Spinal cord injury patients are at risk for developing unusual complications such as autonomic dysreflexia while changing suprapubic cystostomy. We report a male patient with spina bifida in whom the Foley catheter was placed in the urethra during change of suprapubic cystostomy with serious consequences.
A male patient, born in 1972 with spina bifida and paraplaegia, underwent suprapubic cystostomy in 2003 because of increasing problems with urethral catheter. The patient would come to spinal unit for change of suprapubic catheter every four to six weeks. Two days after a routine catheter change in November 2009, this patient woke up in the morning and noticed that the suprapubic catheter had come out. He went straight to Accident and Emergency. The suprapubic catheter was changed by a health professional and this patient was sent home. But the suprapubic catheter did not drain urine. This patient developed increasing degree of pain and swelling in suprapubic region. He did not pass any urine per urethra. He felt sick and came to spinal unit five hours later. About twenty ml of contrast was injected through suprapubic catheter and X-rays were taken. The suprapubic catheter was patent; the catheter was not blocked. The Foley catheter could be seen going around in a circular manner through the urinary bladder into the urethra. The contrast did not opacify urinary bladder; but proximal urethra was seen. The tip of Foley catheter was lying in proximal urethra. The balloon of Foley catheter had been inflated in urethra. When the balloon of Foley catheter was deflated, this patient developed massive bleeding per urethra. A sterile 22 French Foley catheter was inserted through suprapubic track. The catheter drained bloody urine. He was admitted to spinal unit and received intravenous fluids and meropenem. Haematuria subsided after 48 hours. The patient was discharged home a week later in a stable condition.
This case shows that serious complications can occur during change of suprapubic catheter in patients with neuropathic bladder. After inserting a new catheter, health professionals should observe spinal cord injury patients for at least thirty minutes and ensure that (1) suprapubic catheter drains clear urine; (2) patients do not develop abdominal spasm or discomfort; (3) symptoms and signs of sepsis or autonomic dysreflexia are absent.
Although complications related to suprapubic cystostomies are well documented, there is scarcity of literature on safety issues involved in long-term care of suprapubic cystostomy in spinal cord injury patients.
A 23-year-old female patient with tetraplegia underwent suprapubic cystostomy. During the next decade, this patient developed several catheter-related complications, as listed below: (1) Suprapubic catheter came out requiring reoperation. (2) The suprapubic catheter migrated to urethra through a patulous bladder neck, which led to leakage of urine per urethra. (3) Following change of catheter, the balloon of suprapubic catheter was found to be lying under the skin on two separate occasions. (4) Subsequently, this patient developed persistent, seropurulent discharge from suprapubic cystostomy site as well as from under-surface of pubis. (5) Repeated misplacement of catheter outside the bladder led to chronic leakage of urine along suprapubic tract, which in turn predisposed to inflammation and infection of suprapubic tract, abdominal wall fat, osteomyelitis of pubis, and abscess at the insertion of adductor longus muscle
Suprapubic catheter should be anchored securely to prevent migration of the tip of catheter into urethra and accidental dislodgment of catheter. While changing the suprapubic catheter, correct placement of Foley catheter inside the urinary bladder must be ensured. In case of difficulty, it is advisable to perform exchange of catheter over a guide wire. Ultrasound examination of urinary bladder is useful to check the position of the balloon of Foley catheter.
Suprapubic cystostomy is performed in spinal cord injury patients in order to prevent complications associated with long-term urethral catheter drainage. We report a patient in whom suprapubic catheter did not drain urine satisfactorily and imaging studies revealed hourglass bladder.
A female patient sustained paraplegia in a traffic accident in 1994 at the age of seventeen years. When she was discharged from spinal unit, she was performing self- catheterisations. In 1995, indwelling urethral catheter drainage was instituted, as she was not able to cope up with self-catheterisations. Intravenous urography, performed in 1994, 1997, 2000 and 2003 showed urinary bladder of normal shape. In 2004, this patient developed frequent blockages and bypassing of catheter; therefore, suprapubic cystostomy was performed. In 2005, she was leaking urine per urethra; therefore, an indwelling catheter was inserted; both suprapubic and urethral catheters drained urine. In 2008, suprapubic catheter failed to drain any urine. Cystogram revealed hourglass bladder. The balloon of suprapubic Foley catheter was located in the upper compartment of hourglass bladder whereas the urethral catheter was placed in the inferior compartment. Ultrasound examination of urinary bladder showed two compartments of hourglass bladder separated by a narrow waist. Computed tomography cystogram delineated smaller superior and larger inferior compartment of the hourglass bladder. At present this patient is happy to manage her bladder with suprapubic and urethral catheters.
