Suprapubic Catheter Insertion Research Articles

Systematic assessment of surgical complications in 438 cases of vaginal native tissue repair for pelvic organ prolapse adopting Clavien-Dindo classification.

To systematically review surgical complications of vaginal native tissue prolapse repair using Clavien-Dindo classification and to show whether concomitant surgery leads to increased complication rates. Retrospective analysis of complications in 438 consecutive vaginal native tissue prolapse repairs and subgroup analysis was performed for concomitant hysterectomy or sacrospinous fixation for level I defects using Fisher's exact tests. Anterior and posterior colporrhaphia was performed in all 438 patients and sacrospinous fixation (SSF) for level I defects in 269 patients. Prolapse repair was combined with hysterectomy in 255 cases. One intra-operative bladder lesion (0.23%) and one rectal lesion (0.23%) occurred. Postoperative urinary tract infection requiring antibiotics was noted in 34 cases (7.8%). Post-void residual volume was medically treated in 24 cases (5.5%). Four patients (0.9%) underwent postoperative suprapubic catheter insertion. Asymptomatic gluteal hematomas were noted in 11 cases (2.5%). Four patients (0.9%) underwent re-operations for postoperative hemorrhage. Mean hospital stay was 5.6 days. Minor complications were classified as CD grade I in 2.5%, as CD grade II in 13.2%, complications requiring surgical intervention as grade IIIa in 0.9% and as grade IIIb in 0.9% of patients. No CD grade IV or V complications occurred. Apart from gluteal hematomas classified as CD grade I occurring in the SSF group (p = 0.019), no other differences of complication rates were found in the hysterectomy subgroup or in the SSF subgroup. Surgery was associated with low rate of CD grade III complications. Re-operation rate was 0.9%. The authors suggest introduction of CD classification for comparability of prolapse surgery.

A validated low-cost training model for suprapubic catheter insertion.

To describe an anatomically correct simulator for use in suprapubic catheter (SPC) insertion training. A scale reproduction of an adult male pelvis with bony landmarks and a subcutaneous fluid-filled reservoir was created using platinum cured silicone rubber. This model was evaluated by 6 expert urologists for content validity with a 16-item 5-point rating scale used to evaluate domains relevant to the simulator—physical attributes, realism of experience, realism of materials, and global rating. The simulator was used by 25 general surgeons from rural practices participating in a 2-day comprehensive specialized surgical skills course. The domains were scored between 1 and 5; 1 being "not at all realistic" and 5 being "highly realistic, no changes needed." The average expert ratings of the domains were 3.9 (physical attributes), 4.3 (realism of experience), and 3.9 (realism of materials). The simulator was rated more valuable as a training tool (4.5) compared with a testing tool (3.8) with an average global rating of 4.1. Experts and trainees reported high satisfaction with their experience using this simulator. Preliminary evidence suggests this simulator is a useful tool that can be integrated into training programs to facilitate learning this necessary urologic skill.

Fatal Surgical or Procedure‐Related Complications: A Finnish Registry‐Based Study

In Finland, all healthcare personnel must be insured against causing patient injury. The Patient Insurance Centre (PIC) pays compensation in all cases of malpractice and in some cases of infection or other surgical complications. This study aimed to analyze all complaints relating to fatal surgical or other procedure-related errors in Finland during 2006-2010. In total, 126 patients fulfilled the inclusion criteria. Details of patient care and decisions made by the PIC were reviewed, and the total national number of surgical procedures for the study period was obtained from the National Hospital Discharge Registry. Of the 94 patients who underwent surgery, most fatal surgical complications involved orthopedic or gastrointestinal surgery. Non-surgical procedures with fatal complications included deliveries (N = 10), upper gastrointestinal endoscopy or nasogastric tube insertion (N = 8), suprapubic catheter insertion (N = 4), lower intestinal endoscopy (N = 5), coronary angiogram (N = 1), pacemaker fitting (N = 1), percutaneous drainage of a hepatic abscess (N = 1), and chest tube insertion (N = 2). In 42 (33.3 %) cases, patient injury resulted from errors made during the procedure, including 24 technical errors and 15 errors of judgment. There were 19 (15.2 %) cases of inappropriate pre-operative assessment, 28 (22.4 %) errors made in postoperative follow-up, 23 (18.4 %) cases of fatal infection, and 11 (8.8 %) fatal complications not linked to treatment errors. Fatal surgical and procedure-related complications are rare in Finland. Complications are usually the result of errors of judgment, technical errors, and infections.

