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The daVinci System

Delta Medix Patient General Information

Suprapubic Cystotomy Tube with or without Cystoscopy

Definition

Suprapubic = above the pubic bone (in the area of the lower abdomen)

Cystotomy = making a hole in the bladder

Cystoscopy = using a small telescope to look into the urethra and bladder Urethra = tube through which you urinate.

A suprapubic tube (SPT) is a catheter that is inserted into the bladder through a hole in the lower abdomen. This procedure may be done in the office using just a local anesthetic(numbing medicine in the area) or may be done in the hospital under heavy sedation or even general anesthesia. The variation will be due to the type of tube placed as well as on the doctor's and patient's preference and overall health. While it is possible to live with a tube in the urethra, in the long run, it is usually more comfortable (especially in the male) and has fewer complications to have an SPT.
There are several reasons that an SPT may be placed: These are all elective reasons (planned procedures in patients that have any of the problems listed below) as opposed to the common urgent reason in a patient who cannot urinate and in whom a urethral catheter could not be or should not be placed.

The first reason is in a patient whose bladder no longer functions and therefore no longer empties itself. Although there may be other reasons, this is usually seen in long-standing, poorly-controlled diabetes, patients whose bladder was severely obstructed and untreated for a prolonged period, and in patients with lumbosacral (bottom portion of the spine) spinal cord or pelvic nerve injuries.

The second reason is in a patient whose obstruction is either too complex or difficult to treat, or in a patient whose comorbidities (other medical problems) prohibit adequate treatment of their obstruction. Common examples of bladder obstruction are due to the prostate, a urethral stricture (scar tissue), and scarring from previous surgery in the area.

A third reason is in patients whose urinary incontinence (the involuntary loss of urine) has not responded to other forms of medical or surgical treatment. In most women, and less commonly in a man, placement of an SPT for this reason would have to be combined with bladder neck closure (sewing the connection of the bladder to the urethra closed so that urine no longer drains into the urethra).

A fourth reason is for temporary drainage as a part of certain prostate and incontinence surgeries. This is discussed in detail with literature covering those specific surgeries.

An SPT must be changed periodically (intervals vary depending on the particular circumstances) to prevent infection and blockage of the tube. Changing an SPT is an office procedure, requires no anesthesia, and usually takes just a few minutes.

An SPT can be attached to a small drainage bag (one that is strapped to a patient's leg and concealed under the clothing), a larger bag (while patients that are in bed or confined to abed), or not to any bag. In this instance, a patient can simply remove a plug or turn a valve and drain the bladder periodically into a container, the toilet, etc. A patient can shower, bathe or swim with an SPT.

A formal open suprapubic cystotomy is done in the hospital, usually with general anesthesia or a spinal. It requires an incision on the abdomen. In this procedure, a full-size tube is usually placed immediately. It usually remains for the full 6-8 weeks until it requires a change. A punch suprapubic cystotomy tube is more often done in the office (or in the patient's room in the hospital) with just local anesthetic alone or with local and minor sedation. This tube is small and is usually increased in size with each change until the desired size is achieved. It can be done with or without cystoscopy (see definition above) depending on the surgeon's preference.

Preparation

There is no particular preparation if your procedure is being done with just local anesthetic injection in the office. It is probably best to not have eaten within a few hours of the procedure. If your procedure is being done in the hospital with anesthesia, you will be asked not to eat or drink anything after midnight on the evening prior. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. In either instance (office or hospital) the procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood ("blood thinners, aspirin, anti-inflammatory medicines, etc."). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

Formal Open Cystotomy: Once you are asleep, a catheter will be placed through the urethra and into the bladder. The bladder will be filled with sterile water so that it is full and distended. This makes it easy to find once the small incision is made in the lower abdomen. The area for the tube will be prepped with a sterilizing solution. Next, an incision will be made on the suprapubic region that will then be extended deeper to the front wall of the bladder. A small incision will then be made in the distended bladder and the large catheter will be placed into the bladder. The catheter will be held in place by either an inflated balloon or by small wing-like extensions on the tip of the catheter. A self-dissolving suture may then be placed into the bladder wall to tighten the tissue around the catheter so that there is no leakage during healing. The skin incision is then sutured closed. A small suture might also be placed in the skin and tied around the tube to secure it further during the short healing period. A small dressing may be placed around the tube.

Punch Cystotomy: If you are to receive minor sedation it will be given to you as a pill(perhaps 15-30 minutes before the procedure) or just prior as an intravenous injection. The area for the tube will be prepped with a sterilizing solution. The location for the tube will be identified and this area will be injected with a local anesthetic agent.

There are two choices at this point. A catheter can be placed in the urethra and the bladder distended with water (like in the open procedure). Or, the urologist may do cystoscopy so that he/she can visualize the inside of the bladder while distending it with water flowing through the scope. In this regard, the urologist can see the SPT as it enters through the bladder wall. Either method is acceptable and depends on the surgeon's preference. Next, the tube is gently pushed through the abdominal wall and down in through the front wall of the bladder. The inner stylet (needle guide) is then removed so that just a soft tube is left. This type of tube has a string device that curls the end of the tube and locks it into the bladder. Often, one suture is placed on the abdominal skin to further secure the tube during the short healing period. A small dressing will be placed around the tube.

