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Parastomal Hernia After Urinary Diversion

Parastomal hernia after urinary diversion can impair appliance fit, cause pain or obstruction, and complicate urinary drainage. Assessment separates an incidental imaging finding from a symptomatic hernia and defines the conduit or catheterizable-channel anatomy before treatment is chosen.[1][2][3]

Much of the abdominal-wall literature concerns fecal stomas.[4] The 2022 ASCRS ostomy guideline states that urostomies are beyond its scope.[4] The 2023 EHS rapid guideline conditionally suggests prophylactic nonabsorbable mesh for end colostomy and strongly recommends it for high-risk end-colostomy patients with life expectancy over two years.[26]

Fecal-Stoma Guidance (ASCRS 2022)​

The ASCRS ostomy guideline grades its statements 1 to 2 (strong or weak) and A to C (high to low quality evidence).[4]

StatementGradeBasis cited
Routine prophylactic mesh at stoma creation is not recommendedWeak, high-quality evidence (2A)A 2017 meta-analysis of 7 randomized trials (432 patients) found fewer clinical hernias with mesh (10.8% vs 32.4%). Later randomized trials of 240 and 200 patients, and a sensitivity analysis limited to low-risk-of-bias studies, showed no significant benefit.[4]
Extraperitoneal tunneling of an end colostomy may decrease parastomal herniaWeak, moderate-quality evidence (2B)A meta-analysis of 10 studies (2 randomized) reported hernia in 6.3% vs 17.8%.[4]
Repair of a parastomal hernia should typically use meshStrong, low-quality evidence (1C)No randomized trial compared repair methods when the ASCRS guideline was written; a 2024 open retromuscular trial is summarized below.[7] Primary suture repair had a 69.4% recurrence rate in a systematic review of 30 observational studies cited by ASCRS.[4]
Minimally invasive repair may be performed in selected patientsStrong, low-quality evidence (1C)Observational studies show similar recurrence to open repair. Open repair is favored for larger defects and for ostomies that are taken down, rematured or resited.[4]

ASCRS also notes that biologic mesh has not been shown to be superior to synthetic mesh for elective repair, and that there is no consensus on when to relocate a stoma. Relocation carries the same high risk of hernia formation.[4] In its pooled data for fecal stomas, recurrence was 10.2% after laparoscopic Sugarbaker repair and 27.9% after keyhole repair (15 studies, 469 patients).[4]

Incidence and Risk Assessment​

Reported incidence depends on imaging, the hernia definition, follow-up duration and the patients available for assessment.

Conduit cohortFindingsInterpretation
Hussein 2018: 383 patients75 developed radiologic hernia; 23/75 were symptomatic and 11/75 received treatment. Estimated radiologic incidence was 9%, 23% and 32% at 1, 2 and 3 years.The 31% symptomatic and 15% treated figures use all 75 hernias as the denominator. Median time to hernia was 13 months, and risk plateaued after year 3.[1]
Ghoreifi 2022: 361 patientsRadiologic hernia in 30% (108 patients), median time 8 months; 26% of these progressed over median follow-up of 27 months.Progression meant radiologic upgrading or surgery.[2]
Liu 2014Of 516 patients, 199 with sufficient follow-up were analyzed; 58 had a hernia and 26/58 underwent repair.Cumulative hernia risk was 12.2% at 1 year and 22.5% at 2 years. Repairs were done for discomfort (58%), obstruction or strangulation (15%), partial obstruction (15%) and other abdominal surgery (12%).[5]

A 2025 systematic review pooled a parastomal hernia incidence of 14.4% across four ileal-conduit studies and listed fascial defect of at least 24 mm, obesity and female sex as the main risk factors.[3] Observational cohorts report the following independent associations:

