Suprapubic Tube Placement Research Articles

Management Of Urinary Retention In An Austere Environment: Suprapubic Catheter Placement

Urinary retention is a true urologic emergency. First-line treatment with a transurethral catheter can and will fail. SOF medics need a reliable and durable method to resolve this problem using a minimal amount of resources and time. Current SOF Medical Handbook guidance for the management of unsuccessful urethral catheterization is inadequate. This article and accompanying video link, functions as a starting point for incorporating suprapubic tube placement in the training regimen and therapeutic armamentarium of SOF medical personnel.

Complete transurethral bladder eversion 3 months after hemipelvectomy

A 46-year-old white female underwent a left hemipelvectomy for chondrosarcoma. She presented with total incontinence and a bulging vaginal mass. Exam confirmed complete transurethral bladder eversion that was addressed with transvaginal multilayer bladder neck closure and suprapubic tube placement. Eventually she underwent abdominal hysterectomy, mesh sacral colpopexy, and catheterizable stoma creation. Patient is continent of urine 3 months postoperatively. We present the first reported case of bladder eversion after hemipelvectomy and propose possible pathophysiologic mechanisms.

Bladder neck closure and suprapubic tube placement in a debilitated patient population

Bladder neck closure (BNC) with suprapubic tube (SPT) placement is a method of bladder management for patients with neurogenic bladders (NGB). We evaluated our experience at one institution. We conducted a retrospective chart review of patients who received BNC with SPT placement from 1999 to 2008. Twenty-nine patients (24 females and 5 males, average age 53.4 +/- 9.6 years) underwent BNC with SPT placement. Cause of NGB was multiple sclerosis (48%), spinal injury (28%), or myelodysplasia (17%). All but one were dependent on caregivers for activities of daily living. Preoperative urodynamics studies were performed on 23 patients. Retropubic BNC was performed in 26 of 29 patients. Two females had a transvaginal approach, and one male had a perineal approach. Early (<90 days) postoperative complication rate was 52%. Persistent urine leakage was present in eight patients: two peristomal leakage and six urethral leakage. All three non-retropubic BNC had postoperative fistulas (P = 0.01). Catheter complications were associated with seven of the eight urinary leaks (P = 0.01). BNC with SPT is a method of bladder management in the NGB population, particularly suited to those with a low functional status. Fistula rates are significantly higher with non-retropubic BNC (P = 0.01). Poor catheter care in the postoperative period is associated with postoperative urinary leakage (P = 0.01).

ROBOTIC REPAIR OF RECTOVESICAL FISTULA SECONDARY TO OPEN RADICAL PROSTATECTOMY

Abstract Introduction: Rectovesical fistula (RVF) is a rare entity that can develop after trauma, radiation, congenital diseases, inflammatory bowel disease, and open radical prostatectomy. Herein we present our experience with robot-assisted fistula repair. Methods: Three patients were treated. The etiology of RVF developed was open radical prostatectomy in all patients. The robotic procedure was postoperative following failed open repair in two patients, and primary in the third. All patients had previously undergone fecal diversion. The operative steps were as follows: (1) cystoscopy, (2) RVF catheterization, (3) five-port transperitoneal laparoscopic mobilization of omental pedicle flap, (4) cystotomy extending toward the fistula tract, (5) robot docking, (6) dissection of the rectovesical plane, (7) interrupted rectal closure, (8) omental interposition, (9) bladder closure, (10) suprapubic tube placement, and (11) drain placement. Results: Mean operative time was 153 mins (range 120–180). No intraope...

A mouse model of simulated birth trauma induced stress urinary incontinence

To facilitate future applications of transgenic or knockout technologies in studies of simulated birth trauma induced stress urinary incontinence (SUI), we aimed to create a mouse model of SUI and explore the possible pathogenesis of this condition. Thirty female C57BL/6 mice were randomly distributed into five groups. Four groups underwent vaginal distention (VD) for 1 hr, using a modified 6-Fr. Foley catheter with a balloon dilated to 0.3, 0.2, or 0.1 ml or sham distention. Four days after VD, all mice underwent leak-point pressure (LPP) measurement via an implanted suprapubic tube (SPT). The normal control group only had SPT placement and LPP measurement. After sacrifice, the urethras of the mice were harvested for routine histological examination and nerve staining. LPPs were significantly lower in groups after VD with 0.3- or 0.2-ml balloon than in control and sham distention groups (10.29 +/- 6.70, 14.65 +/- 6.51, 37.78 +/- 5.10, and 30.30 +/- 5.30 cm H(2)O, respectively). There were no significant differences in LPP between control and sham groups. Histology showed no significant differences in urethral striated muscle among the five groups. The density of immunoreactive neurofilaments in the urethra decreased after VD with 0.3- or 0.2-ml balloon. As a model of birth trauma, VD can induce SUI in female mice, the severity of which is related to intravaginal balloon size. Partial urethral denervation plays a plausible role in the pathogenesis of SUI. This novel mouse model could be used for further mechanistic studies of female SUI.

