Overview
Definition:
Open suprapubic catheter insertion is a surgical procedure to create a direct channel from the bladder lumen to the skin surface via an incision through the abdominal wall, above the pubic bone
It is performed when other methods of urinary catheterization, such as transurethral catheterization, are not feasible or have failed.
Epidemiology:
The incidence of suprapubic catheterization is lower than transurethral catheterization
It is typically indicated in specific clinical scenarios like acute urinary retention due to bladder outlet obstruction, trauma to the urethra, or when prolonged bladder drainage is anticipated.
Clinical Significance:
This procedure offers an alternative route for bladder drainage, bypassing the urethra
It is crucial for managing patients with severe lower urinary tract obstruction, traumatic urethral injuries, or in cases where transurethral catheterization is contraindicated or unsuccessful
Proficiency in this technique is vital for surgical residents preparing for DNB and NEET SS examinations.
Indications
Absolute Indications:
Acute on chronic urinary retention where transurethral catheterization is impossible or contraindicated
Traumatic rupture of the urethra
Postoperative management following pelvic or urethral surgery
Severe symptomatic benign prostatic hyperplasia (BPH) or prostate cancer with unrelieved retention
Neuropathic bladder dysfunction requiring long-term drainage.
Relative Indications:
Prophylactic bladder drainage during certain abdominal or pelvic surgeries
Management of pelvic fractures with associated bladder injury
Facilitation of bladder irrigation or instillation therapy
Patients with morbid obesity making transurethral catheterization difficult
Expected prolonged need for bladder drainage beyond 2-4 weeks where a suprapubic catheter may be more comfortable and lead to fewer urethral complications.
Contraindications:
Distended bowel loops overlying the bladder
Previous extensive pelvic surgery with significant adhesions
Active infection of the abdominal wall or bladder
Coagulopathy that cannot be corrected
Inability to identify the bladder or palpate the pubic symphysis.
Preoperative Preparation
Patient Assessment:
Thorough assessment of the patient's overall health status, comorbidities, and coagulation profile
Review of previous abdominal surgeries and imaging
Confirmation of the indication for catheterization and discussion of risks and benefits with the patient.
Informed Consent:
Detailed explanation of the procedure, including potential risks such as bleeding, infection, bowel injury, and bladder perforation, and obtaining written informed consent.
Anesthesia:
Typically performed under local anesthesia with or without sedation for elective cases
General anesthesia may be used for urgent cases or if combined with other procedures.
Equipment Setup:
Sterile drapes, gown, gloves
Antiseptic solution for skin preparation
Local anesthetic agent
Scalpel (e.g., #11 or #15 blade)
Surgical scissors
Artery forceps
Catheter insertion device (e.g., trocar or dilator)
Appropriate sized suprapubic catheter (e.g., Foley catheter or Malecot catheter)
Syringe for balloon inflation
Sterile irrigation solution
Suture material for wound closure
Dressing materials
Drainage bag.
Bladder Distension:
The bladder should be distended with sterile saline prior to insertion to facilitate identification and reduce the risk of injury to the posterior bladder wall or adjacent organs
This can be achieved by administering IV fluids or by performing a transurethral catheterization and instilling fluid into the bladder.
Procedure Steps Open Technique
Surgical Incision:
A midline or paramedian infraumbilical incision is made, approximately 2-3 cm in length, extending superiorly from the symphysis pubis
The rectus abdominis muscles are separated in the midline, and the anterior fascia is incised.
Bladder Identification And Access:
The peritoneum is carefully dissected to expose the anterior bladder wall
The bladder is then entered, typically using a scalpel or by blunt dissection, ensuring adequate distension to prevent injury to underlying structures
A purse-string suture may be placed around the entry site for secure closure.
Catheter Insertion:
A suprapubic trocar or a pre-mounted catheter system is used to puncture the anterior bladder wall and insert the catheter
Alternatively, after entering the bladder, a guide wire may be inserted, followed by dilation of the tract and insertion of the catheter over the wire.
Catheter Securing:
Once the catheter is positioned in the bladder, the balloon is inflated with sterile water or saline to secure its placement
The abdominal wall layers are approximated loosely around the catheter to prevent leakage
The skin is closed with sutures, leaving the catheter exiting cleanly.
Wound Closure And Dressing:
The surgical incision is closed in layers
A sterile dressing is applied around the suprapubic catheter exit site
The catheter is connected to a sterile urine collection bag.
Postoperative Care
Monitoring:
Close monitoring of urine output, vital signs, and for signs of bleeding or infection
Assess the catheter for patency and for any leakage around the site
Monitor for abdominal pain or distension.
Pain Management:
Provide adequate analgesia, typically with oral or intravenous analgesics as needed
Local anesthetic at the insertion site can also help
Mobilization as tolerated is encouraged to prevent deep vein thrombosis.
Fluid Management:
Ensure adequate hydration
Intravenous fluids may be necessary in the immediate postoperative period
Monitor for electrolyte imbalances.
Catheter Care:
Regular catheter care, including cleaning the exit site with antiseptic solution daily and ensuring the drainage bag is kept below bladder level to prevent reflux
Advise the patient on how to manage the catheter at home, including emptying the bag and recognizing signs of complications.
Antibiotics:
Prophylactic antibiotics are often administered preoperatively and may be continued postoperatively depending on the indication and patient factors, especially if there is a history of recurrent urinary tract infections.
Complications
Early Complications:
Bleeding from the insertion site or into the bladder, which may require transfusions or surgical exploration
Injury to adjacent organs such as the bowel (intestinal perforation) or blood vessels, leading to hematoma formation or hemorrhage
Infection of the abdominal wall (cellulitis) or bladder (cystitis)
Urinary leakage around the catheter site
Inadvertent insertion into the peritoneal cavity or retropubic space.
Late Complications:
Chronic urinary tract infections
Bladder stones
Urethral fistula formation (if there was an associated urethral injury)
Bladder neck contracture or stenosis
Persistent suprapubic wound leakage
Catheter encrustation or blockage
Formation of granulation tissue around the stoma
Rectal injury.
Prevention Strategies:
Accurate anatomical landmark identification and adequate bladder distension are key to preventing organ injury
Meticulous surgical technique, including proper handling of tissues and secure closure
Use of sterile technique throughout the procedure
Careful selection of catheter size and type
Regular catheter care and prompt management of any signs of infection or leakage
Careful post-operative monitoring for early detection of complications.
Key Points
Exam Focus:
Indications for open suprapubic catheterization vs
transurethral
Contraindications
Key steps of the open surgical technique
Potential early and late complications
Management of common complications.
Clinical Pearls:
Always distend the bladder adequately before entry to improve visualization and safety
Use a purse-string suture for secure bladder entry and closure
Ensure the catheter is well secured with the balloon inflated correctly
Consider the possibility of bowel injury in patients with prior abdominal surgery or adhesions
Open technique is preferred when transurethral catheterization is impossible, especially in emergency situations like severe urethral trauma.
Common Mistakes:
Failure to adequately distend the bladder
Inadequate exposure of the anterior bladder wall
Accidental injury to the bowel or major blood vessels
Incomplete closure of the abdominal wall layers, leading to leakage
Insecure fixation of the suprapubic catheter
Overlooking signs of infection or bleeding in the postoperative period.