet colostomyDavis and Noble
StomasTwo, separate urostomy and colostomyOne, sharedTwo, separate
Bowel anastomosisNot requiredNot requiredNot required
Stream separationSeparate stomasInternal, at the shared stomaSeparate stomas
Published series21 (Meijer)11 in Carter 1994 (including the initial 3 reported in 1989); 41 in Golda14

Complications and follow-up​

Counsel about urinary leak, ureterocolonic obstruction, infection, stones, ileus, bowel injury or fistula, stoma problems and metabolic abnormalities. Alemozaffar's 41-patient distal-colon series reported partial small bowel obstruction in 2 patients (4.9%) within 30 days, prolonged ileus in 8 (19.5%), an enterocutaneous fistula in 1 (2.4%) and ureterocolonic stricture in 4 (9.8%) at 90 days or later. At 90 days or later, hypokalemia occurred in 39%, hyperchloremia in 24.4% and metabolic acidosis in 34.1%.[10]

A colon conduit exposes urine to intestinal mucosa and may cause hyperchloremic acidosis and hypokalemia. Assess renal function, electrolytes/acid–base status, upper-tract drainage and both stomas; apply the diversion surveillance framework. Treatment doses belong in the alkali and electrolyte pharmacology companion.[10]

See Also​

References​

1. Meijer RP, Mertens LS, Meinhardt W, et al. "The Colon Shuffle: A Modified Urinary Diversion." Eur J Surg Oncol. 2015;41(9):1264–8. doi:10.1016/j.ejso.2015.02.007

2. Davis BE, Noble MJ. "Simplified Urinary Diversion in Patients With Preexisting or Imminent Colostomy." J Urol. 1992;147(5):1245–7. doi:10.1016/s0022-5347(17)37529-8

3. Theva DP, Kuhnen A, Babayan RK, Katz MH. Concurrent urinary and bowel diversion: Surgical modification with sigmoid colon that avoids a bowel anastomosis. Int Braz J Urol. 2020;46(1):108–115. doi:10.1590/S1677-5538.IBJU.2019.0194. Full text.

4. Cotter KJ, Gor RA, Kwaan MR, et al. "Urinary Diversion With vs Without Bowel Anastomosis in Patients With an Existing Colostomy: A Multi-Institutional Study." Urology. 2017;109:190–4. doi:10.1016/j.urology.2017.06.036

5. Hagemans JAW, Voogt ELK, Rothbarth J, et al. "Outcomes of Urinary Diversion After Surgery for Locally Advanced or Locally Recurrent Rectal Cancer With Complete Cystectomy; Ileal and Colon Conduit." Eur J Surg Oncol. 2020;46(6):1160–6. doi:10.1016/j.ejso.2020.02.021

6. Hebert KJ, Swinney S, Johnson R, et al. "Outcomes After Colon Conduit Urinary Diversion: A Multi-Institutional Retrospective Study From the Reconstruction and Diversion: Improving Outcomes Group." J Urol. 2026;215(5):621–32. doi:10.1097/JU.0000000000004935

7. Carter MF, Dalton DP, Garnett JE. "Simultaneous Diversion of the Urinary and Fecal Streams Utilizing a Single Abdominal Stoma: The Double-Barreled Wet Colostomy." J Urol. 1989;141(5):1189–91. doi:10.1016/s0022-5347(17)41210-9

8. Carter MF, Dalton DP, Garnett JE. "The Double-Barreled Wet Colostomy: Long-Term Experience With the First 11 Patients." J Urol. 1994;152(6 Pt 2):2312–5. doi:10.1016/s0022-5347(17)31665-8

9. Golda T, Biondo S, Kreisler E, et al. "Follow-Up of Double-Barreled Wet Colostomy After Pelvic Exenteration at a Single Institution." Dis Colon Rectum. 2010;53(5):822–9. doi:10.1007/DCR.0b013e3181cf6cb2

10. Alemozaffar M, Nam CS, Said MA, et al. "Avoiding the Need for Bowel Anastomosis During Pelvic Exenteration — Urinary Sigmoid or Descending Colon Conduit — Short and Long Term Complications." Urology. 2019;129:228–33. doi:10.1016/j.urology.2019.03.015