Cystostomy: Anatomy, Indications, Contraindications and Technical Considerations

It is the general term for the surgical creation of an opening in the bladder.

It may be a planned component of urologic surgery or an iatrogenic onset. Often, however, the term is used more strictly to refer to suprapubic cystostomy or suprapubic catheterization.

In an environment in which an individual can not empty his bladder properly and urethral catheterization is undesirable or impossible, suprapubic cystostomy offers an effective alternative.

Cystostomy for suprapubic catheterization can be done in 2 ways:

  1. Through an open approach, in which a small infraumbilical incision is made above the symphysis pubis
  2. Through a percutaneous approach, in which the catheter is inserted directly through the abdominal wall, above the symphysis pubis, with or without ultrasound guidance or visualization through flexible cystoscopy

This article focuses on the percutaneous approach because this method can potentially be performed in outpatient, bedside or urgent care settings.

Relevant anatomy of the cystostomy

The adult bladder is located in the anterior pelvis and is surrounded by extraperitoneal fat and connective tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the retropubic space (of Retzius).

The dome of the bladder is covered by the peritoneum, and the neck of the bladder is fixed to the neighboring structures by the reflexes of the pelvic fascia and by the true ligaments of the pelvis.

The body of the bladder receives support from the external urethral sphincter muscle and the inferior perineal membrane and the internal obturator muscles laterally.

Indications

There are at least 4 situations in which suprapubic cystostomy is considered:

  1. Acute urinary retention in which a urethral catheter can not be passed (for example, due to prostatic enlargement secondary to benign prostatic hyperplasia or prostatitis, urethral stenosis or false passages, or contractures of the bladder neck secondary to previous surgery).
  2. Urethral trauma.
  3. Management of a complicated infection of the lower genitourinary tract
  4. Acute urinary retention without urethral catheterization.

For a patient who is difficult to transurethrally catheterize, several steps are suggested before performing suprapubic cystostomy.

Algorithm to handle patients difficult to catheterize

Failure to pass a urethral catheter may be the result of a false passage created by multiple attempts at urethral catheterization or urethral stricture.

After a reasonable catheterization attempt, including the use of a coudé catheter, and if a urologist is not available for flexible cystoscopy with possible catheter placement on a wire, a suprapubic cystostomy is reasonable.

Urethral trauma

In the context of urethral trauma, a functional bypass of the urethra may be required due to the possibility of urethral disruption. Urethral rupture is usually associated with pelvic fractures or saddle-type lesions and should be suspected when observing the triad of blood in the urethral meatus, inability to urinate, and palpably distended bladder.

The urethral injury must be addressed by a urologist; however, a suprapubic cystostomy can be a valuable measure for emergency bladder drainage.

Complicated lower genitourinary infection

In a complicated infection of the lower genitourinary tract with associated urinary retention (eg, acute bacterial prostatitis), drainage of the bladder with suprapubic cystostomy should be considered.

Another indication for the placement of the suprapubic catheter is Fournier’s gangrene, which often requires multiple procedures of genitourinary debridement and, potentially, skin grafts.

If a urethral catheter prevents wound care and surgical treatment of this complicated and dangerous disease, consider a suprapubic cystostomy to divert urine from these surgical sites.

Long-term urinary diversion

Suprapubic catheterization can also be considered as an option in patients requiring long-term urinary diversion. The British Association of Urologic Surgeons issued practice guidelines suggesting that physicians should consider whether a suprapubic catheter would be preferable to a urethral catheter for patients who require a long-term permanent catheter.

A suprapubic catheter may be considered in patients with neurogenic bladder secondary to spinal cord injuries, stroke, multiple sclerosis, neuropathy, or detrusor sphincter dyssynergia who can not evacuate and who are unable or unwilling to perform a clean intermittent catheterization.

Patients who undergo phallic reconstruction or fistula repair may also require longer-term urinary diversion.

