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Parastomal Hernia After Urinary Diversion

Parastomal hernia (PSH) is the most common long-term stomal complication after urinary diversion. After radical cystectomy with ileal conduit, 20–30% of patients develop a radiologic PSH within 2 years, ~31% of those become symptomatic, and roughly 15% require surgical repair.[1][2][3] Repair carries high recurrence rates (17–52%) regardless of technique and is complicated by the unique vulnerabilities of urinary stomas — UTI, mesh exposure to urine, conduit mesentery, and frequent concomitant ureteroenteric stricture or ventral hernia.[4][5][6][7]

This page is canonical for urinary-stoma PSH. Cross-linked from Continent Catheterizable Channels Principles — PSH also affects continent cutaneous channels (Indiana / Kock / Mitrofanoff) and is discussed below.

Epidemiology and Natural History​

MetricValue
Radiologic PSH at 1 yr12–20%[1][2]
Radiologic PSH at 2 yr22–30%[1][2][3]
Radiologic PSH at 3 yr32%[1]
Pooled clinical incidence (systematic review)14.4%[4]
Symptomatic PSH (of those with radiologic PSH)31%[1]
Requiring surgical repair15–45% of symptomatic patients[1][5]
Median time to PSH development8–13 mo[1][3]
Risk plateauAfter year 3[1]

Approximately 26% of patients with radiologic PSH will progress (radiologic upgrading or need for surgery), with median time to progression of 12 months.[2]

Risk Factors​

Risk factorEffect
Obesity / higher BMIOR 2.8 (BMI ≥30); HR 1.07 per unit BMI[1][2][3]
Fascial defect ≥24–30 mmOR 5.23 for defect ≥30 mm[4][5]
Female sexHR 1.86[1][5]
DiabetesHR 1.81[1]
COPDHR 1.78[1]
Prior laparotomyAdjusted HR 1.98[2]
Longer operative timeOR 1.25[4]
Lower postop eGFROR 2.17[4]
Poor nutritional status (NRI ≤83)AUC 0.731[5]
Postoperative UTIIndependent predictor[5]

No significant difference between open vs MIS cystectomy or intracorporeal vs extracorporeal conduit in most series.[8]

Why Urinary Stoma PSH Is Different​

Urinary stoma PSH carries challenges fecal stoma PSH does not:[4][9][6][10]

  • Urinary complications dominate the postoperative course — ureteroenteric stricture, UTI, urine leak in up to 17–33%.
  • Conduit mesentery must be preserved during dissection, limiting mobilization and mesh-configuration options.
  • Concomitant ureteroenteric stricture may require simultaneous repair.[11]
  • Mesh-infection risk is heightened by constant exposure to urine — mesh extraction was needed in 8.6% in one ileal-conduit series.[6]
  • Neurogenic-bladder patients with continent catheterizable channels have weak abdominal-wall musculature.[9]
  • Stoma-appliance adherence is critical — a large hernia sac stretches overlying skin, often forcing resiting.[12][13]
  • Up to 50% of ileal conduit PSH are associated with a concomitant midline incisional hernia, requiring simultaneous repair.[8][5]

Conservative Management​

Small, reducible, asymptomatic PSH:[12]

  • Hernia belt / support garment.
  • Stoma-appliance optimization (convex pouching, belt attachment).
  • Weight management and avoidance of heavy lifting.

Elective surgical repair is reserved for significant pouching difficulties, pain, recurrent obstruction, or incarceration.[12]

Prevention — Prophylactic Mesh at Index Surgery​

The role of prophylactic mesh at the time of ileal conduit creation is controversial with conflicting RCTs.

StudyDesignMesh typePositionPSH (mesh)PSH (no mesh)Outcome
Liedberg 2020 (ISRCTN 95093825)[14]RCT, n = 242Lightweight syntheticSublay (retromuscular)11% clinical at 24 mo23%HR 0.45 (p = 0.02) — favors mesh
Djaladat 2024 (PUBMIC)[15]RCT, n = 146Biologic (FlexHD)Sublay intraperitoneal31% radiologic at 2 yr38%No significant difference
Donahue 2025 (MSKCC)[16]RCT, n = 178Semi-absorbable (Ultrapro)Sublay retromuscular47% radiologic at 24 mo33%No benefit; mesh arm trended worse

A network meta-analysis (25 studies across all stoma types) found prophylactic mesh significantly reduced PSH beyond 6 mo (OR 0.43, 95% CI 0.33–0.58), with the retromuscular approach lowest.[17] A Cochrane review concluded that mesh placement is safe and reduces PSH, especially with the open extraperitoneal (sublay) technique.[18]

The two most recent urology-specific RCTs (PUBMIC, MSKCC) failed to show benefit — leaving the evidence equivocal for ileal conduits specifically. The discrepancy may relate to mesh type (biologic and semi-absorbable performed worse than lightweight synthetic in the sublay position) and technique.[16][15][17]

