Suprapubic Cystostomy

Cystostomy is the general term for the surgical creation of an opening into the bladder; it may be a planned component of urologic surgery or an iatrogenic occurrence. Often, however, the term is used more narrowly to refer to suprapubic cystostomy or suprapubic catheterization. In a setting where an individual is unable to empty his or her bladder appropriately and urethral catheterization is either undesirable or impossible, suprapubic cystostomy offers an effective alternative.

Cystostomy for the purpose of suprapubic catheterization may be performed in 2 ways, as follows:

• Via an open approach, in which a small infraumbilical incision is made above the pubic symphysis

• Via a percutaneous approach, in which the catheter is inserted directly through the abdominal wall, above the pubic symphysis, with or without ultrasound guidance or visualization through flexible cystoscopy

This article focuses on the percutaneous approach because this method can potentially be performed in outpatient, bedside, or urgent care settings.

Relevant anatomy

The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the retropubic space (of Retzius). The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to neighboring structures by reflections of the pelvic fascia and by true ligaments of the pelvis.

The body of the bladder receives support from the external urethral sphincter muscle and the perineal membrane inferiorly and the obturator internus muscles laterally (see the image below).

For more information about the relevant anatomy, see Bladder Anatomy. See also Female Urinary Organ Anatomy and Male Urinary Organ Anatomy.

At least 4 situations exist in which suprapubic cystostomy is considered:

• Acute urinary retention in which a urethral catheter cannot be passed (eg, because of prostatic enlargement secondary to benign prostatic hyperplasia or prostatitis, urethral strictures or false passages, or bladder neck contractures secondary to previous surgery)

• Urethral trauma

• Management of a complicated lower genitourinary tract infection

• Requirement for long-term urinary diversion (eg, because of neurogenic bladder)

Acute urinary retention without urethral catheterization

For a patient who is difficult to catheterize transurethrally, various steps are suggested before suprapubic cystostomy is performed (see the image below).[1]

Failure to pass a urethral catheter may result from a false passage created by multiple attempts at urethral catheterization or from urethral stricture disease. After a reasonable attempt at catheterization has been made, including use of a coudé catheter, and if a urologist is not available to perform a flexible cystoscopy with potential catheter placement over a wire, a suprapubic cystostomy is reasonable.

Urethral trauma

In the setting of urethral trauma, functional bypass of the urethra may be required because of the possibility of urethral disruption. Urethral disruption is usually associated with pelvic fractures or saddle-type injuries and should be suspected when the triad of (1) blood at the urethral meatus, (2) inability to urinate, and (3) a palpably distended bladder is observed. The urethral injury should be addressed by a urologist; however, a suprapubic cystostomy may be a valuable measure for emergency drainage of the bladder.

Complicated lower genitourinary infection

In a complicated infection of the lower genitourinary tract with associated urinary retention (eg, acute bacterial prostatitis), bladder drainage with suprapubic cystostomy should be considered.

Another indication for suprapubic catheter placement is Fournier's gangrene, which often necessitates multiple genitourinary debridement procedures and, potentially, skin grafting. If a urethral catheter impedes wound care and surgical management of this complicated, dangerous disease, consider a suprapubic cystostomy to divert urine from these surgical sites.

Long-term urinary diversion

Suprapubic catheterization may also be considered as an option in patients who require long-term urinary diversion. The British Association of Urological Surgeons issued practice guidelines suggesting that clinicians should consider whether a suprapubic catheter would be preferable to an urethral catheter for patients who require a long-term indwelling catheter.[2]

A suprapubic catheter may be considered in patients with neurogenic bladder secondary to spinal cord injuries, stroke, multiple sclerosis, neuropathy, or detrusor sphincter dyssynergia who are unable to void and who are unable or unwilling to perform clean intermittent catheterization.[3, 2]

Patients who undergo phallic reconstruction or fistula repair[1] may also require longer-term urinary diversion. In a retrospective study that included more than 10 years of follow-up data from 179 predominantly male patients with spinal cord injuries, similar rates of urinary tract infections, bladder and renal calculi, and renal function preservation were reported for those managed with urethral catheters and those managed with suprapubic catheters.[4]

In this study,[4] urethral strictures, urethral fistulas, and scrotal abscesses were found only in the urethral catheter group; 3 patients with urethral strictures and 3 patients with urethral-cutaneous fistulas switched to suprapubic catheters as a result of these complications. Catheter-specific complications included erosion associated with urethral catheters and leakage around the suprapubic catheter site and from the urethra.

