SUPRAPUBIC

CATHETERIZATION

I G LANANG ANDI S
 Definition
Cystostomy :

the insertion of a catheter into the

bladder via the anterior abdominal
wall.
• (Mosby’s Medical Dictionary 8th edition)
Anatomy Of The Abdominal Wall

CAMPBELL – WALSH UROLOGY 10TH ED, 2012

Anatomy of the Bladder
• LOCATED EXTRAPERITONEALLY
• 3 SURFACES :
• Superior / dome
• inferolateral surfaces
• Posterior

Gray’s Anatomy, 8th 2011

 CYSTOSTOMY
Percutaneous Open
INDICATION
INDICATION
Urine
Urine retention:
retention:
Catheterization
Catheterization was
was INDICATION
INDICATION
failed
failed :: Urine
Urine retention:
retention:
urethral
urethral stricture
stricture Suspicious
Suspicious of of abnormal
abnormal
urethral
urethral rupture
rupture anatomy
anatomy of of bladder
bladder
Impacted
Impacted urethral
urethral stone
stone (operation
(operation scars,
scars, high
high
riding
riding of
of prostate)
prostate)

CONTRAINDICATION
CONTRAINDICATION
All
All patient
patient with:
with:
Scar
Scar and
and fibrotic
fibrotic CONTRAINDICATION
CONTRAINDICATION
Suspicious
Suspicious of
of bladder
bladder All
All patients
patients with:
with:
malignancy
malignancy Suspicious
Suspicious ofof bladder
bladder
Unclear
Unclear cause
cause ofof gross
gross malignancy
malignancy
haematuria
haematuria Unclear
Unclear cause
cause ofof gross
gross
haematuria
haematuria
 TYPE

• Percutaneous cystostomy
• Open cystostomy
PERCUTANEOUS
CYSTOSTOMY
Equipment 1. Trocar set
2. Hecting set
3. Blade no 11
4. Sterile Handscoon
5. Povidone iodine
10% with Gauze
6. Silk 3-0
7. 10 cc syringe
8. Lidocaine 2%
9. Sterile linen
10. Urine catheter
(check the baloon)
11. Urobag
12. Sterile water
13. Sterile gauze
14. Lubricating Gel
PERCUTANEOUS CYSTOSTOMY SET

Half
slot

Obturat
or

Trocar
 Surgical steps
• Inform Consent
• Check Folley Catheter
• Px in supine position
• Operator on the left side of the patient
• Disinfection with 10% povidone iodine, and
demarcations of surgical field with linen sterile
• Local infiltration of lidocaine 2% approximately 2 – 3
fingers above the symphysis pubis in the midline 
check anesthesia
• Make a small incision with blade no. 11 in midline
(1cm). Deepened to the fascia.
 Puncture the area with 10
cc syringe and check the exit
of urine
 feed the trocar to the
caudal (30 degree), gently
push the trocar into the
bladder with a twisting
action
 Trocar get into the bladder
marked with the loss of
resistance and Discharge of
urine through the trocar
• Remove the trocar
and obturator then
leave the half slot.
• Insert Foley
catheter through
the half slot and
inflate the balloon,
make sure that the
balloon was fixed
properly.
• Remove the half
slot
• Stitch the skin and
put sterile dressing
• Do Rectal Toucher
• Measure the Initial
Urine
• Quantity and quality
Complication
• Durante op:
– Bleeding
– False route
• Early Postop:
– Haematoma from LA
• Late Postop
– Infection of operating site
OPEN CYSTOSTOMY
Equipment
• Sterile linen + gown
• 2 x 10 ml Syringe
• Povidone Iodine 10%
• Foley Catheter
• Urobag
• Plain catgut 3-0
• Polypropylene 3-0
• PGA 3-0, 1-0
• Sterile gauze
• Tulle
Blade 11 & 20 and Langenback
Metzenbaum Minor Set,
sterile gloves

Spreader Pean Forceps Kocher Clamp Allis Clamp

Surgical Steps
• Patient in supine position with
general or regional anesthesia
• Operator on the left side of the
patient
• Desinfection with Povidon Iodine
10%
• Demarcated the operation field
• Make a small vertical incision (4–5
cm) in the midline, 2 fingers above
symphysis pubis.
(Hinman’s Atlas of Urologic Surgery,3rd ed)
• Dissect through the
subcutaneous fat and
Rectus Abdominis fascia.

(Hinman’s Atlas of Urologic Surgery,3rd ed)

 Gently split the muscle

(Hinman’s Atlas of Urologic Surgery,3rd ed)

• Reflect the peritoneum and
extraperitoneal fat upward
with gauze piece / still deppers

(Hinman’s Atlas of Urologic Surgery,3rd ed)

 • Identify bladder
• Take 2 stay suture with
plain 3-0
• Put a stab incision over
the bladder with No.11
knife, use suction if urine
comes out.

