Overview
Definition:
Percutaneous suprapubic catheter insertion, often performed using the Seldinger technique, is a minimally invasive procedure to establish urinary drainage directly into the bladder through an abdominal incision above the pubic bone
It is an alternative to urethral catheterization, particularly when urethral access is difficult or contraindicated.
Epidemiology:
The incidence varies based on indications such as acute urinary retention, bladder outlet obstruction, pelvic trauma, and in patients requiring long-term bladder drainage
It is a commonly performed procedure in emergency and elective surgical settings.
Clinical Significance:
This procedure offers a reliable method for bladder decompression and drainage, preventing complications of urinary retention like renal dysfunction, bladder distension, and infection
It is crucial for managing patients with specific urological and gynecological conditions and is an important skill for surgical residents to master for DNB and NEET SS examinations.
Indications
Absolute Indications:
Acute urinary retention where urethral catheterization has failed or is impossible
Complete bladder outlet obstruction due to benign prostatic hyperplasia, urethral stricture, or trauma
Neurogenic bladder dysfunction requiring suprapubic drainage
Post-operative bladder drainage after certain pelvic surgeries.
Relative Indications:
Need for long-term bladder drainage in patients with chronic urinary retention
Pelvic fractures with urethral injury
Patients with coagulopathy or severe immunosuppression where urethral trauma is a concern
Obese patients where urethral catheterization is technically challenging.
Contraindications:
Uncorrected coagulopathy
Previous lower abdominal surgery with extensive adhesions
Active urinary tract infection (relative contraindication, may require treatment before)
Inability to identify the bladder or palpate the pubic symphysis
Distended bowel loops in the prevesical space.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination to confirm indications and rule out contraindications
Assess for urinary retention, bladder distension, and any pelvic abnormalities
Review of prior abdominal surgeries and imaging is essential.
Laboratory Investigations:
Complete blood count (CBC) to assess for anemia and infection
Coagulation profile (PT/INR, aPTT) to evaluate bleeding risk
Serum electrolytes and renal function tests (creatinine, BUN) to assess for pre-renal azotemia secondary to urinary retention.
Imaging:
Ultrasound of the bladder and kidneys is highly recommended to confirm bladder distension, assess bladder wall thickness, and identify any intraluminal abnormalities or adjacent masses
Abdominal X-ray or CT scan may be useful in cases of trauma or suspected pelvic fracture.
Informed Consent:
Detailed discussion with the patient or their legal guardian regarding the procedure, indications, benefits, risks, potential complications, and alternatives
Obtaining signed informed consent is mandatory.
Procedure Steps Seldinger
Patient Positioning And Anesthesia:
The patient is typically placed in a supine position
Local anesthesia (e.g., lidocaine with epinephrine) is infiltrated into the skin, subcutaneous tissue, and rectus muscle along the planned insertion path
Sedation may be administered for anxious patients.
Site Selection And Preparation:
The insertion site is usually 2-3 cm superior to the pubic symphysis, in the midline
The area is prepped and draped in a sterile fashion
A small skin incision is made to facilitate trocar insertion.
Needle Insertion And Guidewire Placement:
A puncture needle (typically 16-18G) is advanced under ultrasound or palpation guidance into the bladder
Once the needle is in the bladder, confirmed by aspiration of urine, the stylet is removed, and a flexible guidewire is passed through the needle into the bladder.
Dilatation And Sheath Insertion:
The needle is removed over the guidewire
A small skin incision is made at the wire entry point
A series of dilators are then sequentially passed over the guidewire to create a tract of adequate size
A peel-away introducer sheath is then advanced over the dilators and guidewire into the bladder.
Catheter Insertion And Removal Of Sheath:
The dilators and guidewire are removed
The suprapubic catheter (e.g., Foley catheter, Malecot catheter) is then inserted through the introducer sheath
Once the catheter is correctly positioned in the bladder, the peel-away sheath is removed, leaving the suprapubic catheter in place
The tract may be secured with a stitch.
Confirmation And Postoperative Care:
Urine should flow freely from the catheter, confirming correct placement
The catheter is secured to the skin, and a drainage bag is attached
Postoperative monitoring for bleeding, pain, and signs of infection is essential.
Complications
Early Complications:
Bleeding (most common), hematuria, urinary tract infection (UTI), bowel injury (rare), injury to adjacent organs (e.g., intestines, peritoneum), wound infection, leakage of urine around the catheter site.
Late Complications:
Chronic infection, bladder stones, bladder neck contracture, urethral stricture (if trocar traverses urethra), vesicocutaneous fistula, incrustation of the catheter, pain or discomfort.
Prevention Strategies:
Meticulous sterile technique throughout the procedure
Careful patient selection and pre-operative assessment
Accurate landmark identification and ultrasound guidance
Appropriate sizing of the catheter and dilators
Secure catheter fixation to prevent dislodgement
Prompt treatment of UTIs
Patient education on catheter care.
Postoperative Care
Monitoring:
Regular vital signs monitoring
Observation for signs of bleeding (hematuria, abdominal distension)
Assessment of urine output and quality
Monitoring for signs of infection (fever, dysuria, wound redness/discharge).
Pain Management:
Adequate analgesia is crucial
Parenteral or oral analgesics can be prescribed based on patient’s pain level
Bladder spasms may require antispasmodics (e.g., oxybutynin).
Catheter Care:
Regular perineal hygiene
Ensuring unobstructed urine flow
Monitoring for kinks or blockages in the catheter tubing
Periodic catheter irrigation if needed
Patient education on self-care, fluid intake, and recognizing signs of complications.
Removal And Follow Up:
Catheter removal is typically indicated once the underlying cause of retention is resolved or when bladder function recovers
This may involve a trial without catheter
Follow-up may be required to ensure adequate voiding and to monitor for long-term complications like strictures.
Key Points
Exam Focus:
Indications and contraindications for suprapubic catheterization
Differentiating Seldinger technique from open technique
Key steps and potential complications of Seldinger insertion
Management of common complications like bleeding and infection.
Clinical Pearls:
Always confirm bladder filling with ultrasound before insertion
Use epinephrine in local anesthetic to minimize bleeding
Ensure the guidewire is securely within the bladder lumen before dilatation
Listen for the "pop" as the needle enters the bladder
Secure the catheter well to prevent accidental traction.
Common Mistakes:
Performing the procedure on an empty bladder
Inadequate anesthesia
Insufficient sterile draping
Incorrect guidewire manipulation leading to perforation or entanglement
Over-dilating the tract
Failure to adequately secure the catheter
Not identifying and managing complications promptly.