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Suprapubic catheter change resulting in terminal ileal perforation
Urological Science xxx (2013) 1e2
Contents lists available at ScienceDirect
Urological Science journal homepage: www.urol-sci.com
Case report
Suprapubic catheter change resulting in terminal ileal perforation Chih-Peng Chang, Jian-Ri Li*, Chen-Li Cheng, Yen-Chuan Ou, Hao-Chung Ho, Kun-Yuan Chiu Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
a r t i c l e i n f o
a b s t r a c t
Article history: Received 12 April 2012 Received in revised form 15 May 2012 Accepted 25 July 2012 Available online xxx
Suprapubic cystostomy is commonly performed in patients with neurogenic bladder or bladder outlet obstruction. The most serious complication is bowel injury, which usually occurs during catheter insertion. Bowel perforation during suprapubic catheter exchange is rare. We herein report an extremely rare case of terminal ileal perforation resulting from a change of suprapubic catheter. After insertion of the suprapubic catheter, a feculent material was noted in the terminal ileum. A cystography revealed that the contrast medium passed directly into the terminal ileum and colon. A computed tomographic scan confirmed the presence of a balloon tip in the terminal ileum. Terminal ileum perforation was diagnosed. Emergent laparotomy and loop ileostomy were performed. The patient’s recovery was uneventful. Copyright Ó 2013, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: suprapubic cystostomy suprapubic catheter change terminal ileal perforation
1. Introduction Suprapubic cystostomy is commonly used for long-term bladder drainage in patients with bladder dysfunction or voiding problems. It is considered a safe procedure due to a low incidence of complications. Bowel injury is the most serious sequela and usually occurs during initial placement. We herein present a rare case of misplacement of suprapubic catheter into the terminal ileum during suprapubic catheter exchange.
terminal ileum and colon without fistula formation (Fig. 1). A computed tomography scan subsequently demonstrated the presence of the balloon tip in the cecum (Fig. 2). An exploratory laparotomy confirmed the site of perforation. Adhesion of the terminal ileum to the anterior abdominal wall below the puncture site and penetration of the terminal ileum up to the area of cecum by the Foley catheter were observed (Fig. 3). Subsequently, loop ileostomy was performed instead of primary closure because of the patient’s poor performance. No surgery-related complications were noted during hospitalization.
2. Case report A 77-year-old man with a history of hepatocellular carcinoma and neurogenic bladder underwent a monthly change of suprapubic cystostomy catheter three times after the initial placement. He was brought to the emergency department for urinary catheter blockage. After the catheter exchange, drainage of a feculent material was immediately observed. He developed worsening abdominal pain after 4 hours. There was no urine drainage from the suprapubic catheter and urine leakage from urethra orifice was noted. He developed septic shock within 24 hours. Enterovesical fistula was impressed initially. A cystogram through a suprapubic catheter showed contrast medium passed immediately into the
* Corresponding author. Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Number 160, Section 3, Chung-Kang Road, Taichung, Taiwan, ROC. E-mail address: fisherfi[email protected] (J.-R. Li).
3. Discussion Suprapubic cystostomy is a common urologic procedure used for the management of neurologic bladder and bladder outlet obstruction. It is considered a safe procedure with a low incidence of complication. Typically, complications are minor, such as catheter-related infection, bleeding, and obstruction. Bowel injury, including small bowel obstruction, small bowel perforation, and colon perforation, is the most serious complication. Sheriff et al and Ahluwalia et al reported a 2.7% and 2.4% incidence of bowel injury, respectively.1,2 Bowel perforation almost always occurs at the time of tube insertion and very rarely happens during catheter exchange. A review of the literature reveals only three cases of bowel injury at catheter exchange, including sigmoid, cecum, and terminal ileum injury.3e5 The aforementioned cases had undergone catheter exchange periodically prior to the iatrogenic bowel injury. In this case, ileal
1879-5226/$ e see front matter Copyright Ó 2013, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.urols.2012.07.012
Please cite this article in press as: Chang C-P, et al., Suprapubic catheter change resulting in terminal ileal perforation, Urological Science (2013), http://dx.doi.org/10.1016/j.urols.2012.07.012
2
C.-P. Chang et al. / Urological Science xxx (2013) 1e2
Fig. 3. Adhesion of the small bowel to the anterior abdominal wall (arrow). The suprapubic catheter penetrated the percutaneous tract into the terminal ileum.
