Suprapubic Aspiration and

Cystotomy
Dr. Bobby Hery Yudhanto, SpU
Anatomy : Position of the Bladder

The bladder is an abdominal organ The bladder is a pelvic organ in the

in the neonate and infant. older child, adolescent, and adult

Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019

 SUPRAPUBIC ASPIRATION

INDICATION

1. Obtaining an uncontaminated urine sample from the bladder.

2. Temporarily relieve urinary retention when the bladder outlet is obstructed and one is
unable to place a transurethral catheter

• Suprapubic aspiration may be required to isolate intravesicular infections, to rule out

contamination with asymptomatic bacteriuria, or in cases of urinary retention from a
phimosis

Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019

 CONTRAINDICATION Suprapubic aspiration is absolutely contraindicated in the absence
of an easily palpable and distended or ultrasonographically
localized and distended urinary bladder

The bladder must be distended to push the bowel away from the anterosuperior surface of the bladder to
avoid perforating the bowel

• In individuals with prior lower abdominal surgery or traumatic injury.

• The bowel may be adhesed to the anterior abdominal wall
• This heightens the risk of inadvertent entry into the peritoneal cavity and bowel
injury
• It should not be placed in patients with abdominal wall infections, bladder cancer, or
subcutaneous vascular grafts in the suprapubic region

Relative contraindication : Any coagulopathy, bleeding diathesis, platelet dysfunction, and/or

thrombocytopenia should be corrected prior to performing this procedure.
Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019
• Povidone iodine or chlorhexidine solution
EQUIPMENT FOR
• Sterile gloves
SUPRAPUBIC ASPIRATION
• 22 to 24 gauge needle or spinal needle, 11⁄2 to 3 inches long for neonates,
infants, and young children
• 22 to 24 gauge needle or spinal needle, 3 inches long for older children,
adolescents, and adults
• 10 mL syringe
• Injectable local anesthetic solution, most commonly 1% lidocaine
• 4×4 gauze squares
• 25 gauge needle and 3 mL syringe for anesthetic administration
• Sterile towels or drapes
• Specimen containers for urine analysis and culture
• Bandage
• US machine (recommended)
• Sterile US gel
• Sterile US transducer covers
• 5 to 10 MHz linear US transducer for neonates, infants, and children
Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed;
• 2 to 5 MHz curvilinear abdominal US transducer for adolescents and adults 2019
PATIENT PREPARATION

1. Explain the risks, benefits, and alternative procedures to the patient and/or their representative.
• Obtain an informed consent for the procedure and place this in the medical record
• When performing the procedure on a neonate or child, it is advisable to give the parent the option to
leave the room or look away as the procedure can be disconcerting to some parents.
2. It is important to identify the distended bladder by palpation, percussion, transillumination, or
ultrasonography.
• Transillumination of the full bladder may be conducted in the neonate. Place the patient supine

3. Prepare and drape the abdomen in a sterile fashion from the umbilicus to the pubis.
4. Clean the skin of any dirt and debris.
5. Apply povidone iodine or chlorhexidine solution and allow it to dry. Apply sterile drapes.

Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019

 TECHNIQUE

NEONATES AND INFANT

1. Have an assistant place and hold the neonate or infant supine in the frog-leg position
2. Identify the needle insertion site in the midline and 2 cm cephalad to the pubic symphysis
3. The use of US is recommended to assist in determining the proper needle insertion site
4. Inject a local anesthetic agent, usually 1% lidocaine, to create a subcutaneous wheal in the area of the intended skin puncture site
5. Place a 22 or 24 gauge spinal needle onto a 10 mL syringe.
6. Occlude the urethra to prevent reflexive micturition by applying manual pressure to the urethral meatus of the female or the glans
penis of the male
7. Insert the needle through the anesthetized skin and at a 70° angle from the skin
8. Advance the needle cephalad while applying negative pressure to the syringe. Stop advancing the needle when urine is aspirated