When prompt replacement of a mal-functioning suprapubic catheter fails to rectify the problem, computer tomography cystography should be performed to check precise location of suprapubic catheter and structural abnormalities of urinary bladder. In this patient, cystogram revealed hourglass bladder. Possible reasons for development of hourglass bladder in spinal cord injury patients are: traction applied to dome of urinary bladder by Foley balloon when suprapubic catheter is taped tightly to anterior abdominal wall for several months; uncoordinated contractions of detrusor muscle; chronic cystitis leading to hypertrophy of bladder wall.
Squamous cell carcinoma arising from a suprapubic cystostomy tract (SCC-SCT) is a relatively rare bladder malignancy. We present a case of highly differentiated SCC-SCT involving the bladder in a 61-year-old patient with transplanted kidney. Abdominal magnetic resonance imaging revealed an anomalous mass (8 cm × 6 cm × 5 cm) surrounding the suprapubic cystostomy and a space-occupying lesion in the bladder. The pathology report revealed highly differentiated SCC. The patient received radiation therapy after he refused aggressive surgical management in 2012. There was no evidence of metastasis at his latest follow-up in early 2015.
Squamous cell carcinoma; suprapubic cystostomy; bladder malignancy
We review urological procedures performed on a spinal cord injury patient during three decades.
A 23-year-old male patient sustained T-12 paraplegia in 1971. In 1972, intravenous urography showed both kidneys functioning well; division of external urethral sphincter was performed. In 1976, reimplantation of left ureter (Lich-Gregoir) was carried out for vesicoureteric reflux. As reflux persisted, left ureter was reimplanted by psoas hitch-Boari flap technique in 1978.
This patient suffered from severe pain in legs; intrathecal injection of phenol was performed twice in 1979. The segment bearing the scarred spinal cord was removed in September 1982.
This patient required continuous catheter drainage. Deep median sphincterotomy was performed in 1984. As the left kidney showed little function, left nephroureterectomy was performed in 1986. In an attempt to obviate the need for an indwelling catheter, bladder neck resection and tri-radiate sphincterotomy were carried out in 1989; but these procedures proved futile. UroLume prosthesis was inserted and splinted the urethra from prostatic apex to bulb in October 1990. As mucosa was apposing distal to stent, in November 1990, second UroLume stent was hitched inside distal end of first. In March 1991, urethroscopy showed the distal end of the distal stent had fragmented; loose wires were removed. In April 1991, this patient developed sweating, shivering and haematuria. Urine showed Pseudomonas. Suprapubic cystostomy was performed. Suprapubic cystostomy was done again the next day, as the catheter was pulled out accidentally during night. Subsequently, a 16 Fr Silastic catheter was passed per urethra and suprapubic catheter was removed. In July 1993, Urocoil stent was put inside UroLume stent with distal end of Urocoil stent lying free in urethra. In September 1993, this patient was struggling to pass urine. Urocoil stent had migrated to bladder; therefore, Urocoil stent was removed and a Memotherm stent was deployed. This patient continued to experience trouble with micturition; therefore, Memotherm stent was removed. Currently, wires of UroLume stent protrude in to urethra, which tend to puncture the balloon of urethral Foley catheter, especially when the patient performs manual evacuation of bowels.
We failed to implement intermittent catheterisation along with anti-cholinergic therapy. Instead, we performed several urological procedures with unsatisfactory outcome; the patient lost his left kidney. We believe that honest review of clinical practice will help towards learning from past mistakes.
The optimal bladder management method should preserve renal function and minimize the risk of urinary tract complications. The present study is conducted to assess the overall incidence of urinary tract infections (UTI) and other urological complications in spinal cord injury patients (SCI), and to compare the incidence of these complications with different bladder management subgroups.
Materials and Methods:
545 patients (386 males and 159 females) of traumatic spinal cord injury with the mean age of 35.4±16.2 years (range, 18 – 73 years) were included in the study. The data regarding demography, bladder type, method of bladder management, and urological complications, were recorded. Bladder management methods included indwelling catheterization in 224 cases, clean intermittent catheterization (CIC) in 180 cases, condom drainage in 45 cases, suprapubic cystostomy in 24 cases, reflex voiding in 32 cases, and normal voiding in 40 cases. We assessed the incidence of UTI and bacteriuria as the number of episodes per hundred person-days, and other urological complications as percentages.
