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Percutaneous Placement of a Suprapubic Tube with Peel away Sheath Introducer
0022-534 7/91/1455-1015$03.00/0 Vol. 145, 1015-1016, May 1991
THE JOURNAL OF UROLOGY Copyright© 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Printed in U.S.A.
Urologists At Work PERCUTANEOUS PLACEMENT OF A SUPRAPUBIC TUBE WITH PEEL AWAY SHEATH INTRODUCER WALTER M. O'BRIEN From the Division of Uro/,ogy, Georgetown University Hospital, Washington, D. C.
ABSTRACT
A new technique for percutaneous placement of a suprapubic tube has been developed, which allows controlled entry into the bladder over a guide wire to avoid the potential hazards of blind trocar cystotomy. A Foley style catheter can be placed, which is less likely to become dislodged than other types of percutaneous suprapubic catheters currently available. KEY WORDS:
bladder, cystostomy
A new technique for percutaneous placement of a suprapubic tube has been developed, which allows controlled entry into the bladder over a guide wire. With this approach a 14F balloon style catheter can be placed without the use of a trocar. TECHNIQUE
The suprapubic tube can be placed with the patient under either local or general anesthesia. The distended bladder should be palpated in the lower midline. If the tube is to be placed with the patient under local anesthesia the area of the intended puncture site is infiltrated with 1% lidocaine delivered through a 22 gauge spinal needle. The needle is introduced in the midline Accepted for publication September 25, 1990.
2 cm. above the symphysis pubis, directed towards the anus and advanced until return flow of urine confirms entry into the bladder. An 18 gauge thin-walled needle is then advanced adjacent and parallel to the spinal needle into the bladder. If the procedure is done while the patient is under general anesthesia the 18 gauge needle can be used for the initial puncture to find a path into the bladder. Return flow of urine through the 18 gauge needle confirms proper entry into the bladder. A 0.038 guide wire is advanced through the needle into the bladder (fig. 1, A) and the needle is withdrawn. A 5 mm. skin incision is made along the insertion site of the guide wire. An 18F fascial dilator with an associated peel away sheath is advanced over the guide wire and into the bladder (fig. 1, B). The guide wire
FIG. 1. A, 18 gauge needle is in bladder. Guide wire is advanced through needle. B, dilator and peel away sheath are advanced over guide wire. C, dilator and guide wire are removed. Through peel away sheath 12 or 14F catheter can be introduced into bladder. D, balloon is inflated, and sheath is pulled back and peeled away.
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and dilator are withdrawn leaving only the peel away sheath in place. A standard 14F Foley catheter is inserted through the peel away sheath (fig. 1, C). The balloon is inflated with 10 cc sterile water. The sheath is pulled up and peeled away leaving only the Foley catheter in place (fig. 1, D). The catheter is secured to the abdomen with tape. RESULTS
Percutaneous placement of a Foley style suprapubic tube with a peel away sheath introducer set* has now been performed by 10 different physicians, most in resident training, in 40 patients without any complications. The procedure has been easy to learn and simple to perform. In more muscular patients there has been resistance to the advancement of the dilator at the fascia level. In these cases a small incision in the fascia made with a 15 blade immediately adjacent to the guide wire permitted easy advancement of the dilator sheath set into the bladder. In 4 patients a balloon style catheter was placed after another type of suprapubic catheter had been dislodged. With the balloon style catheter there were no subsequent cases of tube dislodgement. DISCUSSION
There are a variety of indications for either the temporary or l?ermanent placement of suprapubic catheters. Techniques available for closed suprapubic cystotomy include Bonanno, Cystocath, Argyle Ingram and Stamey systems. 1 Complications associated with the insertion of suprapubic catheters using a punch trocar technique include perforation of the ileum2- 4 and colon 5 as well as serious retropubic hemorrhage. 2 Less serious but more common problems include kinking, blockage, breaking and tube dislodgement. 6 There are several advantages to this new system. It allows controlled entry into the bladder over a guide wire, since the initial puncture is made with an 18 gauge needle. If the needle is placed in an inappropriate position, there is less potential for injury compared to that which can occur with a trocar system (fig. 2). A balloon style catheter can be placed, which is less likely to be inadvertently dislodged than other types of suprapubic tubes. This system allows placement of a standard Foley catheter, which provides a soft and flexible suprapubic tube that is easy to bend and tape onto the abdomen. In patients who undergo endoscopic bladder neck suspensions the tube is easy to conceal under clothes. The improved flexibility allows easy home management by these patients. The tube can be connected to all standard types of drainage bags without the need for a special adaptor. Finally, a permanent style supra* Cook Urological Inc., Spencer, Indiana.
