PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of bmjcrBMJ Case ReportsVisit this articleSubmit a manuscriptReceive email alertsContact usBMJ
 
BMJ Case Rep. 2010; 2010: bcr06.2009.1968.
Published online 2010 March 11. doi:  10.1136/bcr.06.2009.1968
PMCID: PMC3029561
Learning from errors

Plausible mechanism of small bowel injury during trocar cystostomy

Abstract

An 86-year-old man presented with urinary retention secondary to detrusor failure and bulbar urethral stricture. He had a non-tender, palpable, grossly distended bladder and a very poor tone in the muscles of the abdominal wall. He did not allow urethral or suprapubic catheterisation under local anaesthesia; hence, a trocar cystostomy was performed under a short general anaesthesia, which led to injury to the small bowel when least expected. We discuss its subsequent management and plausible mechanism underlying this unexpected complication in the given circumstances.

Background

Suprapubic trocar cystostomy is a commonly performed procedure, both under local and general/regional anaesthesia, for a variety of indications, by urologists as well as general surgeons; it is particularly indicated when urethral catheterisation is not feasible. It is generally a safe procedure but has its risks of complications, albeit rare. It is performed as a blind procedure in the presence of a grossly distended bladder; however, an open insertion of a suprapubic catheter under direct vision is advocated in selected cases, to reduce if not totally eliminate the risk of injury to abdominal viscera.

We decided to write this case up because we encountered a rare but well recognised complication of small bowel injury following blind trocar suprapubic cystostomy when it was least expected and as such had a significant bearing on its management.

We have endeavoured to provide a plausible mechanism underlying this inadvertent complication, with a view to put fellow colleagues on guard when they come across a similar situation in their clinical practice, so that a re-occurrence of this particular adverse event could be prevented by following suggested precautionary measures.

Case presentation

An 86-year-old man had a long term urethral catheter fitted for proven detrusor failure. At his fourth routine catheter change in the community, he could not be re-catheterised. He presented 48 h later for re-insertion of urethral catheter in the secondary care but, despite several attempts, could not be re-catheterised. An ultrasound scan confirmed a bladder residue of over 750 ml; however, the patient did not allow insertion of a suprapubic catheter (SPC) under local anaesthesia.

Urethroscopy under a short general anaesthesia revealed a tight, tubular bulbar urethral stricture that could not be opened with a Sache’s urethrotome. Hence, a percutaneous suprapubic trocar cystostomy was performed 1 cm above the pubic symphysis after aspirating urine with a 22 G needle. Over 700 ml of turbid urine was drained and a sample sent for microbiological examination, which later grew coliform organisms. The procedure was uneventful and the patient was put on oral antibiotics in view of the infected urine.

Twenty-four hours later, the patient developed pyrexia and signs of peritonism localised to the left lower abdomen. In view of the uncomplicated nature of the SPC insertion, clear urine draining down the SPC, and an inconclusive abdominal computed tomography (CT), it was managed conservatively, following a general surgical consult, as a case of a possible incidental sigmoid diverticular perforation/exacerbation of diverticulitis.

Investigations

  • Routine blood tests
  • Blood culture
  • Contrast CT (abdomen/pelvis).

Differential diagnosis

  • Acute exacerbation of diverticulitis
  • Diverticular perforation.

Treatment

The patient was deemed high risk (ASA III-IV) for any further surgical intervention (with severe degree of pectus excavatum, poor respiratory reserve, advanced age and mild dementia). He responded well to resuscitative measures and stabilised. Forty-eight hours later, he started draining contents of small bowel from the peri-catheter region.

Exploratory laparotomy revealed that the SPC had perforated the distal small bowel along the anti-mesenteric border about 106 cm from the duodenal–jejunal flexure.

Outcome and follow-up

A segmental resection of small bowel was performed and the SPC re-sited into the bladder. The patient, however, went into septic shock and died 2 days later.

Discussion

Iatrogenic injury of the small/large bowel is a rare but well recognised complication of suprapubic trocar cystostomy. It is known to occur after a percutaneous blind procedure as well as following a transurethral, cystoscopically guided/open trocar cystostomy. It has been described not only as a primary complication at the time of insertion of an SPC but also at the time of a routine catheter change down a mature tract following previous insertion of an SPC.1 In the latter situation, diagnosis has been delayed for up to 3 months after initial SPC insertion1,2 and consequent ileocutaneous fistulae have been known to heal spontaneously or with delayed secondary closure.3 Thus, the possibility of bowel injury should be borne in mind, even at the time of a routine SPC change, based on clinical findings of abdominal pain and an unexpected deterioration in the clinical picture. Cystography via the SPC, CT scan and even laparoscopy can help locate the position of a misplaced SPC1 and make a definitive diagnosis of bowel injury. Various segments of the intestinal tract have been involved including the caecum and the sigmoid colon, but the most commonly injured bowel segment is the terminal ileum.14 In a large series of 185 suprapubic cystostomies performed for neurogenic bladders at a spinal injuries unit, a 2.7% incidence of bowel injury was reported with only one fatality; the authors stated that, even in expert hands, this procedure was not without complications.5