CohortFactor (effect estimate)
Hussein 2018[1]Fascial defect of 30 mm or more (OR 5.23), lower postoperative eGFR (OR 2.17), longer operative time (OR 1.25)
Ghoreifi 2022[2]Female sex (HR 1.86), diabetes (HR 1.81), COPD (HR 1.78), BMI (HR 1.07 per unit)
Donahue 2014, 386 patients with complete data[24]Female sex (HR 2.25), higher BMI (HR 1.08 per unit), lower preoperative albumin (HR 0.43 per g/dL)
Liu 2014[5]Prior exploratory laparotomy (adjusted HR 1.98), severe obesity (adjusted HR 4.26)

Effect sizes vary between cohorts, and none of these is a validated individual risk calculator. Modifiable risks are optimized and the patient's symptoms and operative fitness are discussed. Ghoreifi found no factor associated with hernia progression.[1][2][5]

Evaluation and Initial Management​

  • Examine the stoma and abdominal wall, including appliance seal, skin injury, reducibility and any associated midline hernia. Review the original diversion operation and prior repairs.
  • Use cross-sectional imaging when needed to define the defect, hernia contents, conduit or channel course, associated ventral hernia and upper-tract abnormalities. Investigate impaired drainage or recurrent infection.
  • For a reducible hernia with little symptom burden, offer stoma-nurse review, appliance adjustment and a fitted support garment when helpful. Reassess worsening symptoms.
  • Consider elective repair for persistent pain, major appliance problems, recurrent obstruction or meaningful functional impairment after weighing recurrence and surgical morbidity. Acute pain with an irreducible swelling, vomiting or obstruction, systemic illness or threatened bowel or stoma viability requires urgent surgical assessment. The emergency approach depends on the findings.[3][6][7]

Prevention at Ileal Conduit Creation​

Routine prophylactic mesh for every ileal conduit is not established. Conduit-specific randomized trials conflict, and the two more recent trials did not demonstrate benefit. They studied different materials and outcome definitions and are not a head-to-head comparison of mesh types.[8][9][10]

TrialPopulation and interventionResult and practical limit
Liedberg 2020242 randomized at three centers; lightweight synthetic sublay mesh versus conventional constructionClinical hernia within 24 months: 10/92 evaluable mesh patients versus 20/89 controls (11% versus 23%; p=0.06). Time-to-event analysis favored mesh, HR 0.45 (95% CI 0.24–0.86). Operating time was longer; no increase in mesh-related complications was detected.[8]
PUBMIC 2024146 randomized; FlexHD biologic mesh versus no meshAt median 24-month follow-up, radiologic hernias occurred in 18 versus 19, and clinical hernias in 8 versus 8. The trial did not demonstrate a protective effect. No definite mesh-related adverse events were reported.[9]
Donahue 2025 phase 3 trial178 randomized; 137 evaluable; semiabsorbable Ultrapro mesh behind rectus and in front of the posterior sheathAt the final 24-month assessment, radiologic hernia occurred in 32/68 with mesh versus 23/69 controls (47% versus 33%); risk difference 14 percentage points (95% CI −4 to 31; p=0.14). No preventive benefit was shown; the higher hernia rate was nonsignificant.[10]

The 2018 Cochrane review included 10 trials and 844 participants across ostomy surgery. Hernia incidence favored mesh, but certainty was low, heterogeneity substantial, and a reduction in reoperation was not demonstrated. Its search predates the three conduit trials above. The Cochrane review reported an overall hernia incidence of 22 versus 41 per 100 (RR 0.53, 95% CI 0.43–0.66), with no difference in reoperation. Likewise, a 2024 network meta-analysis mixing stoma types and techniques predates the negative 2025 trial. Neither supports a pooled ranking as guidance for all urinary stomas.[11][12]

A 2023 cost-effectiveness model found prophylactic mesh cost-effective ($2,115 per QALY), sensitive to the probability of mesh infection. It depends on an assumed preventive benefit and predates the 2024 and 2025 trials.[13]