FIG. 2. Comparison of 18 gauge needle to cystocatheter trocar (A) and Stamey (B) trocar. Initial puncture is made with smaller needle which lessens potential for serious injury if improper placement occurs'.
pubic tube can be placed with the patient under local anesthesia only. In 2 patients a 14F Foley catheter was placed at the ?edside_. The tube was then changed at 2-week intervals using mcreasmgly larger Foley catheters until a large bore catheter was in place. This method avoided the need for a formal suprapubic cystotomy. In conclusion, this technique allows controlled entry into the bladder with a small gauge needle and guide wire, which lessens the potential for complications when compared to punch cystotomy with a trocar. A soft and flexible balloon style catheter can be placed, which is difficult to dislodge. REFERENCES
1. Hilton, P. and Stanton, S. L.: Suprapubic catheterisation. Brit.
Med. J., 281: 1261, 1980. 2. Flock, W. D., Litvak, A. S. and McRoberts, J. W.: Evaluation of closed suprapubic cystostomy. Urology, 11: 40, 1978. 3. Hebert, D. B. and Mitchell, G. W., Jr.: Perforation of the ileum as a complication of suprapubic catheterization. Obst. Gynec., 62: 662, 1983. 4. Moody, T. E., Howards, S.S., Schneider, J. A. and Rudolf, L. E.: Intestinal obstruction: a complication of percutaneous cystostomy. A case report. J. Urol., 118: 680, 1977. 5. Browning, D. J.: Potential hazard of suprapubic catheterization. Med. J. Aust., 2: 580, 1977. 6. Drutz, H. P. and Khosid, H. I.: Complications with Bonanno suprapubic catheters. Amer. J. Obst. Gynec., 149: 685, 1984.
THE JOURNAL OF UROLOGY Copyright© 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Printed in U.S.A.
Urologists At Work PERCUTANEOUS PLACEMENT OF A SUPRAPUBIC TUBE WITH PEEL AWAY SHEATH INTRODUCER WALTER M. O'BRIEN From the Division of Uro/,ogy, Georgetown University Hospital, Washington, D. C.
ABSTRACT
A new technique for percutaneous placement of a suprapubic tube has been developed, which allows controlled entry into the bladder over a guide wire to avoid the potential hazards of blind trocar cystotomy. A Foley style catheter can be placed, which is less likely to become dislodged than other types of percutaneous suprapubic catheters currently available. KEY WORDS:
bladder, cystostomy
A new technique for percutaneous placement of a suprapubic tube has been developed, which allows controlled entry into the bladder over a guide wire. With this approach a 14F balloon style catheter can be placed without the use of a trocar. TECHNIQUE
The suprapubic tube can be placed with the patient under either local or general anesthesia. The distended bladder should be palpated in the lower midline. If the tube is to be placed with the patient under local anesthesia the area of the intended puncture site is infiltrated with 1% lidocaine delivered through a 22 gauge spinal needle. The needle is introduced in the midline Accepted for publication September 25, 1990.
2 cm. above the symphysis pubis, directed towards the anus and advanced until return flow of urine confirms entry into the bladder. An 18 gauge thin-walled needle is then advanced adjacent and parallel to the spinal needle into the bladder. If the procedure is done while the patient is under general anesthesia the 18 gauge needle can be used for the initial puncture to find a path into the bladder. Return flow of urine through the 18 gauge needle confirms proper entry into the bladder. A 0.038 guide wire is advanced through the needle into the bladder (fig. 1, A) and the needle is withdrawn. A 5 mm. skin incision is made along the insertion site of the guide wire. An 18F fascial dilator with an associated peel away sheath is advanced over the guide wire and into the bladder (fig. 1, B). The guide wire
FIG. 1. A, 18 gauge needle is in bladder. Guide wire is advanced through needle. B, dilator and peel away sheath are advanced over guide wire. C, dilator and guide wire are removed. Through peel away sheath 12 or 14F catheter can be introduced into bladder. D, balloon is inflated, and sheath is pulled back and peeled away.
