Suprapubic cystostomy

suprapubic cystostomy,
urinary diversion

1. SUPRAPUBIC CYSTOSTOMY (SPC) Dr Bashir Yunus Surgery Resident AKTH 28-Apr-15 [email protected] 1

2. OUTLINE DEFINITION INDICATIONS TYPES PRE-OPERATIVE PREPARATION PRE-INCISION EXPOSURE AND PROCEDURE CLOSURE POST-OP MGT COMPLICATIONS 28-Apr-15 [email protected] 2

3. DEFINITION A form of urinary diversion , in which a self retaining catheter is placed into the bladder via the suprapubic region for purpose of draining urine. 28-Apr-15 [email protected] 3

4. INDICATIONS Urine retention when urethral catherization fails. Ruptured urethra Urethero-cutenous fistulae Periurethral abscess Extravasation of urine Chronic retention in neurogenic bladder 28-Apr-15 [email protected] 4

5. TYPES OPEN OR PERCUTENEOUS TEMPORAL OR PERMERNENT EMERGENCY OR ELECTIVE 28-Apr-15 [email protected] 5

6. PRE-OP PREPARATION History and examination for likely cause for the need of SPC Investigation may depend on the indication; Pcv , u/ Ecr , clotting profile, Abd USS. Informed consent Pre-op shaving Pre-op antibiotics 28-Apr-15 [email protected] 6

7. PRE-INCISION ANAESTHESIA Local Spinal or GA POSITION Supine Surgeon, assistant and nurse scrub, and gowned. The skin is prepared; cleaning from the nipple line to the mid-thigh and draped exposing the suprapubic region 28-Apr-15 [email protected] 7

8. INCISION Transverse incision along the skin crease 2 finger breadth above the pubic symphisis (heals better less likely to herniate) Subumbilical median incision, 3-5cm long, 3cm from symphysis 28-Apr-15 [email protected] 8

9. EXPOSURE The incision is deepened into the subcutaneous tissue; fascia camper and scamper, securing hemostasis. Langenberg retractor placed and edges retracted to expose the rectus sheath A nick is made on the rectus sheath transversely on the midline, artery forceps are placed on the cut lips and held by surgeon and assistant, the incision is extended on both sides laterally The rectus sheath is freed from the rectus muscle by sharp dissection at the middle and blunt laterally. The muscles are separated at the midline with artery forceps and the retractor repositioned and retracted laterally. 28-Apr-15 [email protected] 9

10. The transversalis fascia, preperitoneal fat and peritoneum are carefully pushed upwards by guaze dissection until the bladder is exposed The bladder is pale, thin 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 tumour 28-Apr-15 [email protected] 10

11. The suprapubic catheter is placed through the abdominal wall by a stab incision in the upper skin flap, inserted into the bladder. The catheter is secured with a 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 28-Apr-15 [email protected] 11

12. CLOSURE The wound is closed in layers with a drain in the prevescical space Rectus is approximated with vicryi 2-0 Rectus sheath nylon 1 Skin with nylon2-0 Wound is cleaned and dressed 28-Apr-15 [email protected] 12

13. POST OP MGT Antibiotics Analgesics Monitoring urine output 28-Apr-15 [email protected] 13

14. COMPLICATIONS Haematuria Prevesical fluid collection Surrounding organ injury Catheter blockage Encrustation and retained catheter Dislogment Skin site infection UTI Stone formation Urothelial neoplasm 28-Apr-15 [email protected] 14

15. REFERENCES E A BADOE ET AL ;PRINCIPLES AND PRACTICE OF SURGERY INCLUDING PATHOLOGY IN THE TROPICS, 4 TH EDITION FARQUHARSON’S TEXTBOOK OF OPERATIVE GENERAL SURGERY, 8 TH EDITION CAMBELL UROLOGY 28-Apr-15 [email protected] 15