303 Percutaneous, Suprapubic and Results Nicholas Papanicolaou1 Richard C Pfister1 Barry N Nocks2 Large-Bore, Cystostomy: Technique A technique to insert large-bore suprapubic cystostomy catheters (18-French or larger) percutaneously, under radiologic imaging guidance, is described in 15 men who required long-term drainage of the bladder This single-stage procedure is earned out under local anesthesia with optional IV sedation It consists of rapid enlargement of the percutaneous track by means of a balloon dilatation catheter followed by insertion of a self-retaining associated Foley with the cystostomy catheter placement of the through catheters a peel-away occurred, ance has been satisfactory Our results suggest that percutaneous, large-bore preferred alternative to surgical cystostomy sheath and No complications long-term suprapubic patient cystostomy compli- may be a Percutaneous suprapubic cystostomy has long been used for the treatment of acute urinary retention, regardless of cause, when standard urethral catheterization of the bladder is either impossible or contraindicated [1 -4] The placement of a small-diameter trocar suprapubic catheter is quick and safe and requires only local anesthesia Although effective in urgent situations, this cystostomy system is not suitable for long-term drainage of the bladder, primarily because of the small lumen of the catheter and the sutures required for securing it Surgical placement of large cystostomy catheters (20- to 30-French) usually requires hospitalization, spinal or general anesthesia, and an open procedure [5]; their use in high-risk anesthesia patients cannot be advocated Because of these shortcomings, we inserted large-bore cystostomy catheters percutaneously in 15 patients in whom long-term bladder drainage was necessary The technique, complications, and long-term compliance were reviewed to establish the safety and effectiveness of the procedure Materials Received sion October Presented Roentgen 1988 August 30, 1988; 6, 1988 after revi- at the annual meeting of the American Ray Society, San Francisco, CA, May Department diology, partment accepted of Radiology, Massachusetts Division General Hospital, of Uroraand De- of Radiology, Harvard Medical School, Boston, MA 02114 Address reprint requests to N Papanicolaou, Dept of Radiology, Massachusetts General Hospital, Boston, MA 02114 I.kOIOgiCaI Hospital, Service, and Department ical School, Boston, AJR 152:303-306, Massachusetts of Surgery, MA 02114 February 1989 0361 -803X/89/1 522-0303 © American Roentgen Ray Society Harvard General Med- and Methods Between February 987 and July 1988, we inserted percutaneously large-diameter suprapubic cystostomy catheters (1 French or larger) in 15 men (31-95 years old (median age, 69) Eight patients had a combination of neurogenic bladder (CNS disorders, cerebrovascular disease, or spinal cord injury) and mechanical obstruction of the bladder outlet (enlarged prostate) Three patients had radiation cystitis with refractory bladder spasms In two, severe urethral trauma had been caused by motor vehicle accidents One had multiple urethral strictures and severe coronary artery disease, and one developed pyocystis of his defunctionalized bladder Urodynamic assessment of neuromuscular function of the bladder and sphincter and voiding cystography were performed in all patients except the two patients with urethral trauma and the patient with pyocystis Intermittent catheterization of the bladder or placement of an indwelling catheter was deemed inapplicable in these rehabilitation patients, as were sphincterotomy and continuous penile condom drainage With the exception of the two trauma cases, the remaining 13 patients were poor surgical and anesthesia risks In three patients, was unsuccessful percutaneous insertion of a suprapubic catheter without imaging guidance 304 PAPANICOLAOU The procedure was performed with the patient under local anesthesia (Fig 1) In addition, IV sedation and analgesia (morphine sulfate, meperidine hydrochloride, midazolam, diazepam, or fentanyl) were used in 10 patients Under fluoroscopy, the urinary bladder was opacifled and distended via a suprapubic 20-gauge needle or a transurethral catheter (Fig 1) in most contrast material (allowing visualization der) displaced direct of the bladder for subsequent insertion catheter A paramedian oblique approach pubis and a 9-gauge needle-sheath system was widened, [24-30 wire and a balloon French] in diameter The percutaneous dilatation of the above the were used catheter (8-1 mm and 10 cm long) was inserted track was then rapidly dilated over the for 3-4 mm (Fig 2B) In seven cases, further dilatation of focal areas of persisting narrowing was performed by using track could easily accommodate away sheath-dilator Bloomington, IN) was system then rigid fascial dilators the peel-away (38-PFISTER-B-021 inserted over the was applied around the catheter February 1989 entry site We did not suture the catheter to the skin, because the retention balloon effectively secured good position and comfortable wear Within 4-6 weeks after cystostomy, the percutaneous track