Urological management (medical and surgical) of BK-virus associated haemorrhagic cystitis in children following haematopoietic stem cell transplantation

Aim: Haemorrhagic cystitis (HC) is uncommon and in its severe form potentially life threatening complication of Haematopoietic stem cell transplantation (HSCT) in children. We present our single centre experience in the urological management of this clinically challenging condition. Patients and Methods : Fourteen patients were diagnosed with BK-Virus HC in our centre. The mean age at diagnosis was 8.8 years (range, 3.2-18.4 years). The mean number of days post-BMT until onset of HC was 20.8 (range, 1 – 51). While all patients tested urine positive for BKV at the clinical onset of HC, only four patients had viral quantification, with viral loads ranging from 97,000 to >1 billion/ml. 8 patients had clinical HC. Ten patients experienced acute GVHD (grade I: 6 patients, grade II: 3 patients, grade 4: 1 patient). Results: Four patients received medical management for their HC. Treatments included hyperhydration, MESNA, blood and platelet transfusion, premarin and oxybutynin (Table 6). Two patients received both medical and surgical management which included cystoscopy with clot evacuation, bladder irrigation and supra-pubic catheter insertion. One patient received exclusive surgical management. Seven patients were treated conservatively. Conclusion : There is limited available evidence for other potential therapeutic strategies highlighting the need for more research into the pathophysiology of HSCT-associated HC. Commonly used interventions with possible clinical benefit (e.g. cidofovir, ciprofloxacin) still require to be evaluated in multi-centre, high-quality studies. Potential future preventative and therapeutic options, such as modulation of conditioning, immunosuppression and engraftment, new antiviral and anti-inflammatory and less nephrotoxic agents need to be assessed. --------------------------- Cite this article as: Vasdev N, Davidson A, Harkensee C, Slatter M, Gennery A, Willetts I, Thorpe A.Urological management (medical and surgical) of BK-virus associated haemorrhagic cystitis in children following haematopoietic stem cell transplantation. Int J Cancer Ther Oncol 2013; 1 (1):01013. DOI : http://dx.doi.org/10.14319/ijcto.0101.3

A Practical Approach to Difficult Urinary Catheterizations

Routine placement of transurethral catheters can be challenging in some situations, such as urethral strictures, severe phimosis and false passages. Intravaginal retraction of the urethral meatus can complicate Foley placement in postmenopausal females. In men, blind urethral procedures with mechanical or metal sounds without visual guidance or guidewire assistance are now discouraged due to the increased risk of urethral trauma and false passages. Newer techniques of urethral catheterization including guidewires, directed hydrophilic mechanical dilators, urethral balloon dilation, and direct vision endoscopic catheter systems are discussed, along with the new standardized protocol for difficult transurethral catheter insertions. Suprapubic catheter placement techniques, including percutaneous trocars and the use of the curved Lowsley tractor for initial suprapubic catheter insertion, are reviewed. Prevention and management of common catheter-related problems such as encrustation, leakage, Foley malposition, balloon cuffing and frequent blockages are discussed.