Conduit construction should preserve perfusion and allow unobstructed passage without excessive fascial enlargement. A three-center retrospective cohort found transrectus passage associated with lower hernia risk (adjusted HR 0.45, 95% CI 0.24–0.84; 505 complete-case patients).[29] In a single-center randomized trial of 104 selected patients, a modified construction combining an extraperitoneal tunnel with peritoneal closure over the proximal conduit and distal ureters had fewer CT-detected hernias than conventional construction (6/52 [11.5%] versus 15/52 [28.8%]) at median 30–32 months; the study excluded BMI ≥40 kg/m² and prior major middle or lower abdominal surgery.[25] Tanaka reported radiologic hernia in 3.5% with a novel construction (fascial passage limited to 2.4 cm, oblique rectus passage, separate anterior and posterior sheath fixation) versus 19.6% with the conventional procedure (p = 0.011), without mesh, in a preliminary cohort.[14]

Planning Repair Around Urinary Anatomy​

The conduit may have limited length and mobility because of its mesentery and ureteric anastomoses. Dissection must protect blood supply and avoid bowel or ureteric injury, kinking and obstruction. A concomitant ureteroenteric stricture or ventral hernia may change the reconstruction. Mesh is not normally continuously exposed to urine; urinary leakage, infection or erosion are complications to prevent and manage.[3][6][15]

A urologist and an abdominal-wall surgeon should plan complex or recurrent repairs together. Select access, mesh plane and configuration according to anatomy, contamination, prior mesh and surgeon expertise. Available urinary-diversion evidence is predominantly observational; there is no universally superior repair.[3][7]

ConfigurationAnatomical principleMain limitation
KeyholeMesh has an aperture for the stoma limb.Aperture sizing must avoid constriction while limiting recurrent herniation.
SugarbakerThe stoma limb travels laterally relative to the mesh; the retromuscular variant offsets the anterior and posterior fascial openings.Adequate length and safe lateralization are essential; do not tension or kink a short conduit to force this configuration.
Stoma resiting with abdominal-wall repairRelocate the stoma when its position or surrounding tissue is unsuitable.Both the original defect and new site need planning.

These principles and their technical risks are described in operative reports and the open retromuscular trial.[7][16][6]

Randomized comparison of repair configuration​

Maskal 2024 randomized 150 patients undergoing open retromuscular repair, including 25 ileal conduits; the remainder had fecal stomas. Patients were randomized only after both configurations were judged feasible. Two-year recurrence, assessed by imaging or examination and by patient-reported bulge when neither was available, was 13/75 (17%) with Sugarbaker and 18/75 (24%) with keyhole; adjusted RR 0.87 (95% CI 0.42–1.69). Sugarbaker was not superior. Reoperations for recurrence were 2 versus 7 and mesh-related complications 4 versus 1, without significant differences. The study was powered for a large superiority difference. Quality of life and decision regret did not differ between groups.[7]

Open and Minimally Invasive Repair​

A 2025 meta-analysis of observational mixed-stoma cohorts found laparoscopic repair associated with a hospital stay about 4 days shorter, fewer surgical-site infections (RR 0.37) and lower mortality (RR 0.18), with no significant difference in recurrence in its main analysis. Robotic repair showed a possible reduction in operative time in limited data. Reduced mortality after minimally invasive surgery is an association with patient selection.[21]

  • Xu 2021. Four patients had robotic repair of a conduit hernia (three with the da Vinci SP). Median stay was 1 day, with no recurrence at median 18.3 months. Concurrent ureteroenteric stricture repair, panniculectomy, stoma revision and abdominal-wall reconstruction were performed in the same operation.[15]
  • Dewulf 2022. Fifteen patients had minimally invasive repair (10 robotic); median stay was 5 days, one third developed a urinary infection and one recurred at day 66. The authors provide a flow chart that chooses the technique by the presence of a concomitant midline incisional hernia.[6]