was mature enough to allow easy replacement of the catheter by the urologist in the office in the blad- to enter the anterior bladder wall (Fig 2A) On aspiration of urine, the needle was exchanged for a 0.97-mm (0.038-in.) torque guidewire, which was coiled into the bladder The skin opening at the site of the puncture AJA:152, ml of dilute bowel loops away from the needle path and provided visualization cystostomy symphysis cases, 300-400 of the guidewire ET AL sheath before the The peel- 583, Cook, Inc., guidewire into the bladder (Fig 2C) The size of the sheath selected was French sizes larger than the cystostomy catheter to be placed The dilator was then removed, and a 5-mI Foley catheter balloon, with an end hole or removed tip, was inserted over the guidewire into the vesical lumen (Fig 2D) The catheter balloon was inflated once satisfactory position of the tube was confirmed The peel-away sheath was then removed, the retention balloon was pulled snug against the anterior bladder wall, and the catheter was put to drainage (Fig 1) A sterile dressing Results All attempts at catheter placement with the use of radiologic imaging under local anesthesia were successful No immediate complications have occurred after large-bore suprapubic cystostomy The catheters have been tolerated well, and their care and function have been satisfactory for periods up to 1.5 years (minimum, patients drainage weeks; and the patient discontinued with mean, months) pyocystis 2-3 months had their after recovery Both trauma suprapubic of the ure- thral injuries and sterilization of the bladder, respectively After removal of the catheter, the percutaneous tracks closed promptly within 2-3 days One patient with malignant melanoma and neurogenic bladder died of metastases weeks after placement of the catheter Two of the 1 long-term cystostomies were complicated transiently by urinary tract infections, which were controlled with oral trimethoprimsulfamethoxazole All 11 remaining patients have been maintained on suprapubic cystostomy drainage, oral antimicrobial prophylaxis, and catheter changes every months Discussion A Long-term drainage of the urinary bladder has been accomplished by various methods, including an indwelling catheter, intermittent catheterization, transurethral sphincterotomy with continuous condom drainage, and suprapubic cystostomy [2, 6-8] The choice of management depends on the type of neurogenic bladder, the presence of obstruction of the bladder outlet, age and medical condition of the patient, and expected compliance and care after discharge from the hospital Among the catheter methods, the suprapubic one is best tolerated by patients who are physically unable or psychologically unwilling to catheterize themselves In men, intermittent catheterization is an uncomfortable procedure, especially in the presence of urethral strictures or prostatic enlargement; it is ideally suited to patients who not have mechanical obstruction Also, in certain long-term chronic care facilities intermittent catheterization often is not a viable option The percutaneous trocar method of suprapubic cystostomy via 8- or 12-French Silastic catheters has been useful for the short-term treatment of urinary retention of any cause and for temporary urinary diversion at any age For long-term man- Contrast through needle Pubic sYmPhYssj11i ladder Dilator te:r oith away // Sheath Foley and E F through , sheath agement, Fig 1.-Successive steps (A-I) in percutaneous Foley catheter for suprapubic cystostomy placement of large however, a larger-bore catheter to facilitate irriga- tion and drainage is desirable For this purpose, Ingram [9] described a stylet-trocar cystostomy system accommodating 12- and 16-French catheters, which he successfully used in 86 gynecologic patients The surgical placement of a large cystostomy tube is a simple procedure technically; however, it carries with it the AJA:152, February 1989 SUPRAPUBIC CYSTOSTOMY 305 Fig 2.-Percutaneous placement of 20French Foley suprapubic cystostomy catheter in elderly man with prostatic enlargement and recent cerebrovascular hemorrhage A, After bladder distension and opacification via transurethral catheter (arrow), 19-gauge sheath is used to insert and coil torque wire into vesical lumen B, Rapid dilatation of percutaneous track is accomplished by using balloon dilatation cathetsr (arrows) C, After track dilatation, peel-away dilatorsheath is placed into bladder 0, Dilator is removed and Foley cystostomy catheter is inserted into bladder through sheath Balloon of catheter is inflated to ease confirmation of intravesical positioning (arrow) E, Peel-away sheath is split and removed with wire, whereas catheter is held In position in bladder risks and expense of anesthesia, open surgery, and hospitalization Therefore, percutaneous placement of a similar-size tube is advantageous and was performed as an outpatient procedure in two of our cases The procedure was safely performed with imaging guidance in all patients, including three patients in whom blind placement of a suprapubic cystostomy catheter by others had failed The technique