Percutaneous suprapubic cystostomy is absolutely contraindicated in the following circumstances:

• The bladder is not distended, is not easily palpable, or cannot be localized with ultrasonographic assistance

• The patient has a history of bladder cancer

Relative contraindications include the following:

• Coagulopathy

• Previous lower abdominal or pelvic surgery (because of the possibility of adhesions between the bowel and the bladder)

• Pelvic cancer, with or without a history of irradiation (because of the possibility of adhesions)

• Placement of orthopedic hardware for pelvic fracture repair – Although some reports suggest that suprapubic tubes leading to infection of hardware is a relatively rare complication,[5] consult with the orthopedist before performing suprapubic catheterization in patients with hardware

If percutaneous placement is contraindicated and an open surgical approach to suprapubic cystostomy is necessary to provide appropriate dissection through adhesions, avoid bowel injury, and achieve effective hemostasis, this would probably have to be done by a general surgeon or urologist in an operative setting.[3]

Procedural planning

There are 2 key issues that must be kept in mind when placement of a suprapubic cystostomy is being considered. The first issue is whether the patient’s bladder can be sufficiently well drained with a urethral catheter. If this is the case, urethral catheterization may be a more appropriate choice because it is often easier and is associated with less short-term morbidity, especially in women and men who develop acute urinary retention and may regain the ability to void with straightforward medical management (eg, alpha-blocker therapy).

On the other hand, suprapubic cystostomy may be preferable to urethral catheterization when the catheter is needed for long-term bladder management, as in patients with neurogenic bladders. For instance, male patients with suprapubic cystostomies have a decreased incidence of traumatic hypospadias and a reduced risk of urinary tract infection, prostatitis, urethritis, and epididymitis. Male patients also retain sexual function. Female patients have a decreased incidence of urinary tract infection and can avoid development of a patulous urethra.

If the procedure can be planned in advance, referring the patient to a urologist for an informed discussion of elective procedures might be best. In those emergent situations where the patient is unable to empty his or her bladder and a urethral catheter cannot be placed, suprapubic cystostomy is a viable option.

The second issue is selecting the method that will be used to place the suprapubic cystostomy. As noted (see Background), either an open approach or a percutaneous approach to suprapubic catheterization may be taken. Most individuals with training in general surgery or urology find the open procedure straightforward. Most other physicians prefer a percutaneously placed suprapubic cystostomy, which can be performed by means of 5 different methods (see Technique). Unfortunately, the percutaneous option is not always a safe possibility.

Regardless of how a suprapubic cystostomy is placed, it is always advisable to distend the bladder during localization of the surgical site. This affords the physician the best opportunity to find the bladder quickly and avoid bowel injury.

In urgent circumstances, when the urethra cannot be cannulated and the bladder must be decompressed, the bladder is probably already distended with urine. This can be observed on physical examination. Otherwise, if the urethra can be cannulated with a Foley catheter or a flexible cystoscope, the bladder can be distended with normal saline. To prevent gram-negative bacteremia, an appropriate preprocedural intravenous gram-negative antibiotic should be administered before instrumentation of the genitourinary tract.[3]

A study by Lavelle et al indicated that suprapubic catheterization improves the urologic quality of life in patients with neurogenic bladder. Only 3 of 58 patients (5.2%) who responded to the Patient Global Impression of Improvement (PGI-I) questionnaire reported a negative score, with more than 80% reporting a better quality of life (mean time of 48.3 mo between catheter placement and questionnaire).[6]

Obtain informed consent from the patient or guardian. The patient should be informed in advance that the procedure involves placing a tube and draining the bladder through the abdominal wall.