In a retrospective study that included more than 10 years of follow-up data from 179 predominantly male patients with spinal cord injuries, similar rates of urinary tract infections, kidney and bladder stones, and preservation of renal function were reported in those treated with urethral catheters and those managed with suprapubic catheters.

In this study, urethral strictures, urethral fistulas and scrotal abscesses were found only in the urethral catheter group; 3 patients with urethral stenosis and 3 patients with urethro-cutaneous fistulas changed to suprapubic catheters as a result of these complications.

Specific catheter complications included erosion associated with urethral catheters and leaks around the suprapubic catheter site and the urethra.

Contraindications of a cystostomy

Percutaneous suprapubic cystostomy is absolutely contraindicated in the following circumstances:

  • When the bladder is not distended, it can not be easily felt or can not be located with ultrasound help
  • When the patient has a history of bladder cancer
Relative contraindications include the following:
  • Coagulopatía
  • Previous surgery of the lower abdomen or pelvic (due to the possibility of adhesions between the intestine and the bladder)
  • Pelvic cancer, with or without a history of irradiation (due to the possibility of adhesions)
  • Placement of orthopedic fittings for the repair of pelvic fractures; Although some reports suggest that the suprapubic tubes that lead to the infection of the hardware are a relatively rare complication, you should consult with the orthopedist before performing the suprapubic catheterization in patients with iron fittings.
  • If percutaneous placement is contraindicated and an open surgical approach for suprapubic cystostomy is necessary to provide adequate dissection through adhesions, avoid intestinal injury and achieve effective hemostasis, this should probably be done by a general surgeon or a urologist in an environment surgical.

Technical considerations

There are two key issues that should be considered when considering the placement of a suprapubic cystostomy:

The first problem is whether the patient’s bladder can be drained sufficiently well with a urethral catheter. If this is the case, urethral catheterization may be a more appropriate option because it is often easier.

It is also associated with less morbidity in the short term, especially in women and men who develop acute urinary retention and can recover the ability to cancel with direct medical treatment. (For example, alpha-blocker therapy).

On the other hand, suprapubic cystostomy may be preferable to urethral catheterization when the catheter is necessary for the long-term treatment of the bladder, as in patients with neurogenic bladder. For example, male patients with suprapubic cystostomies have a decreased incidence of traumatic hypospadias and a reduced risk of urinary tract infection, prostatitis, urethritis and epididymitis.

Male patients also retain sexual function. Female patients have a lower incidence of urinary tract infection and can prevent the development of a patulous urethra.

If the procedure can be planned in advance, referring the patient to a urologist for an informed discussion of the elective procedures may be best. In those emergent situations where the patient can not empty his bladder and a urethral catheter can not be placed, the suprapubic cystostomy is a viable option.

The second problem is to select the method that will be used to place the suprapubic cystostomy. As indicated, an open approach or a percutaneous approach to suprapubic catheterization can be taken. Most people with training in general surgery or urology find that the open procedure is simple.

Most other doctors prefer a percutaneously placed suprapubic cystostomy, which can be done by 5 different methods. Unfortunately, the percutaneous option is not always a safe possibility.

Prevention of complications

Regardless of how a suprapubic cystostomy is placed, it is always advisable to dilate the bladder during the location of the surgical site. This gives the doctor the best chance to find the bladder quickly and avoid bowel injuries.

In urgent circumstances, when the urethra can not be cannulated and the bladder should be decompressed, it is likely that the bladder is already distended with urine. This can be seen in the physical examination.

Otherwise, if the urethra can be cannulated with a Foley catheter or a flexible cystoscope, the bladder can be distended with normal saline. To prevent gram-negative bacteremia, an appropriate intravenous gram-negative antibiotic should be administered before instrumentation of the genitourinary tract.

Results

A study by Lavelle et al indicated that suprapubic catheterization improves urological quality of life in patients with neurogenic bladder.

Only 3 of 58 patients (5.2%) who responded to the Global Impression of Patient Improvement questionnaire (PGI-I) reported a negative score, with more than 80% reporting a better quality of life (average time of 48.3 hours). months between catheter placement and questionnaire).