Supra pubic cystostomy

Healthcare

1. Supra – Pubic cystostomy Presented by: KPEHE JIG MAIME – INTERN

2. Outline Definition Indication Contra- indications Anatomy Types Pre – Operative Preparation Pre – Incision Exposure and Procedure Closure Post – Op Management Complications

3. Definition   Is a form urinary diversion A self retaining catheter is placed into the bladder via the suprapubic region for purpose of draining urine.

4. Indications Urine retention when urethral catherization fails Ruptured urethra Urethero – Cutaneous Fistula Periurethral abscess Extravasation of urine Chronic retention in neurogenic bladder

5. Contra- indications (Absolute) Bladder Not distended Not Palpable Cannot be localized by Ultrasound Patient has a history of bladder cancer

6. Contra- indications (Relative) Coagulopathy Previous lower abdominal or pelvic surgery Pelvic Cancer

7. Anatomy

8. Types Open or Percutaneous Temporal or Permanent Emergency or Elective

9. Pre – Op Preparation History and examination Investigations based on indication ; - U/A, Clotting profile, Abd Us Informed Consent Pre – Op shaving Pre – Op Antibiotics (Ciprofloxacin Preferably)

10.   Pre – Incision Anesthesia Local Spinal GA   Position - Supine Surgeons, Assistant or nurse scrub and gowned The skin is prep (from the nipple line to the mid – thigh) and draped exposing the supra – pubic region.

11. Incision The transverse incision along the skin crease 2 finger breath above the pubic symphysis (heals better less likely to herniate) Sub umbilical median incision, 3 – 5 cm long , 3 cm from the symphysis

12. Exposure The incision is traverse the subcutaneous tissue; fascia Achieve hemostasis by ligation and pressure Open the rectus sheath, starting in the upper part of the wound. Continue dissection with scissors to expose the gap between the muscles The muscles are separated at the midline with artery forceps and the retractor repositioned and retracted laterally

13. Exposure The transversalis fascia, preperitoneal fat and peritoneum are carefully pushed upwards by gauge dissection until the bladder is exposed The bladder is pale, thing wall vessels courses over the surface and can be aspirated with needle and syringe The wall of the bladder is fixed with two stay sutures (Silk 1-0) Using electrocautery or knife, a transverse incision is made about 2cm distal to the fundus between the stay sutures The bladder is then emptied by suction The interior explored with the finger to exclude calculi, diverticuli and tumor

14. Exposure The suprapubic catheter is placed through the abdominal wall by stab incision in the upper skin flap, inserted into the bladder The catheter is secured with purse string ( Vicryl 2-0) The balloon is then inflated The catheter then anchored to the skin with nylon – 2-0, before wound closure and continuous drainage established.

15. Closure The wound is closed in layers with a drain in the prevesical space Rectus is approximated with vicryl 2-0 Rectus sheath nylon – 1 Skin with nylon 2-0 Wound is cleaned and dressed

16. Post – Op Management Antibiotics Analgesics Monitoring urine output

17. Complications Hematuria Surrounding organ injury Catheter blockage Dislodgment Skin site infection UTI Stone formation

18. References WHO Surgical Manual at District Hospital Norman S. Williams et al, Bailey & Love Short Practice of Surgery , 25 th Edition Principles & Practices of Surgery in the Tropics “ Archampong 2010 Edition.