A cost-effectiveness analysis found prophylactic mesh cost-effective ($2,115 / QALY gained), sensitive to mesh-infection probability.[19]

Novel stoma-construction technique​

Tanaka et al. limit the fascial passage to ≤2.4 cm, create an oblique passage through the rectus, and separately fix the anterior and posterior rectus sheaths to the conduit. Radiologic PSH dropped from 19.6% to 3.5% (p = 0.011) without mesh.[20]

Indications for Surgical Repair​

  • Symptomatic hernia: pain, pouching difficulties, cosmetic distress.
  • Recurrent bowel obstruction or incarceration / strangulation (emergency).
  • Difficulty with stoma-appliance adherence.
  • Concurrent need for other abdominal surgery.[12][13]

The ASCRS guidelines recommend mesh reinforcement for PSH repair (Grade 1C) — primary suture repair carries 46–78% recurrence vs ~20% with mesh.[13]

Mesh-Repair Techniques​

TechniqueConfigurationRecurrence in ileal-conduit series
KeyholeMesh with aperture for the stoma limb35–52% — highest among mesh techniques.[4][13][6][21]
SugarbakerIntact mesh underlay; stoma exits laterally under mesh edge10–21.5% — generally lowest.[4][13][6][21]
SandwichTwo mesh sheets above and below fascia; stoma passes through13.5% in one prospective randomized study.[13]
3-D mesh implant (IPST)Purpose-made 3D alloplastic mesh via small open incision7.4% at median 29 mo (n = 40); 1 wound infection, no removals.[22]

The only RCT comparing Sugarbaker vs keyhole in the retromuscular position (Maskal, JAMA Surg 2024, n = 150) found no significant difference at 2 yr — Sugarbaker 17% vs keyhole 24% (adjusted RR 0.87, 95% CI 0.42–1.69). No difference in mesh-related complications, wound morbidity, QoL, or decision regret.[7]

Mesh position​

PositionRecurrenceNotes
Preperitoneal6.5%Lowest in one large series[5]
Onlay25%Accessible but higher recurrence[5]
Intraperitoneal36.4%Most common in MIS repairs[5][2]
Retrorectus17–24% (RCT)Conflicting smaller-series data[5][7]

Mesh type​

  • Permanent synthetic (polypropylene, polyester) — most commonly used; overall morbidity 24.9%, SSI 3.8%, mesh infection 1.7%.[13]
  • Biologic — recurrence ~15.7–18% at 3.8 yr; not superior to synthetic for elective repair.[13]
  • Synthetic resorbable — limited data; used in some prophylactic series.[23]

Open vs Minimally Invasive Repair​

ParameterOpenLaparoscopic / Robotic
OR timeLongerShorter (p <0.001)[24]
Hospital stay6–7 d1–5 d (p <0.001)[24][25]
Wound complications18.6%Similar or lower[24]
SSIHigherRR 0.37–0.63 (p = 0.02–0.03)[24]
MortalityHigherRR 0.18 (p = 0.0009)[24]
Recurrence17–21%Similar (no significant difference)[24][25]

ASCRS allows MIS repair in selected patients (Grade 1C). Open is favored for larger defects and when stoma resiting is needed.[13] A 2025 meta-analysis confirmed laparoscopic repair shortens LOS by ~4 d, lowers SSI and mortality, with no difference in recurrence.[24]

Robotic-assisted repair​

  • Xu 2021 — 4 patients robotic-assisted (3 Da Vinci SP). Median LOS 1 day, no intraoperative complications, no recurrences at median 18.3 mo. Concurrent ureteroenteric stricture repair, panniculectomy, and abdominal-wall reconstruction performed simultaneously.[11]
  • Dewulf 2022 — 15 patients, 10/15 robotic. Median LOS 5 d. One recurrence (6.7%) at d 66. One-third developed postop UTI.[10]

The robotic platform handles adhesiolysis in a hostile abdomen, allows simultaneous ureteroenteric stricture repair, and provides the dexterity needed for complex mesh placement around the conduit mesentery.[11][10]

Stoma Resiting vs In Situ Repair​

Resiting has fallen out of favor because hernia recurs at the new site:[12][13][5]

  • Holland series — recurrence after resiting with mesh 34.8% vs 17.3% for in-situ mesh repair.[5]
  • All recurrences after resiting were at the new stoma site, independent of prophylactic mesh use.[5]

Resiting remains necessary when overlying skin is too damaged for appliance adherence or when body habitus has changed substantially.[13]

Laparoscopic stoma resiting for both continent channels and incontinent diversions has been described — channel dropped into the abdomen, hernia repaired with mesh, channel brought out through a laparoscopic port site. Continence and patency 100% at 2 yr.[9]

Continent Cutaneous Diversion PSH​

PSH also complicates Indiana pouch, Kock pouch, and Mitrofanoff appendicovesicostomy:[9][26][27]

