Saving the Suprapubic Tract - Juniper Publishers

 Urology & Nephrology - Juniper Publishers

Abstract

Suprapubic Catheters (SPC) are commonly used for drainage of urine in the frail, elderly patient group worldwide. Losing the suprapubic tract post insertion can occur for numerous reasons, which subject patients for further surgical procedures to regain the suprapubic urine drainage with a higher risk of sustaining complications such as bowel injury. In this article we describe our technique of saving the suprapubic tract in the emergency setting.

Methods: Patients presenting to our hospital with failure to reinsert their SPC over a 6 months period were invited to have their SPC reinserted using our technique. A surgeon and an assistant were present to perform the procedure with the Instruments used including; Ultrasound Scan (USS), guidewire and open-tip urinary catheter.

Result:The procedure was done successfully in the 4 patients presenting with loss of their SPC. Operative time was less than 5 minutes and the procedure were well tolerated with regular analgesia. All patients were satisfied by their procedure and no post-operative complications were observed. Patients were discharged home on the same day and follow-up ensued with their district nurses as normal, with no change in their SPC care plan.

Conclusion: In the presence of the USS and the required instruments, the suprapubic tract can be salvageable in a frail patient group without the need for an emergency or an elective procedure under general anaesthesia. Decreasing the burden on the patient and the operative theatres;

Keywords: Long term catheters, Bladder drainage, Surgical treatment, Palliative, Suprapubic Catheter, Haematuria

Introduction

Long term catheters for bladder drainage is an alternative for urine drainage. Indications include; bladder outlet obstruction in patients with co-morbidities and unable to have definitive surgical treatment, palliative use for elderly frail patients and neurological disorders. Together with long term indwelling urethral catheter, Suprapubic Catheter (SPC) placement is a common method for urine drainage for patients requiring long term catheterisation. The procedure is usually performed under general anaesthesia and can be done under local anaesthesia, especially in the emergency settings. In addition to anaesthetics complications, SPC insertion complications include haematuria, catheter blockage, and recurrent urinary tract infections [1]. Also, one of the not uncommon risks during placing SPC is bowel perforation [2] which can be up to 2.5%, resulting in mortality in 30 days in 1.8% of the cases. This has a higher prevalence among patients with previous lower abdominal surgery [3], mainly due to abdominal wall adhesions, which can be found in up to 59% of patients with previous midline laparotomy scars [4]. After the initial SPC insertion, the first change is usually performed after at least 2 weeks, allowing the suprapubic tract to mature [5] and thereafter SPC changes can be done on a 2-3 monthly basis according to the catheter used. Despite being a routine urological procedure, changing the SPC has risks of its own, such as inadvertent bowel injury [6]. Another complication is failure to reinsert SPC whether during routine change of SPC or after falling out of the catheter. This dictates immediate urological attention, as losing the suprapubic tract would result in the need for another surgical operation for resisting the SPC. This carries the risk of higher chance of visceral injury as the risk of abdominal wall adhesion increases after lower abdominal surgery. In this article we explore the use of Ultrasound Scan (USS) and guidewire to salvage the suprapubic tract.

Methods

In the period between October 2018 to April 2019, 4 patients have been referred to our emergency services with expelled SPC, either during routine change with failure of insertion or spontaneous expulsion of the SPC.

Patients were met promptly in the surgical admission unit by the urology team and rapid assessment took place. Verbal and implied consent were obtained to attempt reinserting their SPC. Instruments used included;

a) Sensor® PTFE-Nitinol guidewire with a hydrophilic tip (Boston Scientific)

b) Open-tip catheter

c) USS machines with a lower frequency abdominal probe (3.5 -6MHz) have greater depth penetration and are more useful for abdominal scanning. The effective width of the US beam is affected by probe construction, depth and focussing and for a 3.5 MHz probe this commonly ranges between 3 to 5 mm.

Technique

a) Implied and verbal consent is sought in a similar manner to inserting a urethral catheter. Antibiotic prophylaxis and analgesia can be administered. Preparation of the operative field using betadine/chlorhexidine is important as usually previous manipulation(s) have been attempted.

b) An aseptic approach to avoid catheter-related urinary tract infections. An aseptic technique includes prepping and covering the puncture site with a large sterile drape, wearing sterile gloves, covering the US probe and cable with a sterile cover/shield and using a sterile conductive medium (USS gel) [7].

c) US scanning of the bladder/supra pubic tract; starting with a transverse lie, just underneath the site of the suprapubic puncture, where the bladder is usually seen partially full and the suprapubic tract is observed. An appreciation of the US probe and beam geometry is essential

d) Ask your assistant to hold the US probe in place and the sensor guidewire is fed through the suprapubic tract to the bladder and is confirmed under direct vision by the USS, you can rock the guidewire in small in and out motions to visualise it and confirm presence in the bladder.

e) Open tip catheter is introduced over the guidewire while assistant keeping the guidewire straight and prevent its expulsion.

f) Urine is drained, guidewire is removed, while catheter is held in place in bladder at the suprapubic tract and the balloon is inflated.

g) Position of the balloon is confirmed with US at the end of the procedure.