The overall incidence of bacteriuria was 1.70 / hundred person-days. The overall incidenceof urinary tract infection was 0.64 / hundered person-days. The incidence of UTI per 100 person-days was 2.68 for indwelling catheterization, 0.34 for CIC, 0.34 for condom drainage, 0.56 for suprapubic cystostomy, 0.34 for reflex voiding, and 0.32 for normal voiding. Other urological complications recorded were urethral stricture (n=66, 12.1%), urethritis (n=78, 14.3%), periurethral abscess (n=45, 8.2%), epididymorchitis (n=44, 8.07%), urethral false passage (n=22, 4.03%), urethral fistula (n=11, 2%), lithiasis (n=23, 4.2%), hematuria (n=44, 8.07%), stress incontinence (n=60, 11%), and pyelonephritis (n=6, 1.1%). Clean intermittent catheterization was associated with lower incidence of urological complications, in comparison to indwelling catheterization.
Urinary tract complications largely appeared to be confined to the lower urinary tract. The incidence of UTI and other urological complications is lower in patients on CIC in comparison to the patients on indwelling catheterizations. Encouraging CIC; early recognition and treatment of the UTI and urological complications; and a regular follow up is necessary to reduce the medical morbidity.
Spinal cord injury; urinary bladder; clean intermittent catheterization; urological complications; indwelling catheterization
Herein we report a case of a squamous cell carcinoma of a well-healed suprapubic cystostomy tract scar involving the bladder mucosa in a 56-year-old man. He presented with a spontaneous suprapubic urinary leak from a suprapubic cystostomy tract scar. He had a history of urethral stricture and failed urethroplasty. Preoperative cystoscopy suggested a bladder mass. Transurethral biopsy of the bladder mass revealed a squamous cell carcinoma confined to the suprapubic cystostomy tract involving the bladder mucosa. The patient died 6 months after the start of radiation therapy after lung metastasis and pneumonia.
Cystostomy; Squamous cell carcinoma; Urinary bladder neoplasms
Chronic indwelling catheters may induce histologic changes within the bladder, and these changes are sometimes pre-malignant. There are many documented cases of squamous cell carcinoma associated with indwelling catheters, but only three cases of catheter-associated adenocarcinoma have been reported. In this case report, we present radiographic findings of a case of mucinous adenocarcinoma of the bladder and suprapubic (SP) tract in a quadriplegic patient.
A 71-year-old male with a history of spinal cord injury presented with hematuria and SP discharge after SP catheterization for 51 years. CT urography was performed and revealed an irregular, infiltrative, and heterogeneous mass arising from the anterior bladder at the level of the suprapubic catheter and extending along the SP tube tract. Cystoscopy and biopsy revealed an adenocarcinoma of the anterior bladder and stoma with extensive associated mucin production and a background of acute and chronic inflammation. Surgical therapy included cystoprostatectomy, abdominal wall resection, ileal conduit creation, and abdominal wall reconstruction. The final diagnosis was a high-grade, T2a/N0/M0 (Stage II) mucinous adenocarcinoma of the bladder. There has been no evidence of tumor recurrence over the previous 5 years.
Few cases of adenocarcinoma associated with long term indwelling catheter have been reported in the literature, and due to the rarity of this disease process, the prognosis with surgical therapy is not well known. The patient described herein has been free of recurrence for the previous five years, suggesting that surgery is a viable management option for these patients.
Adenocarcinoma; Suprapubic tube; Catheter; Bladder
Inflating the balloon of Foley catheter in urethra is a complication of urethral catheterisation. We report five patients in whom this complication occurred because of unskilled catheterisation. Due to lack of awareness, the problem was not recognised promptly and patients came to harm.