(Hinman’s Atlas of Urologic Surgery,3rd ed)

 • Widened the incision
field with retractors.
• Evaluate the bladder

(Hinman’s Atlas of Urologic Surgery,3rd ed)

• Put a Foley’s catheter
• Inflate the balloon with 10 ml distilled water
• Do the closure of the bladder in 2 layer with
plain catgut 3-0 for mucosa, and PGA 3-0 for
serosa
• Approximation the muscle with PGA 1-0
• Closure the fascia with PGA 1-0
• subcutaneous tissue with plain catgut 3-0
• Sticth the skin with polypropelene 3-0 and
put sterile dressing
• Do rectal touche
(Hinman’s Atlas of Urologic Surgery,3rd e
Complication
• Durante op:
– Bleeding
• Early Postop:
– hematuria
• Late Postop
– Surrounding organ injury
– infection

(Harrison, et al. BAUS SUPRAPUBIC CATHETER PRACTICE GUIDELINES. 2010)

 FOLLOW UP
• Routine cystostomy tube care (every 2 weeks)

(Harrison, et al. BAUS SUPRAPUBIC CATHETER PRACTICE GUIDELINES. 2010)

THANK YOU
THANK YOU
THANK YOU
VESICOLITHOTOMY
Definition

Incision of the bladder for removal of a calculus.

(Dorland's Medical Dictionary for Health Consumers.2007)

Anatomy
Indication
• Large Stone and hard stone (more than 3 cm)
• Bladder stones that can not be solved with a lithotriptor
• Multiple bladder stone
• Not obtained access through the urethra

(Hinman’s Atlas of Urologic Surgery,3rd ed)

Contraindication
• Suspicious of bladder malignancy
• Unclear cause of gross hematuria
• Bleeding disorder

(Campbell – Walsh, 10th ed, 2012)

 Preparation

Surgical cap, mask, sterile gawn, sterile hand Sterile

Sterile gauze, povidone iodine 10%
10%
gloves

Disinfection clamp, doek clamp

 Preparation

Electronic
Electronic cauter,
cauter, suction
suction machine
machine
Surgical blade no 22, 11, scalpel
handle
handle

Langenback Allis clamp Kocher Suction

Sharp spreader
 Preparation

Pean/mosquito
Pean/mosquito
clamp
clamp Pinset Scissors Metzenbaum Needle
Needle holder
holder

Stone
Stone forceps
forceps
Spreader
Spreader
 Preparation

Redon
Redon Drain
Drain

Stappler

Foley catheter +
urobag
Polyglycolic
Polyglycolic
Acid
Acid 1-0

Plain cut gut 3-0 Polyglycolic

Polyglycolic Chromic
Chromic cat
cat
Acid
Acid 3-0 gut
gut 3-0
3-0
Procedures
• Inform consent and Marking one day before operation
• Placement the imaging
• Patient in general anesthesia or spinal block.
• Operator in the left patient (right handed).
• Patient in supine position.

(Hinman’s Atlas of Urologic Surgery,3rd ed)

Procedures
• Desinfects the abdomen, penis, and both inner thigh with
Povidone Iodine 10%
• Cover it with sterile drappings.

• (Hinman’s Atlas of Urologic Surgery,3rd ed)

Procedures
• Draw the incision
design
• Make the incision 2
finger upper symphisis
pubis
• Open layer by layer

(Hinman’s Atlas of Urologic Surgery,3rd ed)

Procedures

• Incise the fascia

• widened with
the scissors

(Hinman’s Atlas of Urologic

Surgery,3rd ed)
Procedures
• Enter between the recti and
separate them bluntly.
• Hold the muscles back with
two retractors to expose the
prevesical fat.

(Hinman’s Atlas of Urologic Surgery,3rd ed)

Extraperitoneal fat and
peritoneum overlying
the bladder seen

Reflect the peritoneum

upward with still depper

Identify the bladder

(Hinman’s Atlas of Urologic Surgery,3rd ed)
• Place two 3- 0 plain
catgut stay sutures
into the bladder wall
well above the
symphysis.

• (Hinman’s Atlas of Urologic

Surgery,3rd ed)
Procedures

• Incise the
bladder
between the
sutures with
mesh no 11 .

(Hinman’s Atlas of
Urologic Surgery,3rd
ed)
Procedures
• Enlarge the incision
• Grasp the stone
with stone forceps
and remove it
(evaluate the size,
color, and number
of stone).

(Hinman’s Atlas of Urologic

Surgery,3rd ed)
• Washout the bladder cavity with
normal saline
• Evaluate the bladder wall
• (for tumor or diverticle), the ureter ends
(for stones and ureteric jet), and size of
bladder neck. Inspect the base of the
bladder for other stones.
• Evaluate the prostate through the
bladder neck (using the finger)
• Insert a 16 F urethral catheter then washout
the bladder cavity through the catheter.
• Close the bladder with a running 3-0 chromic
catgut suture applied to the muscularis
mucosal layer.
• Reinforce it with interrupted sutures of 3-0
polyglycolic acid placed through the
seromuscularis.
• Fill the bladder with 250 cc of normal
saline through urethral catheter, evaluate
if there is any leaks within the sutures.
Procedures
• Place a small suction drain
(paravesical) to exit through
the wound for a few days.
• Stitch layer by layer
• fascia of rectus abdominis
muscle with polyglycolic acid
1-0
• subcutaneous tissue with
plain catgut 3-0
• the skin with stepler
• Close the wound with tulle
and sterile gauze.

(Hinman’s Atlas of Urologic Surgery,3rd

ed)
Complications

(Campbell,10th ed)
Post Surgical Care
• Remove the catheter after day 7.
• Remove the drain if the production is minimal (<20 cc/24
hour) after catheter removal.
• Analyze the composing material of the stone.
THANK YOU