JOURNAL OF ENDOUROLOGY

Volume 7, Number 2, 1993

Mary Ann Liebert, Inc., Publishers

Percutaneous Suprapubic Cystostomy

PIERCE B. IRBY, III, MD, and MARSHALL L. STOLLER, MD

ABSTRACT

Suprapubic urinary diversion for the management of lesions of the bladder outlet or urethra has been
facilitated by the advent of percutaneous access techniques. Prior to percutaneous endourologic techniques, an
open surgical approach was necessary when the transurethral route was impassable. A variety of percutaneous
suprapubic cystostomy techniques have evolved in recent years. These have been based on several different
access principles and offer the urologist a number of options. Selection of an individual technique is usually a
matter of preference and familiarity with a particular manufacturer's product. The list of indications for such
an approach is diverse and continues to expand.

INTRODUCTION and clean. Suprapubic cystostomy is a convenient way to drain

the bladder after complex pelvic surgery, including culpocys-
tourethropexy, vaginal suspension, suprapubic prostatectomy,
THE DECISION TO ENTER THE BLADDER by a percu-
taneoussuprapubic route must be based on appropriate
indications. These indications are broadly grouped into a re-
transurethral resection of the prostate, open urethroplasty, and
hypospadias repair. The suprapubic cystostomy tube allows
quirement for either long-term bladder drainage or short-term such patients to leave the hospital earlier and perform voiding
access to monitor urinary output, to evacuate the bladder during trials as an outpatient, which can significantly reduce medical
care expenditures. Suprapubic cystostomy is a well-accepted,
surgical procedures, to assess postvoiding urine volume, or to
more convenient, and generally better tolerated form of diver-
gain access for instrumentation.
sion than clean intermittent catheterization for short-term post-
operative management.
INDICATIONS Trauma patients frequently have multiple organ injuries.
Long-term urinary output monitoring may best be established
Difficult urethral catheterizations are more frequently en- with a suprapubic cystostomy, thereby reducing the incidence
countered in male patients with longer urethras. Urethral ob- of iatrogenic urethral injury. Posterior urethral disruption is
struction may be present secondary to strictures, benign pros- usually associated with concomitant pelvic fractures and is fre-
tatic hyperplasia, prostate cancer or other pelvic malignancies, quently addressed after more urgent injuries have been man-
history of radiation therapy, or congenital abnormalities. Other aged. Long-term suprapubic cystostomy drainage will allow the
forms of obstruction may be the result of malfunctioning artifi- contained pelvic hematoma to resolve and partial urethral dis-
cial urethral sphincters (placed around the bulbar urethra or the ruptions to reapproximate. Attempts at placing transurethral
bladder neck), chronic paraphimosis, meatal stenosis, and se- catheters may convert partial disruptions into complete ones
vere phimosis. and can introduce infection and disrupt contained hematomas.
Acute cystoprostatitis with urinary retention may be effec- In the care of spinal injury patients, Noll et al have advocated
tively managed temporarily by suprapubic diversion, thus percutaneous suprapubic cystostomy rather than intermittent
avoiding instrumentation of the infected prostate. Other severe catheterization because of the fewer urinary tract infections in
infections involving the perineum such as Fournier's gangrene their experience.'
may require placement of a suprapubic cystostomy. Suprapubic Suprapubic cystostomy may establish access to perform en-
urinary diversion may help keep difficult perineal wounds dry doscopie procedures. Numerous bladder stones, especially in

Department of Urology, University of California School of Medicine, San Francisco, CA