Bladder Augmentation With Acellular Dermal Biomatrix in a Diseased Animal Model

The use of bowel for bladder augmentation is associated with many complications. We have reported that acellular dermal biomatrix can be used successfully for directing the regeneration of each key bladder wall element in healthy domestic pigs. Before proposing that this material should be used in the human setting a final set of experiments using this scaffold to replace diseased bladder wall is necessary. We determined if acellular dermal biomatrix can be used to replace diseased bladder wall. We compared our findings to our previous results. Six domestic male pigs underwent urethral ligation and suprapubic tube placement. Five female pigs served as controls for bladder dynamics. Machined resistance valves of 5 and 10 cm H(2)O pressure were placed into the lumen of the cystostomy catheter for a mean of 3.3 weeks (range 3 to 4). Obstruction was then relieved and partial cystectomy was performed, followed by augmentation with a 4 x 4 cm segment of acellular dermal biomatrix of the markedly thickened and poorly compliant bladder. Animals were sacrificed 3 months following augmentation. Standard urodynamic studies were performed. Contractility and compliance were measured in freshly isolated regenerated and native bladder tissues. Histological evaluation was performed on hematoxylin and eosin, and Masson's trichrome stained sections. Bladder compliance was markedly decreased after 3.3 weeks of obstruction. Mean compliance +/- SEM before obstruction was 16.28 +/- 9.21 cm H(2)O. After 3.3 weeks of obstruction average compliance was 4.13 +/- 0.98 cm H(2)O. One pig died 2 weeks following augmentation due to graft separation and sepsis. Gross examination of augmented bladders revealed the complete replacement of acellular dermal biomatrix with bladder tissue. Histological evaluation revealed extensive fibrosis with small islands of poorly organized muscle in contrast to the complete regeneration of mucosa, smooth muscle and serosa seen in augmentations previously performed in healthy animal bladders. Maximum contractile tension of the patch tissue was not different than that in the native tissue from the obstructed hypertrophied bladder but it was only approximately 10% of the tension produced by healthy tissue from nonobstructed augmented bladders. The obstructed bladder patch and native tissue was approximately 14 times stiffer than healthy bladder tissue. While augmentation of healthy porcine bladder with acellular dermal biomatrix results in excellent functional bladder tissue regeneration, similar experiments in a porcine model of obstructed bladder disease failed to show favorable results. Therefore, acellular dermal biomatrix cannot be recommended at this time for human bladder dysfunction. Results support the contention that matrices designed for human bladder augmentation should be tested in a disease animal model before recommending them for human bladder dysfunction.

Comparison of Long-Term Results according to the Primary Mode of Management and Type of Injury for Posterior Urethral Injuries

Background: We retrospectively reviewed the records of patients with traumatic posterior urethral injuries, analyzed postoperative findings to compare the results of the primary mode of management, and evaluated whether the Colapinto and McCallum classification system was valuable for predicting the complications. Methods: 55 patients with traumatic posterior urethral injuries were included in the study. A total of 35 patients underwent immediate realignment over a Foley catheter including direct Foley catheter insertion (group 1) and 20 underwent initial suprapubic tube placement followed by delayed urethroplasty (group 2). Urethral injuries were interpreted using the Colapinto and McCallum classification based on the retrograde urethrographies. Results: 44 (80.0%) of the patients were classified to type III in both groups (group 1, 29 [82.9%]; group 2, 15 [75.0%]). Of group 1, mild, moderate and severe urethral strictures developed in 7 (20.0%), 8 (22.9%) and 6 (17.1%), respectively, and developed in 6 (30.0%), 2 (10.0%) and 5 (25.0%), respectively, of group 2. Six (17.1%) and 2 (20.0%) had decreased potency and 4 (11.5%) and 1 (5.0%) were impotent in group 1 and 2, respectively. Of group 1, incontinence developed in 3 patients but 1 did not need treatment, and developed in 2 (10.0%) but 1 (5.0%) did not need treatment of group 2. The score test for trend demonstrated that there were no significant differences of these results. Conclusions: Our findings suggest that complications in patients with posterior urethral injuries are not related to the primary mode of management. Because most injuries are type III, the evolution toward the classification system is needed.

