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A Peel Away Sheath Endoscopic Technique for Difficult Pediatric Urethral Intubation Problems
0022-5347/97/1575-1880603.00/0 ’IkE JOURNAL OF UROLoCY Copyright 0 1997 by AMEHICM UROUJGICAL ~SSOCIATION. INC
Vol. 157. 1880-1881, May 1997 Printed in U S A .
A PEEL AWAY SHEATH ENDOSCOPIC TECHNIQUE FOR DIFFICULT PEDIATRIC URETHRAL INTUBATION PROBLEMS CURTIS A. SHELDON, EUGENE MINEVICH
AND
JEFFREY WACKSMAN
From the Dirision of Pediatric Urology, Chztdren’s Hospital Medical Center, Cincinnati, Ohio
ABSTRACT
Purpose: We describe a useful technique for overcoming difficult pediatric urethral intubation problems. Materials and Methods: An 8F pediatric urethroscope is passed through a peel away sheath, advanced through the urethra into the bladder and removed. An 8F urethral catheter is passed, the balloon is inflated and the peel away sheath is removed. Results: This procedure has been performed in 6 children with difficult urethral problems without complication and with universal success. Conclusions: The peel away sheath technique offers a more reliable and less traumatic mechanism for difficult infant urethral intubation. KEYWORDS:urethra, intubation Pediatric urethral intubation is frequently required for treating infants or children with complex anomalies involving the urethra, such as urogenital sinus and cloacal anomalies, particularly at formal reconstruction. Also, urological consultation is frequently obtained when there is an inability to pass a catheter in such settings as urethral catheter trauma. Typically in these instances, while a catheter cannot be passed blindly, a urethroscope can be advanced under direct vision. The absence of infant sized, open tip balloon catheters creates difficulty when attempting to pass a catheter over a wire. Creating a hole in the tip of a conventional infant sized Foley catheter usually damages the balloon mechanism, or it is so small that resistance to catheter advancement or guide wire withdrawal is sufficient to create the risk of urethral injury, catheter damage or guide wire fraying. Peel away sheaths have been used to aid in the placement of suprapubic tubes*,*and for urethral catheter passage in adults.3
TECHNIQUE
An 8F infant sized urethroscope is lubricated and advanced through a 10F peel away sheath (parts A and B of figure). The urethroscope is then advanced through the urethra into the bladder under direct vision. The urethroscope is withdrawn from the sheath and optimal positioning is confirmed by free urine drainage from the sheath. Lubricant is syringe injected into the sheath and a n 8F infant sized Foley catheter is advanced into the bladder. The balloon is inflated and the peel away sheath is removed (part C of figure).
RESULTS
This technique has been used in 6 pediatric patienu, in,.luding 4 infants. onemale infant had a severe catheter induced urethral injury that subsequently healed without stricture. Of the 3 female infants 2 had urogenital sinus anomalies and 1 had a cloacal anomaly. Two boys 10 and 7 years old had a severe urethral and appendiceal Mitrofanoff Accepted for publication October 3, 1996.
A, UF cystoscope and 10F peel away sheath. B,lubricated cystoscope inserted into sheath. C, lubricated 8F Foley catheter with inflated balloon before removal of peel away sheath.
stricture, respectively. In each case the technique resolved the inability to pass a catheter. It was completed in 2 to 3 minutes and resulted in no complication.
lURO
1881
PEEL AWAY SHEATH ENDOSCOPIC TECHNIQUE DISCUSSION
We report a helpful technique for difficult urethral intubation in pediatric patients that is especially valuable for infants. This technique involves a peel away sheath that is commonly used for inserting central venous catheters and is readily available in most operating room facilities. To date the technique has proved to be safe and reliable. In conclusion, we recommend early consideration of this technique for treating infants with urethral intubation problems.
REFERENCES
1. OBrien, W. M. and Pahira, J. J.: Percutaneous placement of suprapubic tube using peel-away sheath introducer. Urology, 31: 524, 1988. 2. O'Brien, W. M.: Percutaneous placement of a suprapubic tube with peel away sheath introducer. J. Urol., 145: 1015, 1991. 3. Lowe, M. A. and Defalco, A. J.: New endourologic technique for catheter placement after TURP, prostatectomy, and difficult urethroscopy. Urology, 40:461, 1992.