125
126 IRBY AND STOLLER

prepubertal males, may be approached in this fashion. Pédiatrie TECHNIQUE

endoscopes are too small to admit substantial instruments for
stone fragmentation, and the evacuation of stone fragments Percutaneous suprapubic cystostomy can be performed either
through them is problematic. Severe bladder neck contractures at the bedside, in the clinic, or in the operating room. Commer-
or proximal urethral strictures can be incised via this antegrade
cially available kits usually provide sufficient disposable mate-
route, and marsupialization of prostatic or bulbourethral ab- rials to perform most of the procedure. Surgical soap and drap-
scesses can be carried out. Antegrade inspection of posterior
ing need to be provided, as well as local anesthetic, needles,
urethral valves may enable easier incision. Suprapubic cys- syringes, drain suture, urine collection bag/leg bag, and a spinal
tostomy can supply an access port for flexible or rigid endos- needle for bladder localization.
copy. A small urodynamic catheter may be placed, eliminating After appropriate counseling and consent, the first step for
irritating retrograde instrumentation. the surgeon who has made the decision for percutaneous supra-
Relative contraindications to percutaneous suprapubic cys- pubic cystostomy is to familiarize himself with the equipment
tostomy include previous lower abdominal or pelvic surgery, in the kit that will be used. The catheter and trocar/stylet ele-
abdominal wall infection, a contracted, fibrotic, nondistensible ments should be inspected and appropriately assembled. Next,
bladder, bladder malignancy, or the presence of prosthetic ma- one must ensure that the supplemental items mentioned above
terial in the pelvis such as an artificial urinary sphincter.2 are available. An extra pair of hands in the form of an assistant
nurse or technician is frequently helpful. If ultrasonography is

necessary during the procedure, it may be advantageous to

ANATOMIC CONSIDERATIONS perform the procedure where the machine is located unless it is
easily mobile and space permits its presence at the bedside or in
The pelvic location of the adult bladder generally protects it the clinic.
from all approaches except one that is anterior or through the Preprocedure intravenous antibiotics should be considered
dome of the viscus. As the bladder fills and becomes distended, based on urine cultures; if the urine is sterile, a single dose of a
the peritoneal surface, which variably covers a portion of the first-generation cephalosporin such as cefazolin is appropriate.
posterior dome, stretches and tends to be pushed cephalad. The For the awake, alert, and anxious patient, intravenous sedation,
anterior wall expands to fill the prevesical space of Retzius analgesia, or both is helpful for all concerned. The patient is
while the base of the bladder and trigone remain relatively placed in the supine position, the abdomen is prepared from the
fixed. The safest direct percutaneous puncture is generally in umbilicus to the base of the penis or labia, and the genitalia are
the anterior midline through the relatively avascular sagittal draped out of the field. A sterile glove or sleeve can be used to
plane of the linea alba. The approach needs to be cephalad cover the ultrasound transducer on the field. If the bladder does

enough to avoid placement of the catheter tip against the trigone not appear distended, it should be filled transurethrally (if pos-
with resultant potential irritation, yet it must not be so high that sible) with at least 300 ml, or intravenous fluids and furosemide
bowel or peritoneum is skewered. A point 5 to 8 cm (two may be given. A point 5 to 8 cm above the symphysis pubis in
fingerbreadths) above the pubic symphysis in the midline typi- the midline is determined. Local anesthetic (1% lidocaine) is
cally satisfies these conditions when the angle of the puncture is injected as a skin wheal and then into the subcutaneous tissue.
directed slightly caudad from the perpendicular. Diverticula or A spinal needle is passed through the skin wheal in the sagittal
urachal remnants are rarely encountered in this location. plane directed slightly caudad from the vertical. Local anes-
The bladder should be full enough to distend its walls maxi- thetic is injected through the spinal needle during passage. At
mally prior to puncture. A nondistended wall will move away the anticipated depth, the needle is aspirated for urine return.
from the trocar when pressure is applied during the puncture, Return of urine confirms the trajectory and depth for subsequent
collapsing the viscus and making penetration more difficult. trocar passage. Failure to aspirate urine necessitates redirection
Patients who have had prior abdominal surgery, particularly with assisting ultrasonographic guidance if necessary. The nee-
via a midline incision, are at risk of having adhesions with dle may be left in place as a guide. If the same needle is used, it
bowel interposed between the bladder and the anterior abdomi- should be retracted toward the skin prior to future passes. Urine
nal wall where the space of Retzius has been violated. Caution from this aspiration may be sent for culture as appropriate.
is advised in these cases, and the surgeon will be well served to A 1-cm skin incision is made in the midline adjacent to the
have ultrasonographic imaging performed prior to and during spinal needle. For patients with midline surgical scars, it is
the procedure if possible to rule out the presence of adhesive advised to move the entry point just lateral to the cicatrix to
viscera in the puncture path. avoid the difficulty of negotiating densely scarred tissue. The
A puncture that is too deep or one that is angled too caudad trocar is passed through the skin incision and then advanced
may cause the trocar to enter the prostate or potentially even the parallel to the tract of the spinal needle. Resistance is encoun-
vagina or rectum. A man with a large intravesical prostate tered in sequence at the fascial level and then at the bladder
adenoma/median lobe is therefore at higher risk for injury. wall. A definite "give" should be felt at both points. When the
Ultrasonography may be helpful in identifying this condition tip of the trocar is advanced into the bladder, a brisk return of
and avoiding such a complication. urine confirms position. The catheter/stylet assembly should be
Particular care should be taken in the case of children because carefully advanced another 1 to 2 cm to ensure that the shaft of
of the more abdominal location of the bladder until puberty. the trocar is well within the distended lumen of the bladder.
Ultrasound or fluoroscopy should be used to ensure precise Depending on the type of percutaneous technique being used,
placement of the catheter and avoidance of intraperitoneal either the catheter is advanced 5 to 10 cm over the trocar/stylet,
structures. keeping the latter immobile (Stamey style), or a metal sheath is
PERCUTANEOUS SUPRAPUBIC CYSTOSTOMY 127