Fig. 1. A cystographic image showing the contrast agent passing through the suprapubic catheter into the terminal ileum and spreading from the ascending colon to the descending colon.
perforation was noted during the fourth exchange. Iatrogenic bowel injury is a recognized complication of percutaneous suprapubic cystostomy. Early signs and symptoms include poor drainage of suprapubic catheter and abdominal discomfort. A cystogram and an abdominal computed tomography can confirm the misplacement of a catheter. An exploratory laparotomy or laparoscopic resection of representative segments of bowel is the recommended treatment.6 In our case, we performed loop ileostomy instead of immediate primary repair due to patient’s poor performance and a high risk of anastomosis leakage. To reduce the risk of bowel injury, adequate bladder distension and Trendelenburg position are essential. The use of ultrasonography to visualize the bowel loop alongside the puncture site can
also facilitate adequate placement. Extreme caution is necessary in patients who are obese, have undergone previous pelvic surgery, or have a short distance between pubic symphysis and umbilicus.7 In previously described cases of bowel injury during catheter exchange, no significant predisposing factor was noted.3e5 In this case, the suprapubic catheter was inserted by a resident without the use of an instrument to assist with placement. There was no resistance during indwelling of the catheter. As shown in the case presented herein, even in patients who receive a change of suprapubic catheter periodically, a serious complication can still occur, and thus our case serves as an important reminder that the placement of the suprapubic catheter must be performed with extreme care. Early detection of bowel injury is the best way to prevent serious complications. It is therefore imperative that bowel perforation be ruled out in a patient with abdominal pain and poor drainage of suprapubic catheter after indwelling of a suprapubic catheter. Conflicts of interest The authors declare that they have no financial or non-financial conflicts of interest related to the subject matter or materials discussed in the manuscript. References
Fig. 2. A computed tomographic image showing the balloon tip located in the cecum (arrow).
1. Ahluwalia RS, Johal N, Kouriefs C, Kooiman G, Montgomery BS, Plail RO. The surgical risk of suprapubic catheter insertion and long-term sequelae. Ann R Coll Surg Engl 2006;88:210e3. 2. Sheriff MK, Foley S, McFarlane J, Nauth-Misir R, Craggs M, Shah PJ. Longterm suprapubic catheterisation: clinical outcome and satisfaction survey. Spinal Cord 1998;36:171e6. 3. Wu CC, Su CT, Lin AC. Terminal ileum perforation from a misplaced percutaneous suprapubic cystostomy. Eur J Emerg Med 2007;14:92e3. 4. Mongiu AK, Helfand BT, Kielb SJ. Small bowel perforation during suprapubic tube exchange. Can J Urol 2009;16:4519e21. 5. Witham MD, Martindale AD. Occult transfixation of the sigmoid colon by suprapubic catheter. Age Ageing 2002;31:407e8. 6. Liau SS, Shabeer UA. Laparoscopic management of cecal injury from a misplaced percutaneous suprapubic cystostomy. Surg Laparosc Endosc Percutan Tech 2005;15:378e9. 7. Cho KH, Doo SW, Yang WJ, Song YS, Lee KH. Suprapubic cystostomy: risk analysis of possible bowel interposition through the percutaneous tract by computed tomography. Korean J Urol 2010;51:709e12.