  • Helal 1997 (n = 21). 61.9% had simultaneous urinary incontinence — the hernia disrupts the continence mechanism. Repair: transabdominal takedown, hernia closure (Marlex if defect >6 cm), revision of the anti-incontinence segment, and stoma resiting. 89.5% success at 23.4 mo; incontinence corrected in 100% of affected patients.[26]
  • Stout 2021 — laparoscopic repair in 2 continent catheterizable channels and 2 incontinent diversions. 100% continence and patency at 2 yr.[9]
  • Mitrofanoff channels — PSH reported but uncommon (1/31 in one pediatric series). Small caliber of the appendiceal channel makes a smaller fascial defect.[27]

Key considerations for continent-diversion PSH: address the continence mechanism simultaneously (often disrupted by the hernia) and preserve the mesenteric blood supply to the catheterizable channel during dissection.[26][9]

Complications of PSH Repair​

ComplicationIncidence
UTI17–33% (most common in ileal-conduit PSH repair)[4][10]
Wound complications18.6% (SSI, seroma, dehiscence)[24]
Mesh infection requiring removal1.7–8.6% (higher with urinary stomas)[6][13]
Stoma stenosis7.4%[5]
Bowel obstructionRare (mesh or adhesive)[6]
Recurrence17–52% by technique; keyhole highest[1][6][7]
Clavien ≥III7.8–12.9%[24][28]
90-day mortality0–6% (higher in elderly, open repair with resiting)[1][28]

Recurrent PSH​

Recurrent PSH after initial repair is common and uniquely difficult:[6]

  • Roussel series — 22.9% of patients required reoperation for recurrence (30.7% keyhole, 18.2% Sugarbaker).
  • At reoperation, 50% could not receive synthetic mesh because of difficult adhesiolysis, leading to suture-only repair — which then required a third surgery in 37.5%.
  • Authors concluded that both keyhole and Sugarbaker may be inadequate for ileal-conduit PSH and that new approaches need to be explored.

Treatment Algorithm​

  1. Asymptomatic / minimally symptomatic — conservative management with hernia belt and stoma-appliance optimization.[12]
  2. Symptomatic, small defect, no concomitant ventral hernia — MIS (laparoscopic or robotic) with Sugarbaker or sandwich; or 3-D mesh implant via small open incision.[13][24][11][22]
  3. Symptomatic, large defect, concomitant ventral hernia — open retromuscular repair with posterior component separation (transversus abdominis release) and mesh; Sugarbaker or keyhole — no clear superiority at 2 yr.[29][30][7]
  4. Stoma requiring resiting (skin damage, body-habitus change) — open or laparoscopic resiting with mesh reinforcement at new site; counsel re: high recurrence.[9][13][5][12]
  5. Concurrent ureteroenteric stricture — robotic approach allows simultaneous PSH repair and ureteroenteric reimplantation.[11]
  6. Continent diversion PSH — address continence mechanism simultaneously; consider stoma resiting with anti-incontinence revision.[26]
  7. Emergency (incarceration / strangulation) — emergent laparotomy with hernia reduction, bowel assessment, and repair.[12]

See Also​

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. 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

4. 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

5. 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

6. 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

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. Su JS, Hoy NY, Fafaj A, et al. The European Hernia Society classification applied to the rare cases of parastomal hernia after ileal conduit urinary diversion: a retrospective cohort of 96 patients. Hernia. 2021;25(1):125–131. doi:10.1007/s10029-020-02230-6

9. 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

10. 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

11. 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

12. Hedrick TL, Sherman A, Cohen-Mekelburg S, Gaidos JKJ. AGA Clinical Practice Update on management of ostomies: commentary. Clin Gastroenterol Hepatol. 2023;21(10):2473–2477. doi:10.1016/j.cgh.2023.04.035

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Tenzel PL, Williams ZF, McCarthy RA, Hope WW. Prophylactic mesh used in ileal conduit formation following radical cystectomy: a retrospective cohort. Hernia. 2018;22(5):781–784. doi:10.1007/s10029-018-1801-5

24. 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

25. Sarno G, Iacone B, Tedesco A, et al. End-colostomy parastomal hernia repair: a systematic review on laparoscopic and robotic approaches. Hernia. 2024;28(3):723–743. doi:10.1007/s10029-024-03026-8

26. 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.

27. König A, Wiseman AX, Wildhaber B, Vidal I, Birraux J. Mitrofanoff procedure in children: use of the appendix and VQZ plasty seems to minimize complications. Pediatr Surg Int. 2025;41(1):304. doi:10.1007/s00383-025-06204-6

28. 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

29. Maskal SM, Ellis RC, Miller BT. Parastomal hernia repair, trying to optimize the impossible reconstruction. Hernia. 2024;28(3):931–936. doi:10.1007/s10029-024-03041-9

30. Raigani S, Criss CN, Petro CC, et al. Single-center experience with parastomal hernia repair using retromuscular mesh placement. J Gastrointest Surg. 2014;18(9):1673–1677. doi:10.1007/s11605-014-2575-4