Percutaneous Suprapubic Cystostomy

Satya Allaparthi

K. C. Balaji

Philip J. Ayvazian

Percutaneous suprapubic cystostomy was described four centuries ago; safety of the procedure was first demonstrated by Garson and Peterson in 1888. The first modern method was the Campbell trocar set, described in 1951 [1]. It is used to divert urine from the bladder when standard urethral catheterization is impossible or undesirable [2]. In emergency situations, the majority of these patients are men with urethral stricture or complex prostatic disease or patients with trauma with urethral disruption. Complete urethral transection associated with a pelvic fracture is an absolute indication for emergent suprapubic cystostomy. The procedure for placement of a small-diameter catheter is rapid, safe, and easily accomplished at the bedside under local anesthesia. This chapter first addresses methods for urethral catheterization before discussing the percutaneous approach.

Urethral Catheterization

Urethral catheterization remains the principal method for bladder drainage. The indications for the catheter should be clarified because they influence the type and size of catheter to be used [3]. A history and physical examination with particular attention to the patient’s genitourinary system are important.

Catheterization may be difficult with male patients in several instances. Patients with lower urinary tract symptoms (e.g., urinary urgency, frequency, nocturia, decreased stream, and hesitancy) may have benign prostatic hypertrophy. These patients may require a larger bore catheter, such as 20 or 22 French (Fr). When dealing with urethral strictures, a smaller bore catheter should be used, such as 12 or 14 Fr. Patients with a history of prior prostatic surgery such as transurethral resection of the prostate, open prostatectomy, or radical prostatectomy may have an irregular bladder neck as a result of contracture after surgery. The use of a coudé-tip catheter, which has an upper deflected tip, may help in negotiating the altered anatomy after prostate surgery. The presence of a high-riding prostate or blood at the urethral meatus suggests urethral trauma. In this situation, urethral integrity must be demonstrated by retrograde urethrogram before urethral catheterization is attempted.

Urethral catheterization for gross hematuria requires large catheters, such as 22 or 24 Fr, which have larger holes for irrigation and removal of clots. Alternatively, a three-way urethral catheter may be used to provide continuous bladder irrigation to prevent clotting. Large catheters impede excretion of urethral secretions, however, and can lead to urethritis or epididymitis if used for prolonged periods.

Technique

In male patients, after the patient is prepared and draped, 10 mL of a 2% lidocaine hydrochloride jelly is injected retrograde into the urethra. Anesthesia of the urethral mucosa requires 5 to 10 minutes after occluding the urethral meatus either with a penile clamp or manually to prevent loss of the
jelly [4]. The balloon of the catheter is tested, and the catheter tip is covered with a water-soluble lubricant. After stretching the penis upward and perpendicular to the body, the catheter is inserted into the urethral meatus. The catheter is advanced up to the hub to ensure its entrance into the bladder. To prevent urethral trauma, the balloon is not inflated until urine is observed draining from the catheter. Irrigation of the catheter with normal saline helps verify the position. A common site of resistance to catheter passage is the external urinary sphincter within the membranous urethra, which may contract voluntarily. Any other resistance may represent a stricture, necessitating urologic consultation. In patients with prior prostate surgery, an assistant’s finger placed in the rectum may elevate the urethra and allow the catheter to pass into the bladder.

In female patients, short, straight catheters are preferred. Typically, a smaller amount of local anesthesia is used. Difficulties in catheter placement occur after urethral surgery or vulvectomy, or with vaginal atrophy or morbid obesity. In these cases, the meatus is not visible and may be retracted under the symphysis pubis. Blind catheter placement over a finger located in the vagina at the palpated site of the urethral meatus may be successful.

When urologic consultation is obtained, other techniques for urethral catheterization can be used. Flexible cystoscopy may be performed to ascertain the reason for difficult catheter placement and for insertion of a guidewire. A urethral catheter can then be placed over the guidewire by the Seldinger technique. Filiforms and followers are useful for urethral strictures.

Indications

On occasion, despite proper technique (as outlined previously), urethral catheterization is unsuccessful. These are the instances when percutaneous suprapubic cystotomy is necessary. Undoubtedly, the most common indication for percutaneous suprapubic cystotomy is for the management of acute urinary retention in men. Other indications for a percutaneous suprapubic cystotomy in the intensive care unit are provided in Table 18.1.

Contraindications

The contraindications to percutaneous suprapubic cystotomy are provided in Table 18.2. An inability to palpate the bladder or distortion of the pelvic anatomy from previous surgery or trauma makes percutaneous entry of the bladder difficult. In these situations, the risks of penetrating the peritoneal cavity become substantial. The bladder may not be palpable if the patient is in acute renal failure with oliguria or anuria, has a small contracted neurogenic bladder, or is incontinent. When the bladder is not palpable, it can be filled in a retrograde manner with saline to distend it. In men, a 14-Fr catheter is placed in the fossa navicularis just inside the urethral meatus and the balloon is filled with 2 to 3 mL of sterile water to occlude the urethra. Saline is injected slowly into the catheter until the bladder is palpable and then the suprapubic tube may be placed. In patients with a contracted neurogenic bladder, it is impossible to adequately distend the bladder by this approach. For these patients, ultrasonography is used to locate the bladder and allow the insertion of a 22-gauge spinal needle. Saline is instilled into the bladder via the needle to distend the bladder enough for suprapubic tube placement (Fig. 18.1).

Table 18.1 Common Indications for Percutaneous Cystotomy

Unsuccessful urethral catheterization in the setting of acute urinary retention
History of prostate surgery
Presence or suspected urethral trauma
Urethral stricture
Severe hypospadias
Periurethral abscess
Presence of severe urethral, epididymal, or prostate infection

Table 18.2 Relative Contraindications to Percutaneous Suprapubic Cystotomy

Nonpalpable bladder
Previous lower abdominal surgery
Coagulopathy
Known bladder tumor
Clot retention

In patients with previous lower abdominal surgery, ultrasonographic guidance is often necessary before a percutaneous cystotomy can be performed safely. Previous surgery can lead to adhesions that can hold a loop of intestine in the area of insertion. Other relative contraindications include patients with coagulopathy, a known history of bladder tumors, or active hematuria and retained clots. In patients with bladder tumors, percutaneous bladder access should be avoided because tumor cell seeding can occur along the percutaneous tract. Suprapubic cystotomy tubes are small in caliber and therefore do not function effectively with severe hematuria and retained clots. Instead, open surgical placement of a large-caliber tube is necessary if urethral catheterization is impossible.

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