Patients should be instructed on how to care for the catheter and empty and change drainage bags (eg, from a leg bag during daytime use to a larger drainage bag for overnight use). The suprapubic catheter exit site should be washed daily with soap and water and may be covered with gauze. If not otherwise contraindicated, patients should be instructed to drink plenty of fluids.

Patients should be instructed to seek immediate medical attention for catheter replacement if the catheter becomes dislodged. The tract can close very quickly, requiring suprapubic cystostomy to be performed again, if the suprapubic tube is not urgently replaced.

A number of percutaneous suprapubic cystostomy kits are on the market. All are based on the same principle. It should be kept in mind that if a suprapubic catheter kit is not available during an emergency situation that calls for urgent bladder drainage, any device suitable for central venous access can be placed suprapubically by using the Seldinger technique.[3]

Materials used for suprapubic cystostomy include the following (other materials, if equivalent, can be easily substituted):

• Sterile gloves

• Face mask with protective shield

• Clippers/shaver (to remove hair at the suprapubic site)

• Sterile towels (4) or drapes

• Antiseptic solution/applicators (eg, 3 ChloraPreps; CareFusion, Leawood, KS)

• Marking pen

• 1% lidocaine (5 mL) and 0.25% bupivacaine (5 mL) in a Luer-Lok syringe

• 22-gauge, 7.75-cm spinal needle tip (some use 18- and 25-gauge needles)

• Scalpel with a No. 11 blade

• 10 mL of sterile water in a Luer-Lok syringe (to inflate the catheter balloon)

• Skin tape or 3-0 nylon suture on a curved needle (to secure the catheter loosely to the skin)

• Adson tissue forceps, 1 × 2 teeth, 4.7 in.

• Baumgartner needle holder, 5.5 in.

• 4×4 inch drain gauze (2) or drain sponges

• Tube-securing device (eg, Statlock, Bard Medical Division, Covington, GA; or Cath-Secure, M.C. Johnson, Fort Myers, FL)

• Catheter drainage bag

• Suprapubic catheter kit – Many choices exist, all of which have their own slight variations; examples include the Rutner percutaneous suprapubic balloon catheter set, the Cook Peel-Away Sheath Introducer, and the Stamey Percutaneous Malecot suprapubic catheter set (see the image below), all made by Cook Medical (Bloomington, IN)

  An example of the Stamey percutaneous cystostomy set.

Anesthesia

Some physicians desire patients undergoing suprapubic cystostomy placement to receive parenteral analgesia, with or without sedation. To ensure patient and practitioner safety during this invasive procedure, procedural sedation and analgesia may be considered in all patients who are uncooperative or agitated.

Local anesthesia should be used for a percutaneous suprapubic cystostomy. Light sedation may also be beneficial for patient comfort. An example of an appropriate preparation would be a 1:1 formulation of lidocaine 1% 5 mL and bupivacaine 0.25% 5 mL, for a total of 10 mL. Many other formulations compositions would serve equally well as a local anesthetic. With a 22-gauge needle tip, infiltrate the superficial and subcutaneous tissue down to the fascia, approximately 2 fingerbreadths above the pubic symphysis.

Positioning

During percutaneous suprapubic cystostomy placement under cystoscopic guidance, the patient could be either supine, if a flexible cystoscope is being used, or in the dorsal lithotomy position, if a rigid cystoscope is being used. If the urethra can be cannulated, the cystoscope allows observation of the dome of the bladder during the procedure, enabling visual confirmation of percutaneous entry into the bladder.

For any of the other percutaneous techniques (except the Lowsley retractor technique), the patient should be supine. Also, the patient should always be in the Trendelenburg position. This allows the bowels to fall cranially, decreasing the likelihood of puncturing the gastrointestinal tract during catheter placement.[7]

If not already under the care of a urologist, all patients who undergo suprapubic tube placement should be referred to a urologist for correction of the underlying disease, as well as routine cystostomy tube care.