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and dilator are withdrawn leaving only the peel away sheath in place. A standard 14F Foley catheter is inserted through the peel away sheath (fig. 1, C). The balloon is inflated with 10 cc sterile water. The sheath is pulled up and peeled away leaving only the Foley catheter in place (fig. 1, D). The catheter is secured to the abdomen with tape. RESULTS
Percutaneous placement of a Foley style suprapubic tube with a peel away sheath introducer set* has now been performed by 10 different physicians, most in resident training, in 40 patients without any complications. The procedure has been easy to learn and simple to perform. In more muscular patients there has been resistance to the advancement of the dilator at the fascia level. In these cases a small incision in the fascia made with a 15 blade immediately adjacent to the guide wire permitted easy advancement of the dilator sheath set into the bladder. In 4 patients a balloon style catheter was placed after another type of suprapubic catheter had been dislodged. With the balloon style catheter there were no subsequent cases of tube dislodgement. DISCUSSION
There are a variety of indications for either the temporary or l?ermanent placement of suprapubic catheters. Techniques available for closed suprapubic cystotomy include Bonanno, Cystocath, Argyle Ingram and Stamey systems. 1 Complications associated with the insertion of suprapubic catheters using a punch trocar technique include perforation of the ileum2- 4 and colon 5 as well as serious retropubic hemorrhage. 2 Less serious but more common problems include kinking, blockage, breaking and tube dislodgement. 6 There are several advantages to this new system. It allows controlled entry into the bladder over a guide wire, since the initial puncture is made with an 18 gauge needle. If the needle is placed in an inappropriate position, there is less potential for injury compared to that which can occur with a trocar system (fig. 2). A balloon style catheter can be placed, which is less likely to be inadvertently dislodged than other types of suprapubic tubes. This system allows placement of a standard Foley catheter, which provides a soft and flexible suprapubic tube that is easy to bend and tape onto the abdomen. In patients who undergo endoscopic bladder neck suspensions the tube is easy to conceal under clothes. The improved flexibility allows easy home management by these patients. The tube can be connected to all standard types of drainage bags without the need for a special adaptor. Finally, a permanent style supra* Cook Urological Inc., Spencer, Indiana.
FIG. 2. Comparison of 18 gauge needle to cystocatheter trocar (A) and Stamey (B) trocar. Initial puncture is made with smaller needle which lessens potential for serious injury if improper placement occurs'.
pubic tube can be placed with the patient under local anesthesia only. In 2 patients a 14F Foley catheter was placed at the ?edside_. The tube was then changed at 2-week intervals using mcreasmgly larger Foley catheters until a large bore catheter was in place. This method avoided the need for a formal suprapubic cystotomy. In conclusion, this technique allows controlled entry into the bladder with a small gauge needle and guide wire, which lessens the potential for complications when compared to punch cystotomy with a trocar. A soft and flexible balloon style catheter can be placed, which is difficult to dislodge. REFERENCES
1. Hilton, P. and Stanton, S. L.: Suprapubic catheterisation. Brit.
Med. J., 281: 1261, 1980. 2. Flock, W. D., Litvak, A. S. and McRoberts, J. W.: Evaluation of closed suprapubic cystostomy. Urology, 11: 40, 1978. 3. Hebert, D. B. and Mitchell, G. W., Jr.: Perforation of the ileum as a complication of suprapubic catheterization. Obst. Gynec., 62: 662, 1983. 4. Moody, T. E., Howards, S.S., Schneider, J. A. and Rudolf, L. E.: Intestinal obstruction: a complication of percutaneous cystostomy. A case report. J. Urol., 118: 680, 1977. 5. Browning, D. J.: Potential hazard of suprapubic catheterization. Med. J. Aust., 2: 580, 1977. 6. Drutz, H. P. and Khosid, H. I.: Complications with Bonanno suprapubic catheters. Amer. J. Obst. Gynec., 149: 685, 1984.