An obviously distended bladder is the most important prerequisite for a blind percutaneous insertion of an SPC (a standard approach in this situation), under a local, regional or general anaesthetic. However, in the absence of a fully distended bladder or in the presence of lower abdominal scars (signs of previous laparotomy and possible bowel adhesions), an open suprapubic cystostomy and insertion of an SPC under vision is the recommended approach.

Despite the presence of an adequately distended bladder, bowel injury is known to occur, especially if there is abdominal distension secondary to distended loops of small/large bowel, and a slight head low tilt to the operating table (Trendelenberg position) is expected to reduce the risk of bowel injury,4 allowing safe extraperitoneal placement of the SPC.

In the present case, however, distal ileal loop injury occurred most unexpectedly in spite of taking all routine precautions, and despite the absence of any contraindications for a blind percutaneous suprapubic trocar cystostomy into a bladder containing over 700 ml of urine.

We suggest the following plausible mechanism for this unexpected, unexplained complication:

  • Poor tone in the flat muscles of the anterior abdominal wall as well as in the bladder wall due to detrusor failure (see solid arrows in fig 1) allowing a sleeve of peritoneum to slip in front of a distended bladder (fig 1).
    Figure 1
    Poor tone (solid arrows) in the bladder and the anterior abdominal wall muscles (further reduced under general anaesthesia) allowing a coil of small bowel to slip in front of a hugely distended bladder and cross the course of a proposed trocar cystostomy ...
  • Combination of general anaesthetic with relaxed abdominal musculature and generalised abdominal distension secondary to severe pectus excavatum as well as a poor tone in the detrusor; pushing the bowel coils over the dome of the full bladder.
    • In a non-anaesthetised patient, in contrast, the tone in the flat muscles of the anterior abdominal wall is not only maintained but consequent to a degree of local discomfort, perhaps even accentuated as the patient’s defence mechanism against anticipated insertion of an SPC. Hence, we believe that such a complication is much less likely to occur when the procedure is done under a local anaesthetic in a conscious patient.
    • If a blind percutaneous trocar cystostomy needs to be performed on an adequately distended bladder in a patient under a general anaesthetic with or without the benefit of transurethral endoscopic guidance, there is a heightened risk of bowel injury, especially in an elderly patient with poor abdominal and bladder muscle tone. An open insertion of an SPC, after sweeping the peritoneal sleeve up under direct vision via a small Pfannensteil incision, is advisable in such situations, irrespective of the availability of transurethral endoscopic guidance.

Learning points

  • Avoid blind suprapubic trocar cystostomy under general/regional anaesthesia.
  • Open (under vision) suprapubic cystostomy is warranted in elderly/frail patients with poor abdominal/bladder wall tone.
  • Unexpected deterioration in clinical condition following uneventful insertion of an SPC: suspect a bowel injury and have low threshold for exploration if deemed safe.

Acknowledgments

Ann Lush, Dept. of Medical illustration, Norfolk & Norwich University Hospital, Norwich for the line drawings used in this manuscript.

Footnotes

Competing interests: None.

Patient consent: Patient/guardian consent was obtained for publication.

REFERENCES

1. Liau SS, Shabeer UA. Laparoscopic management of caecal injury from a misplaced suprapubic cystostomy. Surg Laprosc Endosc Percutan Tech 2005; 15: 378–9 [PubMed]
2. Witham MD, Martindale AD. Occult transfixation of the sigmoid colon by suprapubic catheter. Age Ageing 2002; 31: 407–8 [PubMed]
3. Noller KL, Pratt JH, Symmonds RE. Bowel perforation with suprapubic cystostomy: Report of two cases. Obstet Gynecol 1976; 48(1 Suppl): 67S–9S [PubMed]
4. Wu CC, Su CT, Lin AC. Iaterogenic bowel perforation from a misplaced percutaneous cystostomy. Eur J Emerg Med 2007; 14: 92–3 [PubMed]
5. Sheriff MK, Foley S, McFarlane J, et al. Long-term suprapubic catheterisation: clinical outcome and survey. Spinal Cord 1998; 36: 171–6 [PubMed]

Articles from BMJ Case Reports are provided here courtesy of BMJ Group