Results

In the period between September 2018 to April 2019, 4 patients have been referred to our emergency services with expelled SPC, either during routine change with failure of insertion or spontaneous expulsion of the SPC. Three patients had SPC due to old age and limited mobility and one patient had it for neurological indication. The average Body mass index of the patients was 28.3kg/m2 (range; 22-34 kg/m2). Time interval between removal of SPC and reinsertion varied between 6-12 hours, with an average of 4.5 hours. Patients were met promptly in the surgical admission unit by the urology team and rapid assessment took place, attempting to insert a routine SPC was unsuccessful due to (tight SPC skin opening and inability of advancing SPC to bladder). USS assessment was performed showing full bladder and suprapubic tract patency. Procedure was performed under 5 minutes, provided a surgeon and an assistant were present. Procedure was tolerated by all four patients with no anaesthesia, one patient needed Entonox for pain due to irritation of the neurogenic bladder by the sensor guidewire. Procedure was performed as outlined with all patients having their SPC reinserted, patients were observed for 2-4 hours post-operatively ensuring no post-obstructive diuresis or decompression haematuria and discharged home within the same day. Wounds healed well, and all patients were satisfied with the postoperative appearance of the SP wound. Patients were followed up until there next routine SPC change with no further complications reported.

Discussion

There is double benefit from adopting this technique, first is reducing the cost needed to re-insert the SPC in theatre setting. In their closed loop audit to assess the effectiveness of SPC insertion under local anaesthesia in an outpatient facility, Khan and Abrams demonstrated the huge cost savings they have cut performing the procedure in a simple outpatient facility, which was estimated to a total of £100,000/year per hospital, £790,000/year in their region, and £9,500,000 in the UK [8]. The second benefit is avoiding the formation of another suprapubic tract which has higher chance of visceral injury due to abdominal adhesions from the initial procedure [4], either it was done in an open (Suprapubic cystostomy and SPC insertion) or a closed manner, additionally avoiding the risks of general anaesthesia in the elderly population. In the description of their technique, Susan Willis and Bruce Montgomery, mentioned the utilisation of sensor guidewire and dilators to dilate the tract prior to reinserting the SPC [9]. Our method uses USS to delineate the suprapubic tract prior to cannulation, ensuring the sensor guidewire is following urine in its way to the bladder and not misguided in the abdominal cavity. Also, the real-time imaging use of USS allow visualisation of the guidewire in the bladder confirming the correct placement prior to further manipulation that can lead to loss of the suprapubic tract [10]. Furthermore, the use of ultrasound can then confirm the position of the catheter within the bladder after insertion.

The utilisation of USS greatly benefits this technique. As an imaging modality, it is quick, which is imperative in the recannulation, to avoid closure of the suprapubic tract. Moreover, having a quick scan can hasten the decision as to whether the patient will need to go to the theatres or not and it involves no radiation. This principle is adopted by BAUS based on advice from the National Patient Safety Agency [10]. The benefits are compared to utilising the use of the USS in the insertion of central venous catheters, which has reduced the complications experienced as well as increased the first-time success rate [11]. Suprapubic catheters are often used to improve the quality of life for patients at a late stage of their lives. Therefore, majority of these patients are elderly, frail, or having palliative treatment and often are not good candidates for general anaesthesia. It is imperative for this patient group to have an easy method to reinsert their catheters, without requiring general anaesthesia.

Despite the promising potentials of this technique, limitations were observed. Starting by the duration the suprapubic tract remains salvageable, which is under question and needs further studies to clarify this. Therefore, It is important to mention in the consent process that saving the SP tract is not guaranteed and there may be need to undergo urethral catheterisation and elective formal SPC insertion in theatres, or SPC insertion under general anaesthesia as an emergency in cases of difficult urethral catheterisation in the case of failure. In our limited patient group who presented as an emergency, attempting reinsertion was successful in all the patients, however the difficulty of the technique was noted in patients with high BMI, needing more than one assistant. No correlation was noted between the body habitus and the chances of success, this needs re-examining in a wider patient group. The greater the amount of subcutaneous tissue, the more difficult USS utilisation becomes, leading to attenuation of the sound waves and a poorer image quality. Despite the advantages of performing the technique under local anaesthesia, this will prove disadvantageous to the high-level spinal cord injury patients (above T6) who are susceptible for autonomic dysreflexia, therefore prolonged manipulation by the guidewire and catheter should be avoided. USS might give the inexperienced user a false sense of security and mislead him/her to neglect traditionally taught principles with regard to needle direction. It is key to visualize the needle (or needle tip) constantly during needle advancement [11]. Therefore, appropriate training of the staff involved in the procedure is crucial for optimum usage of the US and to increase the chances of success of the procedure [12]. This is being addressed in the modern era as urologists have been using USS more frequently, especially with prostate biopsies, and BAUS offer ultrasound courses for urologists [13].

Conclusion

Despite having mobile USS and guidewires in most hospitals readily available, this technique is underutilised in the emergency setting leading to the majority of patients to lose their suprapubic tract. This subjects patients to anaesthetics risks and complications of the procedure, in addition to enduring costs of the operative theatre setting. We believe that utilisation of this technique provides a safe rapid alternative for regaining the SPC in an already frail patient population.

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