Management of bulbous urethral disruption by blunt external trauma: the sooner, the better?

Objectives To investigate whether the incidence of urethral stricture is different according to the primary mode of management, we retrospectively reviewed the record of patients with bulbous urethral disruption by external blunt trauma. Methods A total of 95 patients with blunt bulbous urethral injuries were included in the study. Sixty-five underwent immediate urethral realignment and 30 underwent initial suprapubic tube placement followed by delayed management. The urethral injuries were interpreted as partial or complete disruption on the basis of the retrograde urethrographic findings. Results Urethral stricture developed in 12 patients (18.5%) who underwent immediate management and in 12 patients (40.0%) who underwent delayed management ( P = 0.025). Of the patients with partial disruption, no significant difference was found in the urethral stricture incidence between the two groups. However, of the patients with complete disruption, urethral stricture developed in 10 (31.3%) of 32 patients who underwent immediate management and 11 (68.8%) of 16 patients who underwent delayed management ( P = 0.014). In addition, the degree of urethral stricture in the patients who underwent delayed management was more severe than in those who underwent immediate urethral realignment ( P = 0.023). Conclusions Our findings suggest that better outcomes can be obtained when immediate urethral realignment is successful in patients with bulbous urethral disruption. Additional research, including prospective randomized trials, is needed to confirm these findings.

Urolume stent placement for the treatment of postbrachytherapy bladder outlet obstruction

Objectives. Transurethral resection (TURP) or incision of the prostate is generally not effective for treating bladder outlet obstruction after transperineal brachytherapy for prostate cancer. Furthermore, TURP could compromise full-dose effective radiation delivery to the prostate. We analyzed the efficacy of the UroLume stent in treating the urinary outflow obstruction in such patients. Methods. Five patients who had undergone brachytherapy (3 with 192Ir high-dose radiation and 2 with 125I) subsequently developed one or more episodes of urinary retention 2 weeks to 4 years after treatment. The patients failed or could not tolerate α-blockers or clean intermittent catheterization. Three patients subsequently underwent urethral dilation/optical internal urethrotomy for strictures, and 1 patient underwent suprapubic tube placement. Following the failure of these interventions, each of these patients had a UroLume stent placement. A single UroLume stent (2 cm in 3 patients and 2.5 cm in 2 patients) was placed under local/spinal anesthesia. Results. All patients were able to void spontaneously immediately after stent placement. Of the patients with previous urethral strictures, 1 remained continent and 1 had persistent incontinence. Neither of the patients with early postbrachytherapy retention developed incontinence after stent placement. The main complaints following stent placement were referred pain to the head of the penis and dysuria. Stent-related symptoms necessitated stent removal in 2 of 5 patients, 4 to 6 weeks after placement. Conclusions. The UroLume stent can be used as an alternative form of therapy for managing postbrachytherapy bladder outlet obstruction. The treatment is easily reversible by removing the stent when obstruction resolves.

IS THERE A DIFFERENCE IN OUTCOME WHEN TREATING TRAUMATIC INTRAPERITONEAL BLADDER RUPTURE WITH OR WITHOUT A SUPRAPUBIC TUBE?