Interpreting urinary-diversion series​

A French retrospective series of 51 conduit repairs reported 35% recurrence at median 15.3 months, with recurrence after keyhole repair (52%) higher than after Sugarbaker (10%, p = 0.046) and 7.8% major complications. The 2025 systematic review found the same direction (keyhole up to 52%, Sugarbaker 12.5%, overall 0–47%). Nonrandom selection prevents a causal ranking.[17][3]

Roussel's 35-patient conduit series (13 keyhole, 22 Sugarbaker) reported symptomatic recurrence requiring a second operation in 8 (22.9%; 30.7% keyhole, 18.2% Sugarbaker). Urinary tract infection was the main complication, and 3 patients (8.6%) required mesh removal for infection. Four of the 8 recurrence repairs (50%) were done without synthetic mesh because of difficult adhesiolysis, and 3 patients (37.5%) needed a third operation. The authors concluded that keyhole and Sugarbaker repairs should no longer be used for ileal conduits and that new approaches are needed. These series support counseling about recurrence and revision morbidity.[18]

In the 3-D funnel-mesh report, 27 of 40 operated patients took part in follow-up (median 29 months) with two recurrences (7.4%) and two stoma stenoses; one wound infection occurred, and the low recurrence rate reflects a small selected series.[19] Holland's series of 97 open repairs (12.4% urostomies, mean follow-up 31.6 months) had 20.6% recurrence, with no significant difference by ostomy type. Recurrence was 42.9% after in situ suture repair, 34.8% after resiting with mesh, 17.3% after in situ mesh repair and 0% after stoma reversal (p = 0.042).[20] Among in situ repairs in this mixed-stoma series, recurrence by mesh plane was 6.5% preperitoneal, 25% onlay, 36.4% intraperitoneal and 50% retrorectus (p = 0.035).[20]

Continent Catheterizable Stomas​

Assess catheter passage, emptying, leakage and the continence mechanism as well as the hernia. Preserve the channel and its vascular pedicle when feasible; revise the continence mechanism if it is dysfunctional, rather than automatically reconstructing every channel during hernia repair.[22][16]

Historical evidence is limited. Helal's series evaluated 21 patients (19 ileocecal reservoirs, 2 Kock pouches): 13 (61.9%) had simultaneous incontinence, 2 had difficulty catheterizing and 4 had stomal pain. Nineteen were repaired by transabdominal takedown of the anti-incontinence segment from the abdominal wall, closure through a midline incision, Marlex reinforcement when the defect exceeded 6 cm, revision of the anti-incontinence mechanism when incontinence was present, and repositioning of the stoma. Success was 89.5% at mean 23.4 months, and incontinence was corrected in all 13.[22]

Stout described laparoscopic repair with resiting in four patients (two continent channels, two incontinent diversions). In this four-patient mixed-diversion series, the authors reported 100% continence for the two continent channels and 100% urinary-stoma patency at mean 2 years; one hernia recurred at 7 months, and in one patient the stoma was resited but the hernia could not be repaired laparoscopically because of dense adhesions.[16]

Resiting​

Conduit-specific evidence is insufficient to determine whether resiting improves repair outcomes. A meta-analysis of retrospective mixed-stoma cohorts reported fewer reoperations after relocation (RR 0.15, 95% CI 0.03–0.62), while recurrence remained uncertain (RR 0.94, 95% CI 0.48–1.86); the review rated evidence low to very low certainty.[27] In Holland's mixed-stoma series, all recurrences after resiting were at the new stoma site regardless of mesh use.[20] In a Medicare claims cohort of 17,625 older adults in which ostomy type could not be identified, the hazard of repeat parastomal repair among the 10,059 patients whose ostomies were not reversed was similar for resited and non-resited stomas (adjusted HR 0.93, 95% CI 0.81–1.06).[23] Resiting remains an option when the stoma site or overlying skin prevents appliance fit. For elective relocation, examine the patient standing, sitting and supine before marking candidate sites; intraoperative perfusion and mesenteric length may require a different site (see Stoma Site Marking).[28]

Counseling and Follow-up​

Discuss recurrence, bowel or urinary injury, obstruction, infection, mesh complications and possible further surgery. Follow both abdominal-wall symptoms and urinary function. New hydronephrosis, reduced conduit output, difficult catheterization, recurrent febrile infection or substantial pain warrants reassessment.