is applicable to both men and women Men are more likely to undergo the procedure because of anatomic considerations, such as longer urethra and presence of the prostate, which are often associated with bladder outlet obstruction Fluoroscopy is of great aid in selecting the site of entrance into the bladder (junction of mid and lower third) and final placement of the catheter; the area of the trigone should be spared trauma and irritation to avoid bladder spasms Skin infection is circumvented by securing the catheter with simple intravesical balloon inflation and omitting sutures Catheters that were 18 French or larger provided satisfactory drainage Although a peel-away sheath French sizes larger than the cystostomy catheter is usually appropriate, sheath and catheter should be matched with each other before placement Imprecise size labeling and manufacturing variations in the size of the deflated balloon on the Foley catheter shaft may result in a mismatch; a 4-French difference may then be required for successful placement Potential complications after suprapubic cystostomy placement include penivesical hemorrhage, hematunia, transgression of bowel loops, perforation of the bladder, catheter fragmentation resulting in an intravesical foreign body, and catheter malfunction [1 , 0, 1] Hematuria is always present, but usually is transient and insignificant By distending the bladder during placement of the cystostomy catheter, adjacent bowel loops are displaced superiorly or laterally and are less likely to be injured The concomitant use of sonography should further ensure that bowel loops have indeed been displaced, thus making the procedure safer Bladder distension also makes through-and-through perforation of the bladden unlikely, because the opposing vesical walls are widely separated Both infection and stone formation have been associated with long-standing bladder catheters, including those used for suprapubic cystostomy [6-8, 12-14] In addition, patients who have indwelling urethral catheters or who are on intermittent catheterization may develop urethral strictures The suprapubic type is less likely to cause infection than is the 306 PAPANICOLAOU indwelling urethral catheter and it also compares favorably with intermittent catheterization [7, 13] In summary, our experience indicates that percutaneous placement of a large-bore suprapubic cystostomy catheter under the guidance of radiologic imaging is a single-stage, safe, and well-tolerated procedure for patients requiring longterm drainage of the urinary bladder ET 10 AA Trocar suprapubic cystostomy for postoperin the female Am J Obstet Gyneco! 1966;96: 773-781 Cook JB, Smith PH Percutaneous suprapubic cystostomy after spinal cord injury BrJ Urol 1976;48:119-121 Morehouse DD Emergency management of urethral trauma Urol C/in North Am 1982;9:251-254 Retik AB, Perimutter AD Temporary urinary diversion in infants and young children, in: Walsh PC, Gittes RF, Perimutter AD, Stamey TA, eds Campbell’s urology, 5th ed Philadelphia: Saunders, 1986:2116-2136 Lieber MM, Utz DC Open bladder surgery in: Walsh PC, Gittes RF, AJR:152, February 1989 Perimutter AD, Stamey TA, eds Campbell’s REFERENCES Hodgkinson CP, Hodari ative bladder drainage AL 11 urology, 5th ed Philadelphia: Saunders, 1986:2640-2641 Perkash I Problems with decatheterization in long-term spinal cord injury patients J Urol 1980;124:249-253 Noll F, Russo 0, Kling E, Botel U, Schreiter F intermittent cathetensation versus percutaneous suprapubic cystostomy in the early management of traumatic spinal cord lesions Paraplegia 1988;26:4-9 Anderson RU Urinary tract infections in spinal cord injury patients in: Walsh PC, Gittes RF, Perimutter AD, Stamey TA, eds Campbell’s urology, 5th ed Philadelphia: Saunders, 1986:888-899 Ingram JM Suprapubic cystostomy by trocar catheter: a preliminary report Am J Obstet Gynecol 1972;1 13:1108-1112 Nolier KL, Pratt JH, Symmonds RE Bowel perforation with suprapubic cystostomy: report of two cases Obstet Gynecol 1970;48[suppij:67-69 Frymire U Comparison of suprapubic versus Foley drains Obstet Gynecol 1971;38:239-244 12 Donovan WH, Stolov WC, Clowers intermittent catheterization Rehabil 1978;59:351-357 following DE, Clowers spinal cord MR Bactenuria injury Arch Phys during Med 13 Schaeffer AJ Catheter-associated bacteriuria Urol Clln North Am 1986;13:735-747 14 Donovan WH, Kiriat MD, Clowers DE Intermittent bladder emptying via urethral catheterization of suprapubic cystocath: a comparison study Arch Phys Med Rehabil 1977;58:291 -296 ... large-bore suprapubic cystostomy The catheters have been tolerated well, and their care and function have been satisfactory for periods up to 1.5 years (minimum, patients drainage weeks; and the... approach pubis and a 9-gauge needle-sheath system was widened, [24-30 wire and a balloon French] in diameter The percutaneous dilatation of the above the were used catheter (8-1 mm and 10 cm long)... condom drainage, and suprapubic cystostomy [2, 6-8] The choice of management depends on the type of neurogenic bladder, the presence of obstruction of the bladder outlet, age and medical condition