Early effectiveness of endoscopic posterior urethra primary alignment

Posterior urethra primary realignment (PUPR) after complete transection may decrease the gap between the ends of the transected urethra, tamponade the retropubic bleeding, and optimize urinary drainage without the need of suprapubic catheter facilitating concurrent pelvic orthopedic and trauma procedures. Historically, the distorted anatomy after pelvic trauma has been a major surgical challenge. The purpose of the study was to assess the relationship of the severity of the pelvic fracture to the success of endoscopic and immediate PUPR following complete posterior urethral disruption using the Young-Burgess classification system. A review of our Level I trauma center database for patients diagnosed with pelvic fracture and complete posterior urethral disruption from January 2005 to April 2012 was performed. Pelvic fracture severity was categorized according to the Young-Burgees classification system. Management consisted of suprapubic catheter insertion at diagnosis followed by early urethral realignment when the patient was clinically stable. Failure of realignment was defined as inability to achieve urethral continuity with Foley catheterization. Clinical follow-up consisted of radiologic, pressure studies and cystoscopic evaluation. A total of 481 patients with pelvic trauma from our trauma registry were screened initially, and 18 (3.7%) were diagnosed with a complete posterior urethral disruption. A total of 15 primary realignments (83.3%) were performed all within 5 days of trauma. The success rate of early realignment was 100%. There was no correlation between the type of pelvic ring fracture and the success of PUPR. Postoperatively, 8 patients (53.3%) developed urethral strictures, 3 patients (20.0%) developed incontinence, and 7 patients (46.7%) reported erectile dysfunction after the trauma. The mean follow-up of these patients was 31.8 months. Endoscopic PUPR may be an effective option for the treatment of complete posterior urethral disruption and enables urinary drainage to best suit the multispecialty surgical team. The success rate of achieving primary realignment did not appear to be related to the complexity and type of pelvic ring fracture.

A Cost-effective, Easily Reproducible, Suprapubic Catheter Insertion Simulation Training Model

Suprapubic catheter (SPC) insertion is a basic skill required of surgical trainees. It is likely a trainee's first attempt at the procedure, will be undertaken without direct supervision at night and without access to aids of catheterization. Unfortunately, lack of simulation models and unpredictability of when SPCs are required, make it difficult to acquire this skill. Therefore, junior doctors frequently persist with urethral catheterization, with an increased risk of urethral injury. Improper catheterization has been cited as the causative factor for urethral strictures. The aim of this study was to develop an SPC model and assess its influence on a trainee's confidence in this procedure. An SPC model needs to fulfill a number of criteria. It should have anatomic characteristics of a bladder and provide realistic visual and sensory feedback. Cost effective copies of the model, which are able to be rapidly cycled through simulations are needed for effective clinical workshops. Finally, a trainee's understanding and confidence in performing the procedure should increase after using it. This prototype model has 3 anatomic parts: the bladder, the anterior abdominal wall, and the housing abdominal box. The most crucial component is the bladder, which is a balloon with Mefix tape that prevents leaking and "popping" on trocar insertion. This SPC model can be readily replicated by most clinical school and easily added to surgical workshops to ensure that trainees have hands on experience with this procedure before being required to perform it on patients.

Robot-Assisted Laparoscopic Simple Prostatectomy in Men with Bladder Outlet Obstruction: Modified Urinary Reconstruction Leading to Improving Perioperative Outcomes

Purpose: Robot-assisted laparoscopic simple prostatectomy (RALSP) is a feasible option in men with markedly enlarged prostates (over 100 g) and urinary obstruction.1 Since January 2011, we have modified our surgical method in hope of further enhancing the perioperative outcomes related to RALSP. Herein, we report our initial experience utilizing a circumferential urinary reconstruction technique. Methods: A total of nine patients underwent RALSP with a surgical modification for symptomatic benign prostatic hypertrophy (BPH) in 2011. All, but one patient, were in complete urinary retention preoperatively. All RALSP were performed via the suprapubic approach. Upon removal of the obstructing prostate adenomas, a circumferential anastomosis was completed by advancing and approximating the bladder neck to the prostate urethral stump with 8 to 10 interrupted 2-0 vicryl suture, similar to that of the urethral vesical anastomosis during robotic radical prostatectomy. Six patients who underwent a standard RALSP with bladder trigonization only between August 2009 and December 2010 served as the control group. Results: The two groups were similar in regard to age, BMI, and preoperative prostate size on ultrasonography. No patients in the experimental group required transfusion, suprapubic catheter insertion, or continuous bladder irrigation perioperatively. The control patients were kept with continuous bladder irrigation until urine cleared. Two patients required transfusion of packed red cells due to dropping hematocrit. The mean operative time, pathologic specimen weight, and catheterization time were comparable between the 2 groups, but the average blood loss (100 cc vs. 330 cc, p<0.05) and hospital stay (1.4 days vs. 3.6 days, p<0.05) were significantly shorter in men who underwent RALSP with the surgical modification. Discussion and Conclusion: Our early experience with the modified RALSP technique (a circumferential anastomosis between the bladder neck and prostate urethra) has been associated with a less intraoperative blood loss and a shorter hospital stay due to early resolution of gross hematuria. In our control group, the length of stay was extended due to the requirement of continuous bladder irrigation and need of transfusion in a third of patients. We feel that our circumferential anastomosis is more hemostatic than previous trigonization-only techniques leading to improved outcomes. One drawback to our technique is increased manipulation of the bladder neck and urethra. While this poses a theoretical risk of bladder neck contracture or stricture, we feel that this risk is minimal, as <1% of our robotic radical prostatectomy patients with similar urinary reconstruction have this complication. As other series have reported on modified urethral reconstructions for robotic simple prostatectomies,2 larger prospective series with longer follow-up will be necessary to determine the long-term outcomes. Nevertheless, we feel that this reconstruction technique has promise and has shown in our series to have improved perioperative outcomes. The authors have no conflicts of interest or financial ties to disclose. Runtime of video: 3 mins 4 secs