A tetraplegic patient developed pain in lower abdomen and became unwell after transurethral catheterisation. CT pelvis revealed full bladder with balloon of Foley catheter in dilated urethra.Routine ultrasound examination in an asymptomatic tetraplegic patient with urethral catheter drainage, revealed Foley balloon in the urethra. He was advised to get catheterisations done by senior health professionals.A paraplegic patient developed bleeding and bypassing after transurethral catheterisation. X-ray revealed Foley balloon in urethra; urethral catheter was changed ensuring its correct placement in urinary bladder. Subsequently, balloon of Foley catheter was inflated in urethra several times by community nurses, which resulted in erosion of bulbous urethra and urinary fistula. Suprapubic cystostomy was performed.A tetraplegic patient developed sweating and increased spasms following urethral catheterisations. CT of abdomen revealed distended bladder with the balloon of Foley catheter located in urethra. Flexible cystoscopy and transurethral catheterisation over a guide-wire were performed. Patient noticed decrease in sweating and spasms.A paraplegic patient developed lower abdominal pain and nausea following catheterisation. CT abdomen revealed bilateral hydronephrosis and hydroureter and Foley balloon located in urethra. Urehral catheterisation was performed over a guide-wire after cystoscopy. Subsequently suprapubic cystostomy was done.
Spinal cord injury patients are at increased risk for intra-urethral Foley catheter balloon inflation because of lack of sensation in urethra, urethral sphincter spasm, and false passage due to previous urethral trauma. Education and training of doctors and nurses in proper technique of catheterisation in spinal cord injury patients is vital to prevent intra-urethral inflation of Foley catheter balloon. If a spinal cord injury patient develops bypassing or symptoms of autonomic dysreflexia following catheterisation, incorrect placement of urethral catheter should be suspected.
Spinal cord injury; Foley catheter; Urethral catheterisation
A 65-year-old man with stricture urethra underwent drainage of periurethral abscess and suprapubic cystostomy (SPC) placement. He presented to us 3 months later with a fungating ulcer at the site of perineal incision, the biopsy of which revealed squamous cell carcinoma (SCC). He underwent a total penile amputation, wide local excision scrotum, radical urethrocystoprostatectomy, ileal conduit with the en-bloc excision of the SPC tract. Histopathological examination of the suprapubic tract also revealed SCC. This is the first documented case of SCC of a suprapubic tract in the presence of primary urethral SCC.
Squamous cell carcinoma; suprapubic cystostomy; urethral carcinoma
In female patients with neuropathic bladder, the urethra is closed permanently in order to avoid urine leak. Then Benchekroun hydraulic ileal valve is attached to urinary bladder, thus providing a continent stoma for performing intermittent catheterisations.
We present a female patient with spina bifida who underwent Benchekroun continent vesicostomy in 1993. This patient developed severe stenosis of Benchekroun stoma and stones in urinary bladder. Dilatation of stoma and vesicolithotomy were carried out in 1995. Vesical calculi recurred; suprapubic cystolithotomy was performed in 1999. In March 2000, catheterisation of stoma was not possible and emergency suprapubic cystostomy was done. In April 2000, endoscopy was attempted through Benchekroun stoma. It was not possible to insert ureterorenoscope beyond two inches. The track was completely blocked. In November 2001, X-ray of abdomen showed several vesical calculi; suprapubic cystolithotomy was performed.
In March 2005, this patient developed pain in abdomen. X-ray of abdomen showed a large vesical calculus. In June 2005, suprapubic catheter was removed and a cystoscope was introduced in to the bladder. Then electrohydraulic lithotripsy was performed. In 2007, this patient was concerned about the increasing swelling in lower abdomen. Computed tomography of abdomen revealed midline, lower abdominal wall hernia, which contained several loops of small bowel and ileal cystoplasty. The large hernia was uncomfortable and tender on coughing, but did not cause obstructive bowel symptoms. Surgical repair of hernia was considered. But this patient would require alternative way of urinary diversion because the current location of suprapubic catheter would almost lead to infection of prosthetic material used in reconstruction of the anterior abdominal wall. After discussing risks of operative procedures with patient and her husband, it was decided not to proceed with surgery.
This case is a poignant reminder to spinal cord physicians that novel surgical techniques should be viewed cautiously, and patients should be informed of potential complications of surgical procedures some of which could be irreversible.
Squamous cell carcinoma (SCC) of the bladder is uncommon, but can arise in the setting of long-term bladder catheterization and chronic inflammation. SCC can arise primarily from the suprapubic catheter tract, but fewer than 10 such cases have been reported. We document 2 cases of SCC arising from the suprapubic tract associated with chronic indwelling urinary catheters. SCC must be differentiated from granulomatous conditions, which are quite common in patients with suprapubic catheters.
