Suprapubic Cystostomy Technique

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.

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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.

An example of the Cook Peel-Away Sheath set.

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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.

Erosion of ventral surface of penis. Foley catheter has eroded glans, penile skin, and almost entire penile urethra. (Reprinted from Vaidyanathan S, Soni BM, Hughes PL, et al. Severe ventral erosion of penis caused by indwelling urethral catheter and inflation of Foley balloon in urethra. Adv Urol. 2010; 461539.)

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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]}