Severe Intraperitoneal Haemorrhage following Suprapubic Catheter Insertion in a Patient Treated with Iloprost

Suprapubic catheter (SPC) insertion is a common urological procedure, performed both in the elective and emergency settings. The authors present an unusual case of severe intraperitoneal bleeding following the insertion of an SPC under direct vision, where the use of prostacyclin analogue may have been a contributing factor.

Strangulated incisional hernia after suprapubic catheter insertion: A case report

Introduction: Hernia through the suprapubic catheterization site is extremely rare. Attention is required for such hernias as they can get easily complicated by obstruction and strangulation due to its narrow neck. These are life­threatening complications. Case report: We report a case of a 65­year­old man who presented with a strangulated incisional hernia through the SPC site. He was managed successfully by urgent surgical intervention. Conclusion: Incisional hernia through the suprapubic catheterization site should not be forgotten during examination of patients with abdominal pain, to ensure prompt surgical intervention in case of strangulated hernia.

Improving documentation and use of ultrasound for suprapubic catheter insertions.

The British Association of Urological Surgeons (BAUS) published recommendations for the safe insertion of suprapubic catheters (SPCs) in January 2011. They identified a number of parameters surrounding the insertion and maintenance of catheters that should be identified, implemented and documented on each insertion. One such recommendation was the use of ultrasound, if available and appropriate, to aid insertion and improve patient safety. A previous review of our documentation showed that in 2009, ultrasound imaging was not utilised in any of the 19 SPC insertions.We retrospectively collected data for 36 SPC insertions between April 2010 and December 2011. The information collated was the same as that collected for the BAUS national SPC insertion audit. This quality improvement project identified a significant increase in the use of ultrasound during SPC insertion since 2009 with 17 out of the 36 (47%) cases using this imaging modality. Despite this increase, there was still substantial room for improvement. We also identified some areas of documentation that needed improving, particularly with regard to insertion technique and indication for insertion. As a result, a proforma was designed to be used on each SPC insertion ensuring that all required data is easily identifiable and clearly documented. This proforma is now being used as standard mandatory clinical practice within our Trust.

An audit of suprapubic catheter insertion performed by a urological nurse specialist

Aims:To introduce the concept that a urological Nurse Specialist can perform Suprapubic Catheter (SPC) insertions independently without significant complications, if systematic training is given.Settings and Design:Retrospective study.Materials and Methods:A retrospective audit of Suprapubic Catheter insertions performed by a Urological Nurse Specialist was conducted between April 2009 and April 2011.Results:Of the total 53 patients, in 49 (92.45%) the procedure was successful. Out of the remaining four, two (3.77%) were done by a urologist. One patient's (1.89 %) SPC did not drain after placement and ultrasonography reported that the Foley balloon was lying within the abdominal wall. The other patient's SPC drained well for a month and failed to drain after the first scheduled change in a month. Since the ultrasonography showed the Foley balloon to be anterior to the distended bladder, an exploration was performed and this revealed that the SPC tract had gone through a fold of peritoneum before reaching the bladder. None had bowel injury.Conclusions:If systematic training is given, a urological Nurse Specialist can perform SPC insertions independently without significant complications.