The first catheter change should take place after approximately 4-6 weeks to allow time for a tract to form. Subsequently, if the catheter is intended for long-term use, it can be changed monthly, with upsizing (eg, to a lumen of 22 or 24 French) if desired. Any lumen smaller than 16 French in diameter is at high risk for obstruction (with sediment or mucus) over time. Repeated catheter blockage should be investigated with cystoscopy.[2]

Some patients may require additional procedures, such as revision of the suprapubic catheter site, surgical closure of the bladder neck or urethra, procedures for treatment of calculi, or anticholinergic medication to stop bladder spasms that might be associated with urethral leakage. Over an extended period, long-term indwelling catheters are associated with chronic inflammation of the urothelium, with a small increased risk of bladder malignancy over years.[8] Thus, annual screening cystoscopies should be considered in this patient population.

If percutaneous suprapubic cystostomy is an option, it can be performed by means of 5 different methods:

• Percutaneous placement of a suprapubic cystostomy using Seldinger technique

• Percutaneous placement of a suprapubic catheter over or through a sharp trocar

• Percutaneous placement of a suprapubic cystostomy under direct cystoscopic visualization (see the video below)

• Percutaneous placement of a suprapubic cystostomy under direct ultrasonographic visualization

• Percutaneous placement of a suprapubic cystostomy with localization of the bladder using a Lowsley retractor

  Suprapubic cystostomy placement under cystoscopic guidance.

This article focuses primarily on the first 2 techniques (Seldinger technique and use of a sharp trocar). The third and fourth techniques (cystoscopic and ultrasonographic visualization) are essentially modifications of the second. Both require a certain skill level that must be attained before the procedure is attempted. If the practitioner performing the procedure is familiar with this equipment, both cystoscopy and ultrasonography can provide visual confirmation of appropriate placement of the instruments and catheter.

The fifth technique involves the use of a Lowsley retractor. This surgical instrument is, for the most part, known only to urologic surgeons and should not be used by personnel unfamiliar with it.[9]

Available suprapubic catheter kits, though based on the same general concept, vary considerably in their details. The packet insert that comes with the kit should always be read carefully (see the video and images below).

In most instances, a sharp obturator (or trocar stylet) is used to obtain percutaneous access to the bladder. In other instances, the Seldinger technique is employed. A spinal needle is used to gain percutaneous access to the bladder, with urine aspirated out of the needle. A guide wire is then advanced through the needle, the needle is removed, and a catheter is advanced over the wire and into the bladder.

The following discussion provides step-by-step instructions for placing both the Cook Peel-Away Sheath (One Step Introducer) suprapubic catheter set (Cook Medical, Bloomington, IN) and the Rutner suprapubic catheter set (Cook Medical, Bloomington, IN).

Initial steps

The first steps in a percutaneous suprapubic cystostomy are the same for the Peel-Away Sheath catheter set as for the Rutner catheter set.

Clean the abdominal wall. Shave the suprapubic operative field with clippers. Prepare the site with an antiseptic (eg, 3 ChloraPreps). Create a surgical field with 4 sterile towels, ensuring that the pubic symphysis can be visualized and palpated. Remove the introducer and catheter from the packaging, using aseptic technique, and place in the sterile field.

Ensure that the patient has a full and palpable bladder to confirm urine return. Palpate the distended bladder, and use a marking pen to note the site of percutaneous catheter placement, 2 fingerbreadths above the pubic symphysis in the midline; avoid placing the catheter in natural skin creases.

Fill a 10-mL Luer-Lok syringe with 5 mL of 1% lidocaine and 5 mL of 0.25% bupivacaine. Attach the syringe to a 22-gauge, 7.75-cm spinal needle. Raise a skin wheal at the marked site, and infiltrate the anesthetic into the subcutaneous tissue and rectus abdominis muscle fascia, aiming the needle at a 10-20° angle toward the pelvis. Advance the needle in this direction, while aspirating the syringe; urine should be easily aspirated when the bladder is entered.