To prospectively evaluate the new medical device Transurethral Suprapubic endo-Cystostomy (T-SPeC®), used for suprapubic catheter (SPC) placement via the transurethral (inside-to-out) approach, and examine the 30-day outcomes in the first US series.
IRB approval was obtained for this prospective study. We evaluated the first 114 consecutive cases of SPC placement using the T-SPeC® device by a single surgeon at in a 20-month period. We excluded patients who underwent alternative approaches to suprapubic catheter placement including open abdominal approach (12) and percutaneous approach (5). Preoperative patient demographics, operative detail, success rate and 30-day complication rate were recorded.
We successfully placed an 18 Fr suprapubic catheter using the T-SPeC® device in 98.2 % of patients. During the procedure, the capture housing was missed twice. The mean patient age was 56.6, BMI 29.4 kg/m2, skin to bladder distance 6.7 cm and operative time 3.6 min. There were 12 postoperative complications within 30 days of the procedure including urinary tract infections (6), SPC exit site infection (2), SPC blockage (2) and catheter expulsion (2). There were no Clavien–Dindo grade III–IV complications such as re-operation, small bowel injury, hemorrhage or death.
The T-SPeC® device is a novel, simple, accurate and minimally invasive device for SPC insertion from an inside-to-out approach. Our prospective study demonstrates that the T-SPeC® device can be placed safely and efficiently in a variety of patients with a need for urinary drainage.
Medical device; Urinary bladder; Catheter; Instrumentation; Incontinence
Leakage of urine around a catheter is not uncommon in spinal cord injury patients, who have indwelling urethral catheter. Aetiological factors for leakage of urine around a catheter are bladder spasms, partial blockage of catheter, constipation, and urine infection. Usually, leakage of urine subsides when the underlying cause is treated. Leakage of urine around a suprapubic catheter is very rare and occurs in patients, in whom the urethra is closed due to severe stricture or previous surgery.
We describe a 35-year-old female patient with spina bifida and paraplegia, who had undergone suprapubic cystotomy followed by urethral closure for leakage of urine per urethra. She developed leakage of urine around suprapubic Foley catheter, which did not subside even after changing the catheter, ruling out vesical calculus, and ensuring that there was no kink in catheter or drainage tube. As a desperate measure, we punched a large hole at the tip of a Foley catheter and used this catheter for suprapubic drainage. Leakage of urine around suprapubic catheter stopped and the patient was greatly relieved.
Leakage of urine around a catheter requires prompt attention in spinal cord injury patients; otherwise patients can develop maceration of neuropathic skin and pressure sore. Management of spinal cord injury patients with leakage of urine around a suprapubic catheter should include (i) changing the catheter, (ii) prescribing anticholinergic drugs to control bladder spasm, (iii) treating constipation and urine infection when present, (iv) imaging studies or flexible cystoscopy to look for vesical calculus. If leakage of urine persists despite all these measures, use of a modified Foley catheter in which, a large hole has been made at the tip, is worth trying.
Although Harvey Cushing played a central role in the establishment of neurosurgery in the United States, his work on the spine remains largely unknown. This article is not only the first time that Cushing's spinal cases while he was at Johns Hopkins have been reported, but also the first time his management of spinal trauma has been described. We report on 12 patients that Cushing treated from 1898 to 1911 who have never been reported before, including blunt and penetrating injuries, complete and incomplete spinal cord lesions, and both immediate and delayed presentations. Cushing performed laminectomies within 24 hours on patients with immediate presentations—both complete and incomplete spinal cord lesions. Among those with delayed presentations, Cushing did laminectomies on patients with incomplete spinal cord injuries. By the end of his tenure at Hopkins, Cushing advocated nonoperative treatment for all patients with complete spinal cord lesions. Four patients died while an inpatient, with meningitis and cystitis leading to the death of 1 and 3 patients, respectively. Cystitis was treated with intravesicular irrigation; an indwelling catheter was placed by a suprapubic cystostomy in four. Cushing was one of the first to report the use of x-ray in a spine patient, in a case that may have been one factor leading to his interest in the nervous system; Cushing also routinely obtained radiographs in those with spinal trauma. These cases illustrate Cushing's dedication to and rapport with his patients, even in the face of a dismal prognosis.
