Open suprapubic cystostomy

Open suprapubic cystostomy If a patient must have his urine diverted but his bladder is not distended, you cannot a blind suprapubic puncture, so you have to an open one This can happen as the result of extravasation of urine due to trauma or a stricture A similar operation is needed for the removal of a stone from the bladder (23.15) OPEN SUPRAPUBIC CYSTOSTOMY TEMPORARY [s7]OPEN CYSTOSTOMY ANAESTHESIA (1) Local anaesthesia (A 5.4) (2) Ketamine (A 8.2) INDICATIONS (1) The need to divert a patient's urine, when his bladder is not sufficiently distended, or clear in outline, for a blind cystostomy, as with most cases of extravasation of urine (2) Rupture of the bladder (68.2) (3) The treatment of clot retention (4) As a necessary step in a urethroplasty (4) As a permanent measure for an impassable stricture of the urethra, which is so high up (as in the membranous urethra), that a urethrotomy, which would be preferable, is impossible CONTRAINDICATIONS Avoid doing a suprapubic cystotomy if a patient has carcinoma of his bladder (common in areas where Schistosoma haematobium is endemic), or is suspected of having it, because it may lead to a permanent and distressing urinary fistula METHOD Make a midline vertical suprapubic incision A cm incision is adequate unless he is fat Divide his linea alba, and retract his rectus muscles Use your forefinger, covered with a gauze swab, to push the cellular tissue and peritoneum upwards, away from the anterior surface of his bladder Dissect the loose fatty tissue away from in front of it Recognize his bladder by its characteristic pale appearance with some tortuous blood vessels Aspirate it first, unless it is impalpable (as with trauma causing extravasation) Insert stay sutures, superiorly and inferiorly, at the proposed ends of your vertical bladder incision They will make useful retractors when it sinks into his pelvis Take urine for culture, open his bladder with a longitudinal cm incision, and explore it If you are going to leave a suprapubic catheter in place, pass a Malecot, de Pezzer, or Foley catheter into his bladder through a separate stab incision above or to the side of the main one Make it a snug fit and hold it in place with a purse string suture (many surgeons pass it through the main wound) Close the main bladder incision with layers of 2/0 or 1/0 chromic catgut sutures Close the wound with the catheter emerging through a long, oblique, mid-line track Extend the wound proximally if necessary If it is likely to be infected by contaminated urine, as it may be if you are operating for extravasation, insert a retropubic drain See also Section 23.10 on extravasation of urine, especially if you have to continue suprapubic drainage more than a month CAUTION ! Make sure the suprapubic catheter emerges high, so that the track closes easily, and will not interfere with an approach to the bladder later PERMANENT [s7]OPEN CYSTOSTOMY INDICATIONS Some impassable urinary obstruction: a very tight stricture, or prostatic hypertrophy where catheterization has failed, and he is too ill for surgery Where surgery is even reasonably good, a permanent cystotomy should rarely be necessary METHOD Pass a Foley, a Malecot, or a de Pezzer catheter suprapubically by the method just above, or that in Section 23.6, using a trocar and cannula If necessary, he can go home with the catheter leading into a bag, or closed with a spigot, which will need to be released 4-hourly The bag will need cleaning and replacing after weeks Change his catheter monthly If you use an introducer, you should have no difficulty replacing his catheter, once a track has been established after the first 10 or 14 days Replacing it earlier may be almost impossible If you leave it in for longer, phosphatic encrustation, both inside and out, will make it difficult and painful to remove A high fluid intake and acidifying his urine will minimize encrustation The leak round the tube should not be too inconvenient To leave him with a ''hole' is distressing, because he will be wet all the time He faces the certainty of infection, and the probability of an early death Suprapubic cystostomy is also known as vesicostomy is an emergency and done when patient is not able to pass urine due to some obstruction in bladder, when tried to pass catheter, catheter not go beyond a point, again tried with smaller size catheter, again same problem, at this stage we take decision to perform suprapubic cystostomy Suprapubic Cystostomy is contraindicated in Carcinoma of bladder In this procedure skin is a surgical connection is made between bladder and abdomen skin and Mallécot’s catheter is introduced Block in passage of urine can be due to Benign prostratic hypertrophy Traumatic urethera Congenital defect stone in urethra Spinal cord injury Steps of suprapubic cystostomy give general anaesthesia or spinal anaesthesia clean the abdomen with bedadiene and spirit make a 5-6 cm vertical incision on abdomen wall at mid line an finger above the pubic symphisis we cut skin,superficial fascia, linea alba, we split the transversus abdominus muscle, and peritonium is seperated by blunt dissection Now we check the bladder by spirating the urine with syringe or by looking vesicular plexus give two stitches, make an incision and insert Mallécot’s catheter and stich the layers by layers and done  ... smaller size catheter, again same problem, at this stage we take decision to perform suprapubic cystostomy Suprapubic Cystostomy is contraindicated in Carcinoma of bladder In this procedure skin is... track closes easily, and will not interfere with an approach to the bladder later PERMANENT [s7 ]OPEN CYSTOSTOMY INDICATIONS Some impassable urinary obstruction: a very tight stricture, or prostatic... faces the certainty of infection, and the probability of an early death Suprapubic cystostomy is also known as vesicostomy is an emergency and done when patient is not able