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:
- 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 ) allowing a sleeve of peritoneum to slip in front of a distended bladder ().
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 (more ...)
- 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.
- 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.