Post Procedure

If done in the hospital, you will be in the recovery room for a short time before being sent home. Sometimes following an open cystotomy, it is necessary to spend one night in the hospital There is very rarely any significant discomfort, even with the open procedure. Some patients will have a sense of urgency (the feeling of a need to urinate) due to the minor trauma to the wall of the bladder. This usually dissipates within a couple of days. As mentioned, there may be a small dressing around the area where the tube enters through the skin. This can typically be removed in a few days or so.

The urine can be clear or a little blood stained for a few days. If the tube perforates a small blood vessel in the wall of the bladder as it passes through, the vessel will bleed into the inside of the bladder. This bleeding is almost always minor and usually stops on its own.

The tube will be attached to a bag. Most patients will have had a urethral catheter prior to this SPT, and so they are quite familiar with the emptying of the bag. Otherwise, you will be given specific instructions on how to empty and change the bag. It is quite easy. If you and your doctor plan to have no bag (i.e. work your SPT by turning the valve or pulling out the plug in the end), you will be able to do so after a week or so. It is best to allow the bladder to heal for a short time before allowing it to fill. You should drink copious fluids (preferably water) for the first couple of days after the tube is placed. This will help keep the urine clear. We may also give you a prescription for an antibiotic tablet for a few days or longer depending on the particular circumstances. If you were on medications that are blood thinners, you can resume them the following day unless there is significant blood in the urine.

If you are working, you can usually return to work the following day provided you do not do any heavy lifting or straining. If your occupation entails strenuous activity, you should refrain from this for a few days.

Expectations of Outcome

Patients are usually very happy with an SPT compared with a urethral catheter or compared to being constantly wet (severe incontinence). They are usually comfortable, easy to use, and easy to keep clean. A very motivated patient with good hand coordination can eventually learn to change their own catheter every 6-8 weeks.

It should be noted that the initial small tube that is placed in a "punch" cystotomy is a bit more rigid and therefore not as comfortable as the tube with which it is subsequently replaced. In that regard, it may cause more urinary frequency and/or urgency.

*Although there may be a suture in the abdominal skin (tied around the catheter) with placement of the initial tube, sutures are not necessary after the initial tube is changed.

In instances in which an SPT was placed to help a patient with severe incontinence, the degree of leakage should diminish instantly and dramatically in most instances. Unless the bladder neck is closed (a different, more complex operation), it may take many weeks until the patient is completely dry. In cases of severe incontinence, the leakage from below, while diminished, may never cease completely. Delayed bladder neck closure (if the patient is a candidate for the procedure) may be necessary.

Possible Complications of the Procedure

ALL procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Urinary Tract Infection or Urosepsis (Bloodstream Infection): Even from a minor and sterile procedure, it is possible for you to get an infection with bacteria that typically cause urinary tract infections (UTIs). It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you may feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. If an open cystotomy was done, a wound infection can also occur. It could present with unusual redness, swelling, whitish to yellowish discharge from the incision, or even fevers and chills. Usually, local wound care and antibiotics are all that is necessary. Sometimes, part of the wound needs to be opened to drain the infection. *If you have high temperatures or any symptoms of severe illness (fevers, shaking
    chills, weakness or dizziness, nausea and vomiting, confusion) let your doctor
    know immediately and proceed to the nearest emergency room.
  • Tube Dislodgement: Although the initial tube is secured, the tube can be dislodged by an unexpected pulling force. If this happens within the first one or two weeks, are peat procedure may be necessary to replace it. The longer the tube has been in, the greater the chance it can easily be re-inserted provided you get to the urologist as immediately as possible.
  • Blood Loss/Clot Retention/Transfusion: As previously mentioned, small blood vessels in the wall of the bladder can be injured. This is common and almost always clears within a day or two. If bleeding is more significant, clots can form in the bladder and block up the tube. It may be necessary to irrigate those clots out through the SPT, through a replaced urethral catheter, or through a cystoscope. Bleeding requiring a transfusion is exceedingly rare and in far less than 1% of cases. This degree of bleeding would be associated with injury to a large blood vessel outside of the bladder. Again, this is quite unusual.
  • Adjacent Organ Injury: This is more common with the "punch" cystotomy because the tube is being placed through the abdominal wall without an incision down to the bladder. Although rare in any instance, the small intestine is the most common involved organ. The colon (large intestine) is less commonly involved. When recognized, a general surgeon may be consulted. Surgery on the small intestine or colon might be necessary. Although uncommon in any instance, patients who have had prior surgery in the abdomen or pelvis are at much higher risk.
  • Chronic Discomfort or Irritative Voiding Symptoms: As mentioned, the vast majority of patients find an SPT to be more comfortable than a urethral catheter. If the converse is true, then the SPT may be simply pulled out in the office and replaced with a urethral catheter. In patients who have never had a tube (in those in whom it is placed for severe incontinence), the tube can cause an uncomfortable sense of urgency on a constant basis. Again, these symptoms typically resolve in most patients.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

Delta Medix, P.C.