advanced 5 to 10 cm over the trocar, and a catheter is passed

through the sheath into the bladder (Cystocath). Figures 1
through 3 illustrate a variety of catheter/stylet assemblies.
The Stamey catheter tip assumes a Malecot-like shape when
it is disengaged from the stylet. The stylet is removed, and the
catheter is pulled back until resistance is met, thus seating the
Malecot flanges against the bladder wall, minimizing excess
catheter within the bladder. The longer Stamey "loop" version
requires that the entire distal tip with its drainage sideholes be in
the bladder before the stylet is removed. The drawstring at the
proximal end of the catheter is tightened and secured, curling
the distal loop in the bladder. Then the catheter may be pulled
back until resistance is felt to seat the retaining loop against the FIG. 2. Distal tips of devices with stylets engaged. Balloon
bladder wall. Both of the above catheters are secured to the skin has been inflated in Microvasive catheter.
with an appropriate suture (2-0 silk/nylon).3'4 Compare the
distal tips of these catheters as shown in Figure 3.
The catheter-through-the-sheath technique (Cystocath, 8F or 17.5-gauge puncture needle is passed alongside into the bladder
12F) requires that a 10- to 15-cm length of Silastic tubing be through a skin incision. A 0.035-inch J-tip or floppy coaxial
passed through the metal sheath into the bladder (Fig. 4). The wire is passed through the puncture needle and coiled into the
sleeve is then removed. The catheter is secured to the abdomen bladder. A 5-mm fascial incision should be made alongside the
by a Silastic faceplate that is applied to the skin with adhesive puncture needle; both puncture and spinal needles are then
cement as well as sutures. The faceplate should be glued to the removed, leaving the wire in place. Fascial dilators from 6F to
abdominal skin in the desired position, before the puncture is 12F are passed sequentially over the wire into the bladder. A
performed: attempting to apply the faceplate over the metal Dotter-like catheter is passed over the wire with the excess
sleeve and catheter at the end of the procedure is awkward. length left in the bladder. A Finlayson-like dilation set is then
An alternative to the above commercial kits is the use of a used, passing dilators over the Dotter catheter sequentially until
coaxial dilator system to access the bladder (Fig. 5). This tech- the tract is dilated sufficiently. Lastly, a Peel-away sheath of the
nique is particularly applicable when antegrade access to the desired diameter is passed over the dilators, which are then
bladder is desired for endoscopie procedures. Following local- removed. The sheath is peeled down to the skin, and appropri-
ization of the bladder as above using the spinal needle, a larger ate cystoscopes, resectoscopes, etc. are introduced via the
sheath into the bladder. At the completion of the procedure, a
catheter of choice may be passed through the sheath, and the
sheath can be removed. Advocates of this method of access
maintain that it is less traumatic to the bladder and that it offers
greater control than a punch trocar, thereby resulting in fewer
potential complications.5'6 When antegrade endoscopie proce-
dures are planned requiring access to the bladder, in lieu of the
Peel-away sheath, the Amplatz dilation system can be em-
ployed to establish a tract up to a 34F sheath size.2 Others have
used customized access cannulas or even a simple endotracheal
tube as a port for endoscopie entry to the bladder.7'8
The suprapubic cutdown technique is an efficient method of
providing any formal suprapubic catheter of the surgeon's