Vol. 157. 1880-1881, May 1997 Printed in U S A .
A PEEL AWAY SHEATH ENDOSCOPIC TECHNIQUE FOR DIFFICULT PEDIATRIC URETHRAL INTUBATION PROBLEMS CURTIS A. SHELDON, EUGENE MINEVICH
AND
JEFFREY WACKSMAN
From the Dirision of Pediatric Urology, Chztdren’s Hospital Medical Center, Cincinnati, Ohio
ABSTRACT
Purpose: We describe a useful technique for overcoming difficult pediatric urethral intubation problems. Materials and Methods: An 8F pediatric urethroscope is passed through a peel away sheath, advanced through the urethra into the bladder and removed. An 8F urethral catheter is passed, the balloon is inflated and the peel away sheath is removed. Results: This procedure has been performed in 6 children with difficult urethral problems without complication and with universal success. Conclusions: The peel away sheath technique offers a more reliable and less traumatic mechanism for difficult infant urethral intubation. KEYWORDS:urethra, intubation Pediatric urethral intubation is frequently required for treating infants or children with complex anomalies involving the urethra, such as urogenital sinus and cloacal anomalies, particularly at formal reconstruction. Also, urological consultation is frequently obtained when there is an inability to pass a catheter in such settings as urethral catheter trauma. Typically in these instances, while a catheter cannot be passed blindly, a urethroscope can be advanced under direct vision. The absence of infant sized, open tip balloon catheters creates difficulty when attempting to pass a catheter over a wire. Creating a hole in the tip of a conventional infant sized Foley catheter usually damages the balloon mechanism, or it is so small that resistance to catheter advancement or guide wire withdrawal is sufficient to create the risk of urethral injury, catheter damage or guide wire fraying. Peel away sheaths have been used to aid in the placement of suprapubic tubes*,*and for urethral catheter passage in adults.3
TECHNIQUE
An 8F infant sized urethroscope is lubricated and advanced through a 10F peel away sheath (parts A and B of figure). The urethroscope is then advanced through the urethra into the bladder under direct vision. The urethroscope is withdrawn from the sheath and optimal positioning is confirmed by free urine drainage from the sheath. Lubricant is syringe injected into the sheath and a n 8F infant sized Foley catheter is advanced into the bladder. The balloon is inflated and the peel away sheath is removed (part C of figure).
RESULTS
This technique has been used in 6 pediatric patienu, in,.luding 4 infants. onemale infant had a severe catheter induced urethral injury that subsequently healed without stricture. Of the 3 female infants 2 had urogenital sinus anomalies and 1 had a cloacal anomaly. Two boys 10 and 7 years old had a severe urethral and appendiceal Mitrofanoff Accepted for publication October 3, 1996.
A, UF cystoscope and 10F peel away sheath. B,lubricated cystoscope inserted into sheath. C, lubricated 8F Foley catheter with inflated balloon before removal of peel away sheath.
stricture, respectively. In each case the technique resolved the inability to pass a catheter. It was completed in 2 to 3 minutes and resulted in no complication.
lURO
1881
PEEL AWAY SHEATH ENDOSCOPIC TECHNIQUE DISCUSSION
We report a helpful technique for difficult urethral intubation in pediatric patients that is especially valuable for infants. This technique involves a peel away sheath that is commonly used for inserting central venous catheters and is readily available in most operating room facilities. To date the technique has proved to be safe and reliable. In conclusion, we recommend early consideration of this technique for treating infants with urethral intubation problems.
REFERENCES
1. OBrien, W. M. and Pahira, J. J.: Percutaneous placement of suprapubic tube using peel-away sheath introducer. Urology, 31: 524, 1988. 2. O'Brien, W. M.: Percutaneous placement of a suprapubic tube with peel away sheath introducer. J. Urol., 145: 1015, 1991. 3. Lowe, M. A. and Defalco, A. J.: New endourologic technique for catheter placement after TURP, prostatectomy, and difficult urethroscopy. Urology, 40:461, 1992.