After this point, placement techniques for the 2 catheter sets diverge (see below).

Cystostomy with Peel-Away Sheath suprapubic catheter set

Once needle entry into the bladder has been confirmed by aspiration of urine, suprapubic cystostomy with the Cook Peel-Away Sheath (One Step Introducer) suprapubic catheter set (see the image below) proceeds as follows.

Remove the Luer-Lok syringe from the spinal needle, and advance a guide wire through the needle into the bladder. While holding the wire securely (this is now the route of access to the bladder), carefully remove the needle over the wire, leaving the wire in place.

Directly posterior to the wire, use a scalpel with a No. 11 blade to make a stab incision through the skin and subcutaneous tissue. Pass the Peel-Away Sheath and the indwelling fascial dilator together over the wire and into the bladder. Remove the guide wire and the fascial dilator, leaving only the Peel-Away Sheath inside the bladder.

Pass a Foley catheter (of appropriate size) through the indwelling intravesical sheath and into the bladder. Aspirate urine to confirm proper placement. Inflate the Foley balloon with 10 mL of sterile water, using a Luer-Lok syringe.

Gently withdraw the Peel-Away Sheath from the bladder and anterior abdominal wall; using each side of the Peel-Away Sheath, split the sheath into 2 parts, leaving the catheter in place. Connect the indwelling suprapubic Foley catheter to a drainage bag.

Using a Baumgartner needle holder, an Adson tissue forceps, and 3-0 nylon suture on a curved needle, secure the catheter to the skin of the anterior abdominal wall. Place an air knot at the skin, adjacent to the cystostomy site, and then proceed to use the 2 loose ends of suture (now affixed to the skin by an air knot), to place another knot around the catheter itself.

Place 2 drain gauze pads (4 × 4 in) at the cystostomy site. The catheter may be secured to the patient with foam tape or tube-securing devices (eg, Statlock or Cath-Secure). The aim is to ensure that the catheter is not accidentally tugged or pulled by the patient as a consequence of not being properly secured.

Once needle entry into the bladder has been confirmed by aspiration of urine, remove the spinal needle, and use a scalpel with a No. 11 blade to make a stab incision at this site.

Ready the catheter by removing the protective sleeve from the balloon and discarding it. Place the needle obturator inside the balloon catheter, and secure its position with the Luer-Lok.

Insert the balloon catheter, using one hand to push the catheter from behind the needle hub (using the palm) and the other at skin level to guide the needle. Insert the catheter into the bladder at an 80° angle, aiming at the pubic symphysis. Advance the catheter no more than 4-5 cm beyond where bladder fluid is first seen coming out of the needle obturator. This ensures that the balloon is fully in the bladder (not the subcutaneous tissue) before inflation. The balloon catheter midpoint (etch mark on the needle) is an approximation of the proper depth.

If bladder pressure is low and urine fails to flow spontaneously through the needle obturator, aspirate urine to verify that the balloon catheter is within the bladder. When proper positioning of the catheter is confirmed, inflate the balloon with 10 mL of sterile water. Release and remove the needle obturator. Connect the indwelling suprapubic Foley catheter to a drainage bag.

Using a Baumgartner needle holder, an Adson tissue forceps, and 3-0 nylon suture on a curved needle, secure the catheter to the skin of the anterior abdominal wall. Place an air knot at the skin, adjacent to the cystostomy site, and then use the 2 loose ends of the suture (now affixed to the skin by an air knot) to place another knot around the catheter itself.

Dress the site with 2 drain gauze pads (4 × 4 in).