Please cite this article in press as: Chang C-P, et al., Suprapubic catheter change resulting in terminal ileal perforation, Urological Science (2013), http://dx.doi.org/10.1016/j.urols.2012.07.012
Contents lists available at ScienceDirect
Urological Science journal homepage: www.urol-sci.com
Case report
Suprapubic catheter change resulting in terminal ileal perforation Chih-Peng Chang, Jian-Ri Li*, Chen-Li Cheng, Yen-Chuan Ou, Hao-Chung Ho, Kun-Yuan Chiu Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
a r t i c l e i n f o
a b s t r a c t
Article history: Received 12 April 2012 Received in revised form 15 May 2012 Accepted 25 July 2012 Available online xxx
Suprapubic cystostomy is commonly performed in patients with neurogenic bladder or bladder outlet obstruction. The most serious complication is bowel injury, which usually occurs during catheter insertion. Bowel perforation during suprapubic catheter exchange is rare. We herein report an extremely rare case of terminal ileal perforation resulting from a change of suprapubic catheter. After insertion of the suprapubic catheter, a feculent material was noted in the terminal ileum. A cystography revealed that the contrast medium passed directly into the terminal ileum and colon. A computed tomographic scan confirmed the presence of a balloon tip in the terminal ileum. Terminal ileum perforation was diagnosed. Emergent laparotomy and loop ileostomy were performed. The patient’s recovery was uneventful. Copyright Ó 2013, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: suprapubic cystostomy suprapubic catheter change terminal ileal perforation
1. Introduction Suprapubic cystostomy is commonly used for long-term bladder drainage in patients with bladder dysfunction or voiding problems. It is considered a safe procedure due to a low incidence of complications. Bowel injury is the most serious sequela and usually occurs during initial placement. We herein present a rare case of misplacement of suprapubic catheter into the terminal ileum during suprapubic catheter exchange.
terminal ileum and colon without fistula formation (Fig. 1). A computed tomography scan subsequently demonstrated the presence of the balloon tip in the cecum (Fig. 2). An exploratory laparotomy confirmed the site of perforation. Adhesion of the terminal ileum to the anterior abdominal wall below the puncture site and penetration of the terminal ileum up to the area of cecum by the Foley catheter were observed (Fig. 3). Subsequently, loop ileostomy was performed instead of primary closure because of the patient’s poor performance. No surgery-related complications were noted during hospitalization.
2. Case report A 77-year-old man with a history of hepatocellular carcinoma and neurogenic bladder underwent a monthly change of suprapubic cystostomy catheter three times after the initial placement. He was brought to the emergency department for urinary catheter blockage. After the catheter exchange, drainage of a feculent material was immediately observed. He developed worsening abdominal pain after 4 hours. There was no urine drainage from the suprapubic catheter and urine leakage from urethra orifice was noted. He developed septic shock within 24 hours. Enterovesical fistula was impressed initially. A cystogram through a suprapubic catheter showed contrast medium passed immediately into the
* Corresponding author. Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Number 160, Section 3, Chung-Kang Road, Taichung, Taiwan, ROC. E-mail address: fisherfi[email protected] (J.-R. Li).
3. Discussion Suprapubic cystostomy is a common urologic procedure used for the management of neurologic bladder and bladder outlet obstruction. It is considered a safe procedure with a low incidence of complication. Typically, complications are minor, such as catheter-related infection, bleeding, and obstruction. Bowel injury, including small bowel obstruction, small bowel perforation, and colon perforation, is the most serious complication. Sheriff et al and Ahluwalia et al reported a 2.7% and 2.4% incidence of bowel injury, respectively.1,2 Bowel perforation almost always occurs at the time of tube insertion and very rarely happens during catheter exchange. A review of the literature reveals only three cases of bowel injury at catheter exchange, including sigmoid, cecum, and terminal ileum injury.3e5 The aforementioned cases had undergone catheter exchange periodically prior to the iatrogenic bowel injury. In this case, ileal
1879-5226/$ e see front matter Copyright Ó 2013, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.urols.2012.07.012
Please cite this article in press as: Chang C-P, et al., Suprapubic catheter change resulting in terminal ileal perforation, Urological Science (2013), http://dx.doi.org/10.1016/j.urols.2012.07.012
2
C.-P. Chang et al. / Urological Science xxx (2013) 1e2
Fig. 3. Adhesion of the small bowel to the anterior abdominal wall (arrow). The suprapubic catheter penetrated the percutaneous tract into the terminal ileum.