FIG. 1. Selection of percutaneous suprapubic cystostomy

catheters. From left to right: Stamey percutaneous loop supra-
pubic catheter (Cook Urological); Stamey percutaneous supra-
pubic catheter, Malecot tip (Cook Urological); Cystocath su-
prapubic drainage system (Dow-Corning); percutaneous
suprapubic balloon catheter (Microvasive); suprapubic intro- FIG. 3. Distal tips of devices with stylets removed. Foley
ducer Foley catheter (Bard); SPEC 5 suprapubic catheter catheter balloon has been inflated after passage through sheath
(Porges). (Bard).
128 IRBY AND STOLLER

FIG. 6. Cutdown technique for suprapubic cystostomy. Fol-

FIG. 4. Catheter-through-the-sheath technique (Cystocath). lowing cutdown to Turner-Warwick or Hegar urethral sound
Metal trocar with sheath is placed percutaneously into bladder passed into bladder, Foley catheter is secured to distal end of
(1). Trocar is withdrawn, and catheter tubing is passed through sound (1). Sound is withdrawn and released from catheter (2).
sheath into bladder (2). Sheath is removed and tubing is secured Catheter is pulled back into bladder, and balloon is inflated (3).
to abdominal wall (3).

choice (Fig. 6). This is particularly helpful for catheter use of withdrawn back into the bladder. When withdrawing the cathe-
long duration such as in patients who are permanently or tempo- ter, care should be taken not to pull it too far. Aspiration of fluid
rarily not operative candidates (urinary retention secondary to helps determine an appropriate position. The balloon is in-
prostatic hyperplasia or adenocarcinoma; urethral necrosis from flated, and the catheter is secured to the skin. We have found
Fournier's gangrene, etc.). The abdomen and genitalia are pre- the above sounds to be particularly handy without modification.
pared and draped for access. A Turner-Warwick or Hegar ure- Others have described using a modified Van Buren sound or
thral sound is passed retrograde into the bladder, and the tip of Lowsley retractor.910
the sound is pressed anteriorly, bringing the anterior wall of the
bladder against the midline fascia. An incision to the sound is
performed using a scalpel so that the tip of the sound is exposed COMPLICATIONS
and exits through the abdominal incision. A catheter of choice
such as an 18F Foley is tied by its tip to the end of the sound, Failure to rule out interposing adhesive bowel segments be-
which has holes for this purpose. The sound is then removed tween the bladder and anterior abdominal wall may result in
transurethrally, pulling the Foley catheter tip antegrade out the transintestinal puncture."14 Ultrasonographic imaging of the
external urethral meatus. The tie between the sound and cathe- bladder prior to the procedure should identify this situation. If
ter is cut, the sound is removed, and the Foley catheter is bowel is imaged or suspected, an ultrasonographic window
revealing a bowel-free approach from a different angle over the
bladder may be possible. If this is not possible, a percutaneous
approach is not advised, and a formal open suprapubic cys-
tostomy with careful dissection of bowel off the bladder is
recommended. Puncture of other pelvic organs, including the
rectum, uterus, and vagina, has been reported.15
Hemorrhage from the bladder after percutaneous puncture is
not usually significant and clears within minutes to a few hours.
An approach to the bladder that is not in the midline has a
greater risk of injuring vessels of the lateral abdominal wall,
usually the inferior epigastric artery or veins. Should such a
diagonal approach to the bladder unknowingly penetrate
through and through the bladder wall posteriorly, a significant
possibility of damage and hemorrhage from various pelvic ves-
sels exists. When using the Stamey-type instrument, it is criti-
cal to ensure that the catheter is in the proper position on the
FIG. 5. Coaxial dilation technique. After puncture-needle trocar prior to puncture with the trocar tip fully advanced.
cystostomy with placement of 0.035-inch guidewire, coaxial
fascial dilators are passed over wire, followed by Peel-away Otherwise, tissue may be cored out as the unit is advanced,
sheath (1). Dilators and wire are removed, and Foley catheter is causing hemorrhage. A puncture directed too far caudad may
passed through Peel-away sheath as it is separated and with- enter the prostate, resulting in marked hemorrhage. In any
drawn (2). instance that frank blood returns through the catheter, it should
PERCUTANEOUS SUPRAPUBIC CYSTOSTOMY 129

