Urology & Nephrology - Juniper Publishers
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
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.
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.
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.
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.
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].
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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