Purpose Primary bladder repair with a suprapubic tube is considered to be effective for managing intraperitoneal bladder injury. We compared the outcomes of suprapubic tube placement and no suprapubic tube for this injury. Materials and Methods We reviewed the charts of 31 men and 3 women with a mean age of 28.5 years who required emergency operative repair without a cystogram of traumatic bladder injury from 1992 to 1997. Patient characteristics, mechanism of injury, associated injuries, and short and long-term complications were reviewed. Results Penetrating and blunt trauma occurred in 28 (82%) and 5 (15%) patients, respectively, while 1 had spontaneous bladder rupture. After primary bladder repair the bladder was drained with a suprapubic tube in 18 cases (53%) and a urethral catheter only in 16 (47%). There were no significant differences between the 2 groups with respect to mechanism of injury, patient age, location of injury in the bladder, coexisting medical illnesses, stability in the field or emergency room, or the bladder repair technique. The 18 patients treated with a suprapubic tube had an associated injury that resulted in 2 deaths, while 13 of the 16 treated with urethral catheter drainage only had an associated injury and 1 died. Urological and nonurological complications in the suprapubic tube versus urethral catheter only group developed in 28 and 33 versus 19 and 19% of the cases, respectively (p <0.05). Followup ranged from 1 month to 4 years. No significant long-term morbidity was noted in either group. Conclusions These data indicate that intraperitoneal bladder injuries may be equally well managed by primary bladder repair and urethral catheter drainage only versus suprapubic tube drainage.

Urethral obstruction after primary exstrophy closure: what is the fate of the genitourinary tract?

We assessed the impact of posterior urethral obstruction after primary bladder exstrophy closure. A review of the records of patients with classic bladder exstrophy at our institution identified 29 boys and 12 girls with a mean age of 11.75 years who had had posterior urethral outlet obstruction after closure was done in the neonatal period. Of these 41 patients 75% underwent closure elsewhere. At closure osteotomies were done in 13 patients and 23 were younger than 72 hours. Paraexstrophy skin flaps were used at primary closure in 27 cases (66%). Obstruction presented as recurrent urinary tract infection, upper tract deterioration with or without renal failure, bladder stones, difficult catheterization, urethral stitch erosion, a full bladder on ultrasound, a prolonged dry interval, urinary retention, inability to catheterize, bladder rupture, rectal prolapse and epididymitis or prostatitis. Usually the initial obstructive episode developed within 60 days of closure and it was recurrent. Therapy included suprapubic catheter placement, vesicostomy, ureterostomy, nephrostomy and multiple urethral manipulations, such as dilation with or without steroid injection, internal urethrotomy, urethral stitch removal, clean intermittent catheterization or open urethroplasty. All 6 patients who underwent long-term diversion via vesicostomy, ureterostomy or a conduit for greater than 6 months required permanent bowel segments for reconstruction, while in 5 of the 6 who underwent short-term diversion via nephrostomy or suprapubic tube placement for less than 6 months reconstruction was bowel-free. Of the 36 children in whom functional reconstruction was performed 9 are undergoing staged reconstruction, reconstruction failed in 14, 4 are socially dry and 9 are continent. Posterior urethral obstruction after exstrophy closure markedly decreases the success of staged bladder reconstruction, presents a significant risk to the upper urinary tract and should be detected early.

Endoscopic Realignment of Prostatomembranous Urethral Disruptions

Prior to discussing the endoscopic approach to realignment of prostatomembranous urethral disruptions, some discussion of the general approach to management of prostatomembranous urethral disruptions is appropriate. There have been advocates of both immediate and delayed repair of prostatomembranous urethral disruptions. Proponents of delayed repair of these injuries have suggested that immediate repair results in further damage to the delicate neurovascular structures in the urogenital diaphragm which have been injured. They have suggested that it is better to allow these acute injuries to subside prior to urethral reconstruction. However, advocates of immediate repair of these injuries have argued that impotence and incontinence in these patients are the result of the injury itself and not the method of management. Furthermore, they believe that urethral realignment over a urethral catheter is no more traumatic or less anatomic than a delayed urethroplasty through the fibrotic urogenital bed that results from the injury. The controversy between early versus delayed repair of prostatomembranous urethral disruptions originated in 1972 when Morehouse reported that early repair of these injuries resulted in excess incontinence and impotence compared with initial suprapubic tube placement alone followed by a delayed ~rethrop1asty.l~ In a follow-up study published in 1980, they reported on 58 consecutive patients treated with complete prostatomembranous urethral disruptions managed by initial suprapubic tube placement alone and delayed urethral reconstr~ction.'~ They reported remarkably good results, including a 0% incidence of stricture, a 2% incidence of mild stress incontinence, and only 10% impotence. They compared these results with those of another group of patients who were referred to their medical center after unsuccessful attempts at immediate repair. Not unexpectedly, the patients who underwent unsuccessful attempts at immediate repair had worse results. This report has been appropriately criticized because, in essence, they are comparing those patients who underwent successful management with initial suprapubic tube placement followed by delayed urethroplasty with those patients who were failures of immediate realignment.