Evaluating clinical indications for continued catheterisation

Evaluating clinical indications for continued catheterisation

Detrusor myectomy: Long‐term functional outcomes

Detrusor myectomy is a recognized method of bladder augmentation for treating refractory detrusor overactivity. Herein we report the long-term outcomes of this procedure at the University Hospital of Wales in Cardiff, UK. Detrusor myectomy was carried out in 33 patients (7 males, 26 females) with urodynamically proven detrusor overactivity between 1995 and 2002. The mean patient age was 33 years (range 5-62). A total of 18 patients had idiopathic detrusor overactivity, whereas 15 had neurogenic detrusor overactivity. A total of 24 patients had a detrusor myectomy alone, whereas eight patients had a detrusor myectomy with implantation of artificial urinary sphincter. One patient had detrusor myectomy with transuretero-ureterostomy. The mean follow up was 148 months (range 108-192). A total of 10 of the 18 patients with idiopathic detrusor overactivity (55.5%) and six of the 15 patients with neurogenic detrusor overactivity (40%) showed marked improvement in symptoms. Detrusor overactivity was completely abolished in 11 patients and significantly reduced in five. Postoperatively, mean cystometric capacity improved from 290 to 458 mL, whereas mean maximum amplitude of detrusor contraction was reduced from 44 cm/H(2) O to 20 cm/H(2) O. An overall success rate of 48.5% (16/33 patients) was achieved. Intermittent self catheterization was needed to achieve bladder emptying in 12 of the 16 (75%) patients. Of the remaining 17 patients who did not improve, six had CLAM enterocystoplasty carried out and two await the operation. An ileal conduit diversion and suprapubic catheter insertion was carried out in one patient each, whereas seven patients declined any further intervention. Detrusor myectomy offers a reasonable long-term success rate to patients undergoing surgical treatment for refractory detrusor overactivity.

Safe percutaneous suprapubic catheterisation.

INTRODUCTIONWe describe our technique of percutaneous suprapubic catheter insertion with special reference to steps that help to avoid common complications of haematuria and catheter misplacement.METHODSThe procedure is performed using a stainless steel reusable trocar under local infiltrative anaesthesia, usually at the bedside. After clinical confirmation of a full bladder, the trocar is advanced into the bladder through a skin incision. Once the bladder is entered, the obturator is removed and the assistant inserts a Foley catheter followed by rapid balloon inflation. Slight traction is applied to the catheter for about five minutes. Patients with previous lower abdominal surgery, an inadequately distended bladder or acute pelvic trauma do not undergo suprapubic catheterisation using this method.RESULTSThe procedure was performed in 72 men (mean age: 42.4 years, range: 18–78 years) with urinary retention with a palpable bladder. The average duration of the procedure was less than five minutes. No complications were noted in any of the patients.CONCLUSIONSTrocar suprapubic catheter insertion is a safe and effective bedside procedure for emergency bladder drainage and can be performed by resident surgeons. The common complications associated with the procedure can be avoided with a few careful steps.

Suprapubic catheter insertion using an ultrasound‐guided technique and literature review

What's known on the subject? and What does the study add? The conventional 'blind' technique for suprapubic catheter (SPC) insertion relies on adequate filling of the bladder to displace bowel away from the site of needle puncture. However, in a small percentage of patients this fails to happen, which can occasionally lead to life-threatening bowel injury. Recently published British Association of Urological Surgeons (BAUS) guidelines have recommended that ultrasonography (US) may be helpful to identify bowel loops and recommends its usage whenever possible. This paper describes the technique of US-guided needle puncture and SPC insertion to reduce the likelihood of bowel injury. The paper addresses training, equipment and logistical issues associated with this advice. We have reviewed the available publications on the outcomes from this technique and also present our experience. Suprapubic catheter (SPC) insertion is a common method of bladder drainage in contemporary urological practice. The procedure involves insertion of a sharp trocar into the bladder percutaneously, usually by palpation, percussion or cystoscopy for guidance. Although generally considered a safe procedure, the risk of bowel injury is estimated at up to 2.4% with a mortality rate of 1.8%. Recently published British Association of Urological Surgeons (BAUS) guidelines have recommended that ultrasonography (US) may be helpful to identify bowel loops and recommends its usage whenever possible. The present paper describes the use of US for SPC insertion and discusses the implications of this advice. This paper is designed to support and supplement practical techniques learnt on a course and in clinical practice.