Harvey Cushing; History of neurosurgery; Spinal trauma
Urethral injury is an uncommon surgical complication of penile prosthesis (PP) surgery. Conventional dogma requires abortion of the procedure if the adjacent corporal body is involved or delayed implantation to avert device infection associated with urinary extravasation. Besides the setback of the aborted surgery, this management approach also presents the possible difficulty of encountering corporal fibrosis at the time of reoperation.
We report an approach using primary urethral repair and temporary suprapubic cystostomy for the management of incidental urethral injuries in a cohort of patients allowing for successful completion of unaborted PP implantation.
Materials and Methods
We performed a retrospective analysis of all patients receiving PPs from 1990 to 2014 in which incidental urethral injuries were repaired and PP implantation was completed with suprapubic cystostomy (suprapubic tube [SPT] insertion). After allowing for urethral healing and urinary diversion via SPT for 4–8 weeks, the PP was activated.
Main Outcome Measures
Successful management was determined by the absence of perioperative complications within 6 months of implantation.
We identified four cases, all receiving inflatable PPs, managed with temporary suprapubic cystostomy. These patients sustained urethral injuries during corporal dissection (one patient), corporal dilation (one patient), and penile straightening (two patients). All patients were managed safely and successfully.
Primary urethral repair followed by temporary suprapubic cystostomy offers a surgical approach to complete PP implantation successfully in patients who sustain urethral injury complications, particularly for complex PP surgeries. Anele UA, Le BV, and Burnett AL. Suprapubic cystostomy for the management of urethral injuries during penile prosthesis implantation.
Penile Reconstruction; Penile Fibrosis; Corporal Dilation; Erectile Dysfunction; SPT
Any new clinical data, whether positive or negative, generated about a medical device should be published because health professionals should know which devices do not work, as well as those which do. We report three spinal cord injury patients in whom urological implants failed to work. In the first, paraplegic, patient, a sacral anterior root stimulator failed to produce erection, and a drug delivery system for intracavernosal administration of vasoactive drugs was therefore implanted; however, this implant never functioned (and, furthermore, such penile drug delivery systems to produce erection had effectively become obsolete following the advent of phosphodiesterase type 5 inhibitors). Subsequently, the sacral anterior root stimulator developed a malfunction and the patient therefore learned to perform self-catheterisation. In the second patient, also paraplegic, an artificial urinary sphincter was implanted but the patient developed a postoperative sacral pressure sore. Eight months later, a suprapubic cystostomy was performed as urethral catheterisation was very difficult. The pressure sore had not healed completely even after five years. In the third case, a sacral anterior root stimulator was implanted in a tetraplegic patient in whom, after five years, a penile sheath could not be fitted because of penile retraction. This patient was therefore established on urethral catheter drainage. Later, infection with Staphylococcus aureus around the receiver block necessitated its removal. In conclusion, spinal cord injury patients are at risk of developing pressure sores, wound infections, malfunction of implants, and the inability to use implants because of age-related changes, as well as running the risk of their implants becoming obsolete due to advances in medicine. Some surgical procedures such as dorsal rhizotomy are irreversible. Alternative treatments such as intermittent catheterisations may be less damaging than bladder stimulator in the long term.
The most serious complication of suprapubic cystostomy is bowel injury. By computed tomography (CT), we investigated the risk factors of possible bowel interposition through the percutaneous suprapubic cystostomy tract.
Materials and Methods
From September to October 2009, we consecutively reviewed 795 abdominopelvic CT scans of adult patients performed for various reasons in our hospital. From these scans, we selected the films wherein the urinary bladder was distended more than 6 cm above the symphysis pubis. We then determined whether the bowel was interposed between the bladder and the skin at the routine puncture site of suprapubic cystostomy (the midline of the abdomen 3 cm above the upper margin of the symphysis pubis). We analyzed which factors influenced the possibility of the bowel being interposed between the bladder and the skin at the suprapubic puncture site.
A total of 226 CT (148 males, 78 females) scans were selected. The mean patient age was 63 years (range, 26-84 years). The mean distance between the upper margin of the symphysis pubis and the umbilicus was 14.4 cm (range, 7.2-21.0 cm). In the multivariate analysis, obesity, a positive history of radical pelvic surgery, and a short distance (≤11 cm) between the symphysis pubis and the umbilicus had significant correlations with bowel interposition in the assumed tract.
When performing a suprapubic cystostomy, extreme caution is needed to avoid possible bowel injury in patients who are obese, had a previous radical pelvic operation, or have a short distance between the upper margin of the symphysis pubis and the umbilicus.
