Cystostomy is a term for the creation of a surgical opening into the urinary bladder. Suprapubic cystostomy or suprapubic catheterization refers to a procedure that helps drain the bladder.
Suprapubic cystostomy is indicated as an alternative when an individual is not able to urinate appropriately and urethral catheterization becomes either impossible or undesirable.
In suprapubic cystostomy, a catheter, which is lead out of the lower abdomen, is introduced into the bladder in order to drain it. The two approaches by which suprapubic cystostomy can be performed are:
- Open approach: An incision is made just above the pubic symphysis.
- Percutaneous approach: The catheter is introduced directly through the abdominal wall, above the pubic symphysis, with or without guidance through ultrasound or visualization through flexible cystoscopy.
Conditions requiring Suprapubic cystostomy
Suprapubic cystostomy procedure is considered in conditions when the patient cannot urinate and at the same time, a urethral catheterization is not possible.
- Acute urinary retention: A urethral catheter cannot be passed because of the enlarged prostate secondary to benign prostatic hyperplasia or prostatitis, urethral strictures or bladder neck contractures as a result of previous surgery.
- Narrowing of the urethra
- Urethral trauma: Urethral disruption is associated with pelvic fractures or saddle-type injuries.
- Complicated lower genitourinary infection: acute bacterial prostatitis with associated urinary retention, and in Fournier's gangrene, which requires several genitourinary debridement procedures, a urethral catheter may impede wound care.
- Requirement for long-term urinary diversion: in patients with neurogenic bladder as a result of spinal cord trauma, stroke, multiple sclerosis, or neuropathy.
Suprapubic cystostomy is also indicated if damage to the urethra needs to be avoided and if surgery should be done on the urethra or the surrounding structures.
How is the suprapubic cystostomy performed?
The percutaneous suprapubic cystostomy procedure involves percutaneous placement of a suprapubic catheter either using a sharp, punch trocar or by means of different methods such as:
- Localization of the bladder by palpation or by application of the Lowsley retractor
- Seldinger technique using peel away sheath introducer
- Direct cystoscopic visualization
- Direct ultrasonographic visualization
In most cases requiring percutaneous suprapubic cystostomy, local anesthesia is sufficient to manage the pain during the procedure. However, in patients with spinal cord trauma, general or regional anesthesia is used. In addition, for uncooperative patients, sedation may be added to local anesthesia.
In the majority of cases, a sharp obturator or trocar stylet is employed to obtain percutaneous access to the bladder. In other cases, the Seldinger technique may be used. A spinal needle is inserted to gain access to the bladder, followed by the aspiration of urine out of the needle. A guiding wire is the passed through the needle, after which the needle is withdrawn and a catheter is advanced over the wire to reach the bladder.
Steps Involved in suprapubic cystostomy
Step 1: After anesthesia produces numbness in the area, the surgeon locates the patient's bladder with the help of imaging guidance such as an ultrasound.
Step 2: Insertion of a needle into the patient's lower abdomen and his bladder.
Step 3: A wire will be guided along the needle into the bladder to prepare the insertion of a catheter.
Step 4: A catheter will be inserted into the bladder overlying the wire. Then, the catheter will be sutured in place.
The entire procedure may last for about 10-45 minutes. Postoperative pain and discomfort may be managed with medicines.
What are the possible complications associated with suprapubic cystostomy?
Post-operative complications of suprapubic cystostomy are rare, but, as with any medical procedure, there may be some complications, which include:
- Transient hematuria or bloody urine
- Bowel perforation and damage to other visceral organs in the abdomen
- Infection and bleeding
- Formation of blood clots
- Mucous or mucopurulent discharge around the exit site of the catheter
- Anesthesia reaction