suprapubic cystostomy, urinary diversion

1. SUPRAPUBIC CYSTOSTOMY
(SPC)
Dr Bashir Yunus
Surgery Resident
AKTH
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2. OUTLINE
• DEFINITION
• INDICATIONS
• TYPES
• PRE-OPERATIVE PREPARATION
• PRE-INCISION
• EXPOSURE AND PROCEDURE
• CLOSURE
• POST-OP MGT
• COMPLICATIONS
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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.
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4. INDICATIONS
• Urine retention when urethral catherization fails.
• Ruptured urethra
• Urethero-cutenous fistulae
• Periurethral abscess
• Extravasation of urine
• Chronic retention in neurogenic bladder
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5. TYPES
• OPEN OR PERCUTENEOUS
• TEMPORAL OR PERMERNENT
• EMERGENCY OR ELECTIVE
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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
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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
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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
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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.
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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
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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
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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
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13. POST OP MGT
• Antibiotics
• Analgesics
• Monitoring urine output
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14. COMPLICATIONS
• Haematuria
• Prevesical fluid collection
• Surrounding organ injury
• Catheter blockage
• Encrustation and retained catheter
• Dislogment
• Skin site infection
• UTI
• Stone formation
• Urothelial neoplasm
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15. REFERENCES
• E A BADOE ET AL ;PRINCIPLES AND PRACTICE OF SURGERY INCLUDING
PATHOLOGY IN THE TROPICS, 4TH EDITION
• FARQUHARSON’S TEXTBOOK OF OPERATIVE GENERAL SURGERY, 8TH
EDITION
• CAMBELL UROLOGY
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