Complications; Cystostomy; Punctures
Ultrasound-guided percutaneous placement of a suprapubic cystostomy is a common and generally safe procedure in everyday surgery. In case of adverse patient characteristics such as small bladder capacity or high body mass index, however, the procedure carries an increased risk of severe complications, including bowel perforation. The Suprapur® cystostomy set is supposed to enable a safer procedure. The aim of our work was to evaluate the safety and ease of use of the Suprapur® cystostomy set.
Material and methods
We prospectively evaluated the Suprapur® set in high-risk patients, having either a small bladder capacity below 250 ml or a BMI above 30 kg/m2. Complications and surgical outcome were monitored. In addition, patients’ contentment and pain during the procedure was assessed with a visual analogue scale (VAS). Possible drawbacks and ease of use were evaluated by customized questionnaires for the operating physician.
In total, 26 cystostomies were performed by 15 different physicians, 40% (n = 6) of whom were inexperienced first or second year residents. No complications occurred. Mild gross haematuria occurred in 11.5% (n = 4) of cases. Average VAS for pain during and two hours after the procedure was 2.1 (±1.2) and 0.3 (±0.5) respectively. In 91%, (n = 20) of the procedures, the physicians claimed to have felt safe using SUPRAPUR® and more comfortable (82%, n = 18) than with a conventional cystostomy set.
SUPRAPUR® allows a safe and simple placement of a suprapubic cystostomy even in high-risk patients or in inexperienced hands. It might help to reduce the complications of a common and frequent surgical procedure.
suprapubic cystostomy; complications; bladder drainage; high-risk patients
Emergency percutaneous trocar suprapubic cystostomy is a common surgical procedure for acute urinary retention. Although uncommon it can be associated with a few complications. The most dangerous complication is iatrogenic bowel injury. Literature shows reported cases of small and large bowel injuries. We report a case of inadvertent placement of suprapubic catheter into a dilated and ptotic stomach. This is the first reported case of this complication of suprapubic cystostomy.
Inadvertent bowel injury; iatrogenic bowel injury; suprapubic cystostomy
Neuropathic urinary bladder is often colonised by multidrug-resistant bacteria. We report a 64-year-old male spinal cord injury patient with paraplegia, who received gentamicin on empirical basis before undergoing suprapubic cystostomy, as antibiotic sensitivity report of urine was not available. This patient developed fulminate septicaemia. Although appropriate antibiotic therapy (meropenem) was started when this patient manifested features of sepsis, acute renal failure occurred and he expired. Inappropriate initial antimicrobial therapy was the major contributory factor for this patient's mortality. Learning points from this case are (1) never do a cystostomy without prior urine culture and appropriate antibiogram; (2) in a chronic spinal cord injury patient, full blood count, liver function tests, albumin level, and albumin to globulin ratio should be performed before any surgical procedure.
Silicone Foley catheters tend to become stiffer as size of the catheter increases. Whereas the tip of a size 12 French silicone, Foley catheter is soft and flexible, a size 24 French silicone, Foley catheter is distinctly stiff. Chronically inflamed neuropathic bladders are susceptible to perforation by the tip of a Foley catheter. We report a patient with multiple sclerosis and moderately severe chronic cystitis, in whom a size 22 French Foley catheter burrowed through the dome of urinary bladder.
A 55-year-old, Caucasian male suffering from multiple sclerosis underwent suprapubic cystostomy in January 2007. Initially, a size 16 Fr. silicone, Foley, catheter was inserted. During subsequent catheter changes, silicone Foley catheters of progressively increasing sizes were inserted and in July 2007, a size 22 Fr. catheter was used in order to prevent blockages and consequent bypassing of urine. In April 2008, he had an uneventful change of suprapubic catheter; but a week later, this patient developed profuse bypassing. On examination, suprapubic catheter contained fresh blood; there was hardly any urine in the leg bag, which was attached to suprapubic catheter. Cystogram showed localised extravasation of contrast on the superior aspect of urinary bladder around the tip of Foley catheter, which protruded beyond the dome of urinary bladder. The size 22 Fr. catheter was removed and a size 20 Fr silicone, Foley, catheter was inserted ensuring that the tip of catheter pointed towards bladder neck. This patient received gentamicin intravenously and he was prescribed ciprofloxacin for five days. He did not develop temperature or other features of sepsis. Bypassing stopped completely.
