Bimbingan Sistostomi Terbuka Bedah—-Umum

Sistostomi

1. Suprapubic Cystostomy Farisa Bela Dina Resource Person: dr. Ponco Birowo, SpU(K), PhD Urology Tutorial - Basic Surgery Program Department of Surgery FKUI - RSCM

2. Background Definition: a procedure of urinary diversion , which placed a retaining catheter into the bladder via suprapubic region to drain the urine Approaches: Open approach -- small infraumbilical insicion above the pubic symphisis Percutaneous approach

3. Relevant Anatomy

4. Indications Acute urinary retention in which a urethral catheter cannot be passed Urethral trauma Periurethral abscess Extravasation of urine Uretherocutaneous fistulae Complicated lower urinary tract infection Requirement of long-term urinary diversion -- e.g. chronic retention in neurogenic bladder

5. Preoperative Preparation Informed consent Shaving, AB administration Trendelenburg position Anesthesia and sedation Skin prep and sterile draping

6. Technique Palpate the distended bladder -- 2 fingerbreadth above the pubic symphisis in the midline avoiding natural skin creases; mark with a skin marker pen With a 22-gauge 7.75-cm spinal needle attached to a 10 mL syringe filled with 5 mL of 1% Lidocaine and 5mL of 0.25% Bupivacaine, infiltrate the skin, subcutaneous tissue, and rectus abdominis muscle fascia; aiming the needle at 10 o -20 o angle toward the pelvis Confirm location -- aspirate the urine (A)

7. Cystostomy with Peel-Away Sheath Suprapubic Catheter Set Remove the syringe, advance a guide wire through the needle into the bladder; carefully remove the needle (B) Make a stab incision through the skin and subcutaneous tissue posterior to the wire using a No. 11 blade; pass the dilator and peel-away sheath over the wire into the bladder (C) Remove the fascial dilator and the guide wire; leaving only the peel-away sheath (D)

8. Cystostomy with Peel-Away Sheath Suprapubic Catheter Set Insert a Foley catheter of appropriate size through the indwelling intravesical sheath into the bladder; aspirate urine to confirm proper placement (E) Inflate the balloon with sterile water (F) Remove the sheath from the bladder, anterior abdominal wall, and cutaneous entry site (G) Secure the catheter to the skin using a 3-0 nylon suture (H)

9. Open Approach A transverse incision along natural skin crease 2 fingerbreadth above the pubic symphisis is made, deepened through the subcutaneous tissue, camper and scamper fascias; bleeding is controlled Rectus sheath is exposed using Langenback retractor and freed from the rectus muscles by sharp and blunt dissection The muscles are separated at the midline using artery forceps and retracted laterally

10. Open Approach The transversalis fascia, preperitoneal fat, and peritoneum are pushed upward using gauze dissection carefully until the bladder is exposed The bladder wall is fixated using two stay sutures (Silk 1-0) A transverse incision is made 2 cm distal to the fundus between the stay sutures The bladder is then suctioned empty and explored for bladder stones, diverticles, and tumors

11. Open Approach The suprapubic catheter is placed through the abdominal wall by a stab incision in the upper skin flap into the bladder The catheter is secured with a purse string suture (Vicryl 2-0) The balloon is inflated , the catheter is fixated to the skin using Nylon 2-0 A drain is placed in the prevesical space The wound is sutured layer by layer and dressed

12. Open Approach

13. Follow Up Tract formation -- 4-6 weeks Long term indwelling catheters are associated with chronic inflammation of the urothelium and a small increased risk of bladder malignancy Annual screening cystoscopies should be considered

14. Complications Hematuria Intraperitoneal extravasation Injury of the surrounding organs Catheter obstruction Dislodgement Skin infection on the catheter insertion site UTI Stone formation Urothelial neoplasms

15. References Wein AJ, ed. Campbell-Walsh Urology. 10th ed. Philadelphia: Elsevier; 2011. Roy H. Operations on urology. In: Short textbook of surgery with focus on clinical skills. London: Jaypee Brothers Medical Publishers; 2011. p. 605. Parker, S. Urology. In: Henderson J, Oliviera D, Parker S, editors. General surgery and urology. Banbury: Scion Publishing; 2015. p. 168-70. Cohen SA. Suprapubic cystostomy technique. Available on https://emedicine.medscape.com/article/1893882-overview. Accessed on October 22 nd 2020. Tapper AD. Suprapubic aspiration. Available on https://emedicine.medscape.com/article/82964-overview#a1. Accessed on October 22 nd 2020. Khan AA, Mathur S, Feneley R, Timoney AG. Developing a strategy to reduce the high morbidity of patients with long-term urinary catheters: the BioMed catheter research clinic. BJU Int. 2007 Dec. 100(6):1298-301.

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