In the 17,625 older Medicare beneficiaries undergoing elective parastomal repair, 30-day mortality was 3.8% and the five-year incidence of another parastomal or incisional hernia operation was 21.1%. The claims data could not identify ostomy type. Reversal of a fecal stoma was a comparator in that study.[23]

See Also​

Videos​

Robotic Parastomal Hernia Repair of Ileal Conduit
AUA University — V01-01
Robotic Parastomal Hernia Repair of Catheterizable Stoma (Mitrofanoff)
Sean Elliott, MD

References​

1. Hussein AA, Ahmed YE, May P, et al. Natural history and predictors of parastomal hernia after robot-assisted radical cystectomy and ileal conduit urinary diversion. J Urol. 2018;199(3):766–773. doi:10.1016/j.juro.2017.08.112

2. Ghoreifi A, Allgood E, Whang G, et al. Risk factors and natural history of parastomal hernia after radical cystectomy and ileal conduit. BJU Int. 2022;130(3):381–388. doi:10.1111/bju.15658

3. Cao R, Shao X, Li J. Management and outcomes profiles of parastomal hernia after radical cystectomy and ileal conduit urinary diversion: a systematic review. Hernia. 2025;29(1):180. doi:10.1007/s10029-025-03359-y

4. 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

5. Liu NW, Hackney JT, Gellhaus PT, et al. Incidence and risk factors of parastomal hernia in patients undergoing radical cystectomy and ileal conduit diversion. J Urol. 2014;191(5):1313–1318. doi:10.1016/j.juro.2013.11.104

6. Dewulf M, Pletinckx P, Nachtergaele F, et al. How-I-do-it: minimally invasive repair of ileal conduit parastomal hernias. Langenbecks Arch Surg. 2022;407(3):1291–1301. doi:10.1007/s00423-021-02393-5

7. Maskal SM, Ellis RC, Fafaj A, et al. Open retromuscular Sugarbaker vs keyhole mesh placement for parastomal hernia repair: a randomized clinical trial. JAMA Surg. 2024;159(9):982–989. doi:10.1001/jamasurg.2024.1686

8. Liedberg F, Kollberg P, Allerbo M, et al. Preventing parastomal hernia after ileal conduit by the use of a prophylactic mesh: a randomised study. Eur Urol. 2020;78(5):757–763. doi:10.1016/j.eururo.2020.07.033

9. Djaladat H, Ghoreifi A, Tejura T, et al. Prophylactic use of biologic mesh in ileal conduit (PUBMIC): a randomized clinical trial. J Urol. 2024;211(6):743–753. doi:10.1097/JU.0000000000003902

10. Donahue TF, Assel M, Cha EK, et al. Evaluating benefits of peristomal mesh placement at the time of radical cystectomy and ileal conduit formation: a phase 3 randomized controlled trial. J Urol. 2025. doi:10.1097/JU.0000000000004703

11. Jones HG, Rees M, Aboumarzouk OM, et al. Prosthetic mesh placement for the prevention of parastomal herniation. Cochrane Database Syst Rev. 2018;7:CD008905. doi:10.1002/14651858.CD008905.pub3

12. Hinojosa-Gonzalez DE, Saffati G, Kronstedt S, et al. Use of prophylactic mesh to prevent parastomal hernia formation: a systematic review, meta-analysis and network meta-analysis. Hernia. 2024;29(1):22. doi:10.1007/s10029-024-03219-1

13. Kanabolo DL, Park S. Prophylactic mesh placement with ileal conduit: a cost-effectiveness analysis. Urology. 2023;177:197–203. doi:10.1016/j.urology.2023.03.041