be immediately withdrawn and redirected. If hemorrhage per- Periodic antiseptic irrigation of the catheter and bladder can
sists and transurethral access is possible, evacuation of clots help keep bacterial colony counts reduced and can inhibit stone
and fulguration of bleeding sites should control this complica- formation and encrustation. Instillation of 60 ml of dilute (3%)
tion. acetic acid (vinegar) periodically for 30 minutes is an economi-
Pericatheter leakage implies either obstruction of the catheter cal technique to minimize catheter encrustations for chronic
lumen or dislodgment outside the bladder. If gentle irrigation of catheter maintenance.
the catheter does not restore drainage, a cystogram should be
performed to verify position. If the catheter tip is not com-
pletely extruded, transurethral grasping of the tip may be help-
ful in repositioning it inside the bladder. Alternatively, a MAINTENANCE OF SUPRAPUBIC CATHETERS
guidewire may be placed through a central lumen and used to
help advance such catheters back into an appropriate position. The Stamey catheters are made of polyethylene, a firm mate-
Urinary extravasation with urinoma formation is unusual un- rial that does not easily bend against the patient's abdomen. An
less there is obstruction of the catheter or it is dislodged. One inconvenient, bulky dressing may be required. Fortunately,
problem occasionally encountered results from improper place- such catheters are not intended for long-term use. Softer, more
ment of the Stamey loop entirely within the bladder. Should pliable catheters of the Silastic, latex (Foley or Malecot type),
some of the sideholes on the catheter be outside the bladder, or polyurethane16 variety are more comfortable for the patient.

leakage may occur. This is avoided by advancing the catheter The catheter and skin about the catheter site should be
well into the bladder as the trocar is removed. Visual monitor- cleansed a few times per week with soap and water. Long-term
ing transurethrally during or after the procedure verifies proper Foley or Malecot catheters do not need sutures for security once
placement. the tract is mature. Although stoma adhesive-type coverings are
Rarely, the trocar and catheter become unlocked and separate sometimes used about the catheter site, they tend to become
during the puncture, particularly if care is not taken to ensure messy, break down, and cover up debris. Two 2-inch gauze
that the connection is tight. As the Stamey loop catheter tip has dressings serve as an excellent simple covering. Bacitracin oint-
a curved end, care must be observed to advance the trocar ment about the entry site is optional.
forward to the end of the catheter without slicing through its Patients and family members should receive instruction con-
side. If, during the puncture, the trocar and catheter are noted to cerning use of the leg bag during daytime and ambulatory
be disconnected, both parts should be removed as a unit and periods. The larger standard urine collection bag prevents the
reassembled under direct vision. If an attempt is made to recon- need to awaken and empty the bag during sleep. When the leg
nect these components blindly while they are inside the patient, bag is used at night, it may fill up and prevent further drainage
the catheter may be damaged with possible severe injury to the from the bladder or may burst and leak. Leg bags and night bags
patient. should be rinsed out daily at home with vinegar diluted to half
Occlusion of the lumen may result intrinsically from clots, strength with tap water (3% acetic acid).
tissue, mucous, encrustations, and calculi. Extrinsic obstruc-
tion occurs from a kink in the catheter tubing, usually with the
patient unaware of the situation. Patients, family members, and
nursing staff must be specifically instructed to be vigilant REPLACEMENT OF SUPRAPUBIC CATHETERS
against inadvertent kinking of the cystostomy tube or extension
tubing when the patient changes position. A long-term suprapubic catheter should undergo periodic
Although unlikely with diligent placement, it is possible for replacement to minimize encrustations and degradation of the
the tip of the catheter to find aberrant locations. We have catheter causing cracks, which serve as a haven for bacteria. A
experienced the catheter tip entering a urethral orifice, which change of catheter every 2 to 3 months is reasonable, or more
was not recognized until the patient complained of flank pain frequently if necessary. Disregard for such catheter change may
from ureteral obstruction. If advanced too far, the tip may result in bladder stones, recurrent cystitis, and possible rupture
negotiate the bladder neck into the urethra, causing severe irri- or fracture of the Foley balloon with foreign body remnants in