In this patient, bladder biopsy had shown moderately severe chronic inflammation and congestion. We learn from this case that we should have used a smaller size catheter, which has a softer texture and changed the catheter at shorter intervals rather than insert a larger bore catheter, and run the risk of perforation of neuropathic bladder by the tip of a stiff Foley catheter.
To investigate the treatment of rectourethral fistula.
Eleven cases of male patients with rectourethral fistula were treated in our department from 2011 to 2015. Age 16–66 years old. Causes: three cases of patients with congenital closed anus, four cases of traumatic pelvic fracture with urethral distraction and rectum injury, four cases after radical prostatectomy. The size of the fistula was 0.5–1.5 cm. In addition to the leakage of urine in the large fistula, urine mixed with stool samples. Three patients with congenital closed anal postoperative patients with posterior or anterior median sagittal approach for resection of the fistula, hierarchical closed urethral and rectal wall defect, at least three layer (between the urethral and rectal suture layer), indwelling catheter for 3–4 weeks, no cystostomy. Sigmoid colostomy underwent prior to the surgery. Of which six cases were repaired by perineal approach, one case by abdominal perineal approach, one case by abdominal repair. According to size of fistula and the surrounding scar decide whether or not to adopt tissue interposition, this group of five cases with gracilis muscle flap, one case with bulbocavernosus muscle flap interposed between the rectum and urethra; one case repaired by sigmoid colon pull-through procedure. Post-operation indwelling catheterization for 3–4 weeks with cystostomy.
A total of 10 patients were successful, and no leakage of urine was found after removal of the catheter. One patient improved, occasionally a small amount of drops of urine voiding from anus. Reoperation was successful after 6 months. Recovered enteric continuity 3–6 months post-operation.
The median sagittal approach provide good exposure for the repair of congenital rectourethral fistula; perineal approach is a good choice for patients caused by trauma or surgery; complete resection of scar around the fistula, tension-free anastomosis, tissue interposition and sigmoid colostomy provide necessary guarantee for successful operation.
Baclofen is a gamma- aminobutyric acid B (GABA B) agonist used for the management of spasticity associated with spinal cord injury. Oral baclofen might cause constipation, but intestinal pseudo-obstruction is very rare. We report a 50-year-old male with spasticity following cervical discectomy (C3-4) on oral baclofen for 6 months with intestinal pseudo-obstruction. He had undergone open suprapubic cystostomy for traumatic urethral injury, 45 days prior to the presentation and adhesive intestinal obstruction was also considered a possibility. However, there were no air fluid levels on abdominal radiographs and ultrasound abdomen was non-contributory. Withdrawal of baclofen was therapeutic in this patient. This case is being reported to highlight the rare possibility of oral baclofen induced intestinal pseudo-obstruction.
Adynamic obstruction; baclofen; constipation; intestinal pseudo-obstruction; spasticity
Suprapubic cystostomy (SPC) catheterization is a common and important technique for the management of vesicular drainage, especially in patients with neurogenic bladder. Some serious complications include bowel perforation and obstruction.
A 55-year-old man with C6 American Spinal Injury Association B tetraplegia and a urethral stricture requiring a chronic SPC was admitted for recurrent urosepsis. Computed tomography (CT) of the abdomen revealed severe right hydronephrosis and hydroureter due to obstruction of the right distal ureter by the SPC tip. The SPC (30 French/10-mm silicone catheter with a 10-ml balloon) was removed and replaced with a similar suprapubic catheter (30 French/10-mm silicone catheter with an 8-ml balloon). Symptoms recurred 2 months later and he was readmitted for urosepsis. CT of the abdomen again revealed severe right hydronephrosis and hydroureter due to obstruction of the right distal ureter by the SPC tip. The SPC was removed, and the patient was given a 14 French/4.67-mm urethral silicone catheter with a 5-ml balloon. Follow-up CT of the abdomen 2 months later showed complete resolution of the hydronephrosis and hydroureter. Of note, urodynamic studies 2 years earlier revealed an extremely small bladder with a capacity less than 20 ml.
This case illustrates that obstruction of the ureter by the tip of an SPC can be a cause of recurrent hydronephrosis and urosepsis.
Cystostomy; Hydronephrosis; Hydroureter; Spinal cord injuries; Tetraplegia; Ureteral obstruction; Urinary bladder; Neurogenic; Urosepsis