14. Tanaka T, Yamasaki K, Nofuji S, et al. Development and preliminary evaluation of a novel procedure for creation of an ileal conduit stoma aimed at preventing parastomal hernia. Int J Urol. 2024;31(5):512–518. doi:10.1111/iju.15394

15. Xu AJ, Shakir NA, Jun MS, Zhao LC. Robotic-assisted repair of post-ileal conduit parastomal hernia: technique and outcomes. Urology. 2021;158:232–236. doi:10.1016/j.urology.2021.08.030

16. Stout TE, Kasabwala K, Leslie DB, Elliott SP. A laparoscopic approach to parastomal hernia repair with re-siting of urinary stoma. Urology. 2021;152:199. doi:10.1016/j.urology.2021.01.020

17. Bel N, Blanc PY, Moszkowicz D, et al. Surgical management of parastomal hernia following radical cystectomy and ileal conduit: a French multi-institutional experience. Langenbecks Arch Surg. 2023;408(1):344. doi:10.1007/s00423-023-03062-5

18. Roussel E, Dupuis H, Grosjean J, Cornu JN, Khalil H. Initial and recurrent management of parastomal hernia after cystectomy and ileal conduit urinary diversion: a 10-year single-center experience. Hernia. 2024;29(1):57. doi:10.1007/s10029-024-03207-5

19. Tully KH, Roghmann F, Pastor J, Noldus J, von Bodman C. Parastomal hernia repair with 3-D mesh implants after radical cystectomy and ileal conduit urinary diversion — a single-center experience using a purpose made alloplastic mesh implant. Urology. 2019;131:245–249. doi:10.1016/j.urology.2019.05.006

20. Holland AM, Lorenz WR, Mead BS, et al. Long-term outcomes after open parastomal hernia repair at a high-volume center. Surg Endosc. 2025;39(1):639–648. doi:10.1007/s00464-024-11375-9

21. Abdelsamad A, Mohammed MK, Almoshantaf MB, et al. Minimally invasive versus open parastomal hernia repair: a comprehensive systematic review and meta-analysis. World J Surg. 2025. doi:10.1002/wjs.70013

22. Helal M, Austin P, Spyropoulos E, et al. Evaluation and management of parastomal hernia in association with continent urinary diversion. J Urol. 1997;157(5):1630–1632. PubMed. doi:10.1016/s0022-5347(01)64814-6

23. Howard R, Rob F, Thumma J, et al. Contemporary outcomes of elective parastomal hernia repair in older adults. JAMA Surg. 2023;158(4):394–402. doi:10.1001/jamasurg.2022.7978

24. Donahue TF, Bochner BH, Sfakianos JP, et al. Risk factors for the development of parastomal hernia after radical cystectomy. J Urol. 2014;191(6):1708-13. doi:10.1016/j.juro.2013.12.041

25. Zhou Z, Xiong L, Yao K, et al. "Extraperitonealization of the ileal conduit decreases the risk of parastomal hernia: A single-center, randomized clinical trial." Cell Rep Med. 2024;5(1):101343. doi:10.1016/j.xcrm.2023.101343

26. Stabilini C, Muysoms FE, Tzanis AA, et al. "EHS rapid guideline: Evidence-informed European recommendations on parastomal hernia prevention—with ESCP and EAES participation." J Abdom Wall Surg. 2023;2:11549. doi:10.3389/jaws.2023.11549

27. Abdelsamad A, Mohammed MK, Almoshantaf MB, et al. "Parastomal Hernia: Direct Repair Versus Relocation: Is Stoma Relocation Worth the Risk? A Comparative Meta-analysis and Systematic Review." Updates Surg. 2026;78(1):177–191. doi:10.1007/s13304-025-02155-8

28. WOCN Society. "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

29. Blanc PY, Fournel I, Bel N, et al. "Parastomal hernia after ileal conduit: Incidence, natural history and risk factors." World J Surg. 2024;48(10):2413–2420. doi:10.1002/wjs.12317