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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.
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.
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.
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.
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.
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.1–4 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:
Ann Lush, Dept. of Medical illustration, Norfolk & Norwich University Hospital, Norwich for the line drawings used in this manuscript.
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.