Suprapubic Catheterisation

& Vesicolithotomy

Edi Wibowo (BOW)

 Suprapubic catheterisation:
Definition The insertion of a catheter into the bladder via the anterior
abdominal wall

An opening made in the bladder for drainage, usually

through a catheter inserted through the abdominal skin,
when urethral catheterization impossible

Vesicolithotomy:
Incision of the bladder for removal of a calculus

(Mosby’s Medical Dictionary 9th edition)

ANATOMY of ABDOMINAL WALL

(Oxford Handbook of Surgical, 2014)

ANATOMY of BLADDER

(Netter, Atlas of Human Anatomy 5th edition, 2007)

(Clinical anatomy by regions 8 th editions, 2010)
 VESICOLITHOTOMY
Indication

• Large Stone and hard stone

• Bladder stones that can not be solved with a lithotriptor
• Multiple bladder stone
• Not obtained access through the urethra
• Concomitant open prostatectomy or diverticulectomy

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

 Contraindication

• Suspicious of bladder malignancy

• Unclear cause of gross hematuria
• Bleeding disorder
 Percutaneous
Cystostomy
Equipment
1. Blade no 11
2. Sterile Handscoon
3. Povidone iodine 10%
with Gauze
4. Hecting set
5. Silk 3/0
6. Lidocaine 2%
7. Sterile linen
8. Urine catheter (check the
baloon)
9. Urobag
10. Sterile water
11. Sterile gauze
12. Lubricating Gel
13. Trocar set
Trocar Set
Half
slot

Obturator

Trocar
 Open Blade 11 & 20
and
Cystostomy Metzenbaum

Equipment
1.Blade no 11 & 20
2.Sterile Handscoon
3.Povidone iodine 10%
with Gauze
4.Hecting set
5.Silk 3/0
6.Plain catgut 3/0
7.Polyglycolic acid 3/0
8.10 cc syringe
9.Sterile linen
10.Urine catheter (check
the baloon)
11.Urobag
12.Sterile water
13.Sterile gauze
14. Lubricating Gel Pean Forceps Allis Clamp Kocher Clamp
15.Metzenbaum Langenback
16.Langenback
17.Pean forceps
18.Allis clamp
19.Kocher clamp
Procedure
PERCUTANEOUS
CYSTOSTOMY
• Infiltrate local anesthetic of
lidocaine 2-3 fingers above
pubic symphisis from the skin,
subcutaneous tissue until
fascia.
• Make the incision at the midline,
continue untill fascia.
• Aspirate through the incision
site with syringe to identify
position of bladder.

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

 • Insert the trocar set
150-300 caudally
through incision
wound towards bladder
untill there is no
resistance from fascia
and detrusor muscles.
• When trocar set enters
the blader, urine will
come out from the hole
of the canula

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

 • Remove obturator from
its “sheath” and insert
catheter through a
canal of the sheath,
then inflate the baloon
with 10-15 cc of sterile
water.
• Pull the catheter to
ensure baloon
function.

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

 • Connect the catheter
with urine bag.
• Remove sheath and
pull the catheter untill
the baloon inside the
bladder attach to the
bladder wall.
• Fixate the catheter to
the skin.
• Close the wound with
sterile gauze.

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

OPEN CYSTOSTOMY
 Place the patient supine. Centre a midline
suprapubic incision 2 cm above the symphysis
pubis
Open the rectus sheath
(Oxford Handbook of Urology, 3 Edition, 2013)
rd
 Sweep the fascia and peritoneum upwards,
Absorbab lesuture into the upper part of the bladder,
Puncture the bladder between the sutures and empty it by
suction, Explore the interior of the bladder
(Oxford Handbook of Urology, 3rd Edition, 2013)
hold the edges of the incision with two pairs of
tissue forceps, making sure that the mucosa is
included so that the catheter does not slip
beneath the mucosa (Oxford Handbook of Urology, 3 Edition, 2013)
rd
 Insert a purse-string to ensure a watertight closure
for a long period, Fix the bladder to the abdominal wall
Close the linea alba

(Oxford Handbook of Urology, 3rd Edition, 2013)

 COMPLICATIONS
Percutaneous Open
Cystostomy Cystostomy

Hematoma from LA
Catheter misplacement
During Perforation of peritoneum Bleeding
operation Injury of intraabdominal organ
Bleeding

Early Hematuria Hematuria

Catheter blockage Catheter blockage

UTI UTI
Late Enterocutaneous fistule Incisional hernia
Peritonitis Wound dehiscence
Post surgical care

(Oxford Handbook of Urology, 3rd Edition, 2013)

Vesicolithotomy (cont’d procedure)
• Enlarge the incision
• Grasp the stone with
stone tang 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 plain catgut
suture applied to the muscularis mucosal layer.
• Reinforce it with interrupted sutures of 3-0
polyglactin 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.
 • 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 polyglactin 1-0
• subcutaneous tissue with
plain catgut 3-0
• the skin with stepler/Silk 3-0
• Close the wound with tulle and
sterile gauze.

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

 Complication
• Durante op:
– Bleeding
– Surrounding organ injury
• Early Postop:
– hematuria
• Late Postop
– infection
(Harrison, et al. Baus Suprapubic Catheter Practice Guidelines. 2010)
 Careful!
• Bladder not fully filled
• The incision do not too cranially
• Px position is head down  bladder
more pushed upward
 FOLLOW UP
• 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.

(Harrison, et al. Baus Suprapubic Catheter Practice Guidelines. 2010)

THANKYOU