How to Perform Percutaneous Suprapubic Cystotomy

Two main types of percutaneous suprapubic catheters are the Bonanno percutaneous suprapubic catheter set (Becton-Dickinson and Co., Franklin Lakes, NJ) and Stamey percutaneous suprapubic catheter set in 10F, 12F, or 14F (Cook Urological, Spencer, IA).

• Indications:
  • Urethral stricture
  • False passage
  • Inability to catheterize
  • Acute prostatitis
  • Traumatic urethral disruption
  • Periurethral abscess
• Contraindications:
  • Prior midline infraumbilical incision
  • Nondistended bladder
  • Coagulopathy
  • Pregnancy
  • Carcinoma of the bladder
  • Pelvic irradiation
• Anesthesia:
  1% lidocaine
• Equipment:
  • Bonanno percutaneous suprapubic catheter set or Stamey percutaneous suprapubic catheter set in 10F, 12F, or 14F
  • Urinary drainage bag
  • Sterile prep solution
  • Sterile gloves and towels
  • 20-gauge spinal needle
  • 10-ml syringe (two)
  • 1% lidocaine
  • 22- to 25-gauge needles
  • 3-0 nylon suture
  • Needle driver
  • Suture scissors
  • Scalpel
• Positioning:
  Supine
  
  
• Technique:
  • Administer appropriate antibiotics, especially if urinary tract infection is suspected.
  • Percuss the suprapubic area to confirm an adequately distended bladder.
  • Shave, prep, and drape the suprapubic area.
  • Assemble the catheter.
  For the Bonanno catheter: Place the disposable catheter sleeve adjacent to the suture disc. Insert the 18-gauge puncture needle into the catheter so that the needle tip is always directed along the inside of the curve. To prevent the needle tip from damaging the inside of the catheter during assembly, advance the needle and the catheter sleeve simultaneously (the catheter sleeve straightens the J of the distal catheter), always maintaining the needle tip within the center of the catheter sleeve. Once the bevel of the needle extends beyond the end of the catheter, remove the disposable catheter sleeve and rotate the pink needle hub clockwise to lock the needle to the catheter hub.

For the Stamey catheter: Guide the needle obturator into the catheter tip to stretch and straighten the self-retaining mechanism of the Malecot catheter. Secure its position with the Luer lock to close the Malecot wings.

• If catheter damage occurs during assembly, discard the catheter.
• Anesthetize the skin with 1% lidocaine at a point 4 cm above the symphysis pubis in the midline. If the patient has a previous midline incision scar, anesthetize 4 cm above the symphysis pubis and 2 cm lateral to the incision. Direct the angle of the needle inferomedially toward the symphysis. Real-time ultrasonography can be helpful.
• Insert the spinal needle into the anesthetized skin 4 cm above the pubic symphysis in the midline (also 2 cm lateral to the midline if an old midline incision scar is present). Direct the needle toward the symphysis, using a 60° angle to the skin. After the skin is punctured, two additional points of resistance (rectus fascia and bladder wall) are encountered as the needle is advanced. Stop needle advancement after penetrating through the second point of resistance.
• Remove the obturator of the spinal needle and attach a 10-ml syringe.
• If urine is not aspirated, the obturator of the spinal needle can be safely replaced and the needle can be advanced up to 1 cm at a time until urine is aspirated.
• If urine is aspirated, leave the needle in place as a guide.
  
  
• If the catheter is larger than 14F, consider making a small stab wound on the puncture site with a scalpel to aid catheter insertion. Next, take the previously assembled suprapubic catheter and puncture the skin adjacent to the spinal needle. Advance the suprapubic catheter in a similar manner as described above (step g), following the tract of the spinal needle. The catheter has a reference mark on the needle obturator indicating the distance at which the catheter should have penetrated the bladder in most patients.
• Remove the black vent plug (for Bonanno catheter), attach a 10-ml syringe to the catheter hub, and aspirate.
• Caution: Once the needle has been withdrawn from a suprapubic catheter, do not reinsert it! Remove the entire device from the patient and reassemble as in step d.
• Once urine is obtained, advance the catheter an additional 1–2 cm.
• Disengage the suprapubic catheter and the needle obturator, and advance the catheter.
  • For the Bonanno catheter: Stabilize the catheter and rotate the pink hub of the needle obturator counterclockwise. Stabilize the needle while advancing the catheter over it until the suture disc lies flush with the skin.
  • For the Stamey catheter: Stabilize the catheter and rotate the white hub of the needle obturator counterclockwise. This maneuver opens the Malecot wings.
• Aspirate again to confirm proper catheter placement. Insert the connecting tube between the catheter and the urinary drainage bag.
• For the Stamey catheter, slowly withdraw the catheter until the Malecot wings meet the resistance of the bladder wall. Advance the catheter approximately 2 cm back into the bladder to allow for movement.
• Secure the catheter to the skin with 3-0 nylon suture. Tape the catheter to the abdominal wall to avoid kinking the tubing.
• Complications and Management:
  • Bowel injury
    • Adequate bladder distention and ultrasonographic guidance are helpful in preventing injury to loops of small bowel.
    • If bowel is entered, one may exchange the needle and continue with the procedure. Peritonitis is rare.
  • Hematuria/clots
    • Transient hematuria is common, but usually clears quickly.
    • If obstruction of the catheter from clots is suspected, gently irrigate the suprapubic catheter with normal saline. These percutaneous cystostomy catheters are of small caliber (14-gauge lumen, Bonanno; 10F–14F, Stamey) and are often insufficient for treating gross hematuria with clot obstruction.
    • Leakage around the insertion site may indicate catheter damage, obstruction, or bladder spasm.
    • Urology consult.