tation or even incontinence. the bladder.

Suprapubic catheters become colonized with bacteria within Foley or Malecot catheters usually can be exchanged by
a brief period following placement, typically 24 to 48 hours. direct passage through an established tract. A blunt stylet
The flora responsible are generally different from those associ- passed down the lumen of the Malecot catheter while holding
ated with urethral catheters. Gram-positive species predominate countertraction on the catheter will permit the flanged tip to
as opposed to the gram-negative Enterobacteriaciae seen from collapse for easy removal. Occasionally, a Foley catheter bal-
urethral and perineal contaminants. The urine sediment is uni- loon will not deflate by aspiration of the balloon port. Options
versally abnormal in patients with suprapubic catheters. Inex- to solve this problem include injection of mineral oil or ether
perienced medical personnel occasionally become alarmed at into the balloon port, which causes rupture of the latex balloon
the presence of microhematuria, pyuria, or bacteriuria in the within a few seconds to minutes; direct needle puncture of the
absence of any clinical stigmata of infection. Clinical infections balloon using a spinal needle alongside the catheter in the tract
should be exceptional in the absence of an obstructed catheter or or through the balloon port; and transurethral endoscopie punc-
bladder stones. A thorough work-up should be performed to ture of the balloon using a Collings knife. If ether injection is
evaluate the upper urinary tract as a source of infection as well. performed, the bladder must be full to avoid ether cystitis.
130 IRBY AND STOLLER

CONCLUSION 7. McNicholasTA, Ramsay JWA, Carter SStC, Miller RA: Suprapu-

bic endoscopy: a percutaneous approach. Br J Urol 1988;61:221
8. Lap YY: Letter to the editor. Br J Urol 1988;62:618
Percutaneous suprapubic cystostomy is a key diagnostic and
9. Golomb J, Lindner A: Percutaneous suprapubic cystostomy using
therapeutic technique for lower tract endourology. This form of a modified urethral sound. J Urol 1991:146:813
access can be mastered readily and usually requires relatively
10. Zeidman EJ, Chiang H, Alarcon A, Raz S: Suprapubic cystostomy
little and inexpensive specialized equipment. It frequently is
using Lowsley retractor. Urology 1988:32:54
performed in the outpatient setting of the emergency room or in 11. Flock WD, Litvak AS, McRoberts JW: Evaluation of closed supra-
the clinic but has widening applications in the operating room, pubic cystostomy. Urology 1978; 11:40
from pédiatrie ages to the elderly. A variety of available instru- 12. Hebert DB, Mitchell GW Jr: Perforation of the ileum as a compli-
ments and kits permits the surgeon to tailor the access plan to cation of suprapubic catheterization. Obstet Gynecol 1983;62:662
the specific indication. 13. Moody TE, Howards SS, Schneider JA, Rudolf LE: Intestinal
obstruction: a complication of percutaneous cystostomy: a case
report. J Urol 1970;118:680
14. Browning DJ: Potential hazard of suprapubic catheterization. Med
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