Fig. 1. A cystographic image showing the contrast agent passing through the suprapubic catheter into the terminal ileum and spreading from the ascending colon to the descending colon.
perforation was noted during the fourth exchange. Iatrogenic bowel injury is a recognized complication of percutaneous suprapubic cystostomy. Early signs and symptoms include poor drainage of suprapubic catheter and abdominal discomfort. A cystogram and an abdominal computed tomography can confirm the misplacement of a catheter. An exploratory laparotomy or laparoscopic resection of representative segments of bowel is the recommended treatment.6 In our case, we performed loop ileostomy instead of immediate primary repair due to patient’s poor performance and a high risk of anastomosis leakage. To reduce the risk of bowel injury, adequate bladder distension and Trendelenburg position are essential. The use of ultrasonography to visualize the bowel loop alongside the puncture site can
also facilitate adequate placement. Extreme caution is necessary in patients who are obese, have undergone previous pelvic surgery, or have a short distance between pubic symphysis and umbilicus.7 In previously described cases of bowel injury during catheter exchange, no significant predisposing factor was noted.3e5 In this case, the suprapubic catheter was inserted by a resident without the use of an instrument to assist with placement. There was no resistance during indwelling of the catheter. As shown in the case presented herein, even in patients who receive a change of suprapubic catheter periodically, a serious complication can still occur, and thus our case serves as an important reminder that the placement of the suprapubic catheter must be performed with extreme care. Early detection of bowel injury is the best way to prevent serious complications. It is therefore imperative that bowel perforation be ruled out in a patient with abdominal pain and poor drainage of suprapubic catheter after indwelling of a suprapubic catheter. Conflicts of interest The authors declare that they have no financial or non-financial conflicts of interest related to the subject matter or materials discussed in the manuscript. References
Fig. 2. A computed tomographic image showing the balloon tip located in the cecum (arrow).
1. Ahluwalia RS, Johal N, Kouriefs C, Kooiman G, Montgomery BS, Plail RO. The surgical risk of suprapubic catheter insertion and long-term sequelae. Ann R Coll Surg Engl 2006;88:210e3. 2. Sheriff MK, Foley S, McFarlane J, Nauth-Misir R, Craggs M, Shah PJ. Longterm suprapubic catheterisation: clinical outcome and satisfaction survey. Spinal Cord 1998;36:171e6. 3. Wu CC, Su CT, Lin AC. Terminal ileum perforation from a misplaced percutaneous suprapubic cystostomy. Eur J Emerg Med 2007;14:92e3. 4. Mongiu AK, Helfand BT, Kielb SJ. Small bowel perforation during suprapubic tube exchange. Can J Urol 2009;16:4519e21. 5. Witham MD, Martindale AD. Occult transfixation of the sigmoid colon by suprapubic catheter. Age Ageing 2002;31:407e8. 6. Liau SS, Shabeer UA. Laparoscopic management of cecal injury from a misplaced percutaneous suprapubic cystostomy. Surg Laparosc Endosc Percutan Tech 2005;15:378e9. 7. Cho KH, Doo SW, Yang WJ, Song YS, Lee KH. Suprapubic cystostomy: risk analysis of possible bowel interposition through the percutaneous tract by computed tomography. Korean J Urol 2010;51:709e12.
Please cite this article in press as: Chang C-P, et al., Suprapubic catheter change resulting in terminal ileal perforation, Urological Science (2013), http://dx.doi.org/10.1016/j.urols.2012.07.012