An Unusual Case of Severe Haemorrhage and Small Bowel Injury Following Percutaneous Suprapubic Catheter Insertion

Suprapubic catheterisation is a useful alternative to urethral catheterisation but it carries potentially serious complications, including bowel injury and infection. We present a case of severe intra-abdominal haemorrhage following a suprapubic catheter insertion using the Seldginger technique. The patient’s risk of complications was increased by a previous hysterectomy. This case demonstrates the use of ultrasound guidance during suprapubic catheterisation in high risk patients, such as those with previous abdominal or pelvic surgery. doi:10.4021/wjnu3w

British Association of Urological Surgeons’ suprapubic catheter practice guidelines

What's known on the subject? and What does the study add? The suprapubic catheter (SPC) is a useful and widely used tool in urological practice. However, complications can arise from its insertion or ongoing care. Currently there are no guidelines relating to SPC usage. This study has reviewed the available clinical evidence relating to SPC usage. Where this is lacking, expert opinion has been sought. Guidelines are suggested to help maximise safety and ensure best practice in relation to SPC usage. To report the British Association of Urological Surgeons' guidelines on the indications for, safe insertion of, and subsequent care for suprapubic catheters. A comprehensive literature search was conducted to identify the evidence base. This was reviewed by a guideline development group (GDG), who then drew up the recommendations. Where there was no supporting evidence expert opinion of the GDG and a wider body of consultees was used. Suprapubic catheterisation is widely used, and generally considered a safe procedure. There is however a small risk of serious complications. Whilst the evidence base is small, the GDG has produced a consensus statement on SPC use with the aim of minimising risks and establishing best practice (Table 1). It should be of relevance to all those involved in the insertion and care of suprapubic catheters. Given the paucity of evidence, areas for future research and development are also highlighted. This review has been commissioned and approved by BAUS and the Section of Female, Neurological and Urodynamic Urology. [Table: see text] It is hoped that these guidelines will assist in minimising morbidity associated with SPC usage.

Delayed presentation of small bowel injury during suprapubic catheterisation.

We present a case of small intestine injury resulting from suprapubic catheter insertion. This case is of particular interest for three reasons. Firstly, the presentation of the injury was delayed by three months, until the time of the first catheter exchange. Secondly, the injury was managed conservatively, without surgical exploration. Finally, the injury occurred using a newer, Seldinger-type suprapubic catheter insertion kit.

To clamp or not to clamp? Bladder management by suprapubic catheterization in patients with neurogenic bladder dysfunction

In a small subset of patients with neurogenic lower urinary tract dysfunction, insertion of suprapubic catheters (SPC) cannot be avoided. If SPC has to be utilized, catheter clamping and anticholinergic medication are often recommended, but evidence supporting this view is scarce. We determined the influence of anticholinergic medication and catheter clamping on urodynamic parameters and the status of the urinary tract in patients with chronic suprapubic catheterization. In a retrospective study, the results of urodynamic testing, sonographic evaluations, and urinalyses of 85 patients with chronic (>1 year) suprapubic catheterization due to neurogenic bladder dysfunction were analyzed. The 51 male and 34 female patients (mean age 55 years) were managed with an SPC for 65.3 ± 48.0 months. Forty patients had an SPC for more than 60 months. Comparing the results before SPC insertion with the last follow-up examination, no significant differences in detrusor compliance and maximum detrusor pressure were detected, whereas bladder capacity significantly decreased. In three patients, alterations of the upper urinary tract were found. The results were not significantly different between the patients using anticholinergic medication and/or catheter clamping and those who did not. According to our study, routine use of anticholinergic medication and clamping of catheter does not seem to be necessary to preserve detrusor compliance and renal function in patients with SPC and neurogenic bladder dysfunction.