Adverse events associated with suprapubic cystostomy may include inadvertent urethral catheterization, intraperitoneal extravasation (without a history of previous surgery), altered body image, latex allergy, overgranulation at the cystostomy entry site, extraperitoneal extravasation, obstruction of tubing (by blood, mucus, or kinking), and loss of the cystotomy tract or access if the tubing comes out.[3, 10]  In a study that compared the trocar and Seldinger techniques for performing percutaneous suprapubic cystostomy, Roberts et al reported that catheter occlusion occurred more frequently in the trocar group, whereas bladder spasms were more common in the Seldinger group.[11]

Immediate complications of suprapubic catheter placement include gross hematuria, which is usually transient, and the possibility of postobstructive diuresis, in which urine output may be greater than 200 mL/h. The latter is usually a physiologic response to the volume expansion and solute accumulation that developed during the obstruction, but a pathologic diuresis might ensue.

Patients should be monitored for postobstructive diuresis. Vital signs should be checked, along with serum electrolyte, magnesium, blood urea nitrogen, and creatinine concentrations. The intensity of monitoring depends on the patient’s mental status, renal function, and electrolyte status.[1]

Serious complications of the procedure include bowel perforation and other intra-abdominal visceral organ injuries and urosepsis, whose manifestations may be delayed.[12]

A mucous or mucopurulent discharge around the exit site may occur; if present, it can be managed with local hygiene measures alone if there is no cellulitis and no evidence of systemic infection.[2]

Possible complications from long-term catheter use include penile erosion (traumatic hypospadias, see the image below), recurrent symptomatic urinary tract infection, leakage from the urethra, bladder and renal calculi formation, deterioration of renal function, and increased risk of bladder cancer.

Squamous cell carcinoma of the bladder was a more common subtype in a population of chronically catheterized patients with spinal cord injury who were treated for bladder cancer.[13, 8] Thus, annual screening cystoscopies should be considered in patients with long-term indwelling catheters in place over years.

Suprapubic catheter use may be additionally complicated by exit site infections or leakage. Bladder stones developed in 22-45% of patients with long-term suprapubic catheter use.[14, 15, 4]

The goals of pharmacotherapy are to minimize pain, reduce morbidity, and prevent complications.

Class Summary

The anesthesia should be used for a percutaneous suprapubic cystostomy. Local anesthetics block the initiation and conduction of nerve impulses.

Lidocaine (Xylocaine)

Lidocaine inhibits depolarization of type C sensory neurons by blocking sodium channels. An example of an appropriate preparation would be a 1:1 formulation of 5 mL of lidocaine 1% and 5 mL of bupivacaine 0.25%, for a total of 10 mL. Many other formulation compositions would serve equally well as a local anesthetic. With a 22-gauge needle tip, infiltrate the superficial and subcutaneous tissue down to the fascia, approximately 2 fingerbreadths above the pubic symphysis. Fill a 10-mL Luer-Lok syringe with 5 mL of 1% lidocaine and 5 mL of 0.25% bupivacaine. Attach the syringe to a 22-gauge, 7.75-cm spinal needle. Raise a skin wheal at the marked site, and infiltrate the anesthetic into the subcutaneous tissue and rectus abdominis muscle fascia, aiming the needle at a 10-20° angle toward the pelvis. Advance the needle in this direction, while aspirating the syringe; urine should be easily aspirated when the bladder is entered.

Bupivacaine (Marcaine)

Bupivacaine decreases the permeability to sodium ions in neuronal membranes. This results in the inhibition of depolarization, blocking the transmission of nerve impulses. An example of an appropriate preparation would be a 1:1 formulation of 5 mL of lidocaine 1% and 5 mL of bupivacaine 0.25%, for a total of 10 mL. Fill a 10-mL Luer-Lok syringe. Attach the syringe to a 22-gauge, 7.75-cm spinal needle. Raise a skin wheal at the marked site, and infiltrate the anesthetic into the subcutaneous tissue and rectus abdominis muscle fascia, aiming the needle at a 10-20° angle toward the pelvis. Advance the needle in this direction, while aspirating the syringe; urine should be easily aspirated when the bladder is entered.