• If no urine is aspirated, withdraw the needle to the subcutaneous tissue and redirect it to an 80° angle from the skin.
• If the procedure is unsuccessful on the second attempt, delay further attempts until the bladder is more distended, consult a
Urologist, or obtain urine through another method.
• After urine is obtained, remove the needle and apply a bandage to the skin puncture site.
Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019
 The frog-leg position

The Infant The Older Child

Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019

• Anatomic landmarks for suprapubic bladder aspiration in the neonate and
infant.
• A line is drawn from the umbilicus to the pubic symphysis (dotted line). The
intersection of the line with the suprapubic crease is the landmark for
insertion of the needle.

Suprapubic bladder aspiration in the neonate and infant.

A. Digital pressure on the urethral meatus will prevent micturition in the female.
B. Digital pressure on the glans penis will prevent micturition in the male.
Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019
 OLDER CHILDREN

• The urinary bladder of the older child may be in the abdomen or may have migrated into
the pelvis
• The technique is similar to neonates and infants if the bladder is in the abdomen or that of
adolescents and adults if the bladder is in the pelvis

• The single most important aspect of suprapubic bladder manipulation is the presence of an
identifiable and distended urinary bladder.
• The bladder can be identified by palpation, percussion, transillumination, and ultrasonography
• Under no circumstances should “blind” percutaneous access be attempted if the bladder is not
palpable or visualized with the aid of ultrasonography

Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019

 ADOLESCENCE AND ADULT
1. Place the patient supine.
2. Identify the bladder by palpation or ultrasonography.
3. Identify the needle insertion site in the midline and 2 to 4 cm cephalad of the pubic symphysis.
Inject 1 to 3 mL of local anesthetic solution subcutaneously and into the abdominal wall
musculature at the needle insertion site.
4. Place a 3 inch, 22 to 24 gauge spinal needle onto a 10 mL syringe.
5. Insert the needle through the anesthetized skin and at a 60° angle to the skin of the
abdominal wall
6. Advance the needle caudally while applying negative pressure to the syringe. Stop advancing
the needle when urine is aspirated Suprapubic bladder aspiration
in the adolescent and adult

• If no urine is aspirated, withdraw the needle to the subcutaneous tissue and re advance it in a
slightly different direction (e.g., 50° to the skin of the abdominal wall)
• After urine is obtained, remove the needle and apply a bandage to the skin puncture site.
Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019
 Suprapubic Bladder Catheterization
(Percutaneous Cystotomy)
• Bladder neck injuries • Neurologic disease
and lesions • An obstructing
Suprapubic bladder catheterization is indicated in cases • Enlarged prostates phimosis
when the transurethral route of bladder drainage or (e.g., benign • Palliative care
decompression is technically not possible or contraindicated hypertrophy or • Post- operation
cancer) • Suspected or known
• Iatrogenic urethral traumatic urethral or

INDICATION injuries prostatic disruption

• Intractable urinary • A urethral foreign
incontinence body
• Obstructing urethral • Urethral scarring
lesions • Urethral strictures.

Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019

 CONTRAINDICATION Suprapubic catheterization is absolutely contraindicated in the
absence of an easily palpable and distended or
ultrasonographically localized and distended urinary bladder

The bladder must be distended to push the bowel away from the anterosuperior surface of the bladder to
avoid perforating the bowel

• In individuals with prior lower abdominal surgery or traumatic injury.

• The bowel may be adhesed to the anterior abdominal wall
• This heightens the risk of inadvertent entry into the peritoneal cavity and bowel
injury
• It should not be placed in patients with abdominal wall infections, bladder cancer, or
subcutaneous vascular grafts in the suprapubic region

Any coagulopathy, bleeding diathesis, platelet dysfunction, and/or thrombocytopenia

should be corrected prior to performing this procedure.
Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019
 Relative contraindications to percutaneous bladder catheterization

• Ascites
 May lead the Emergency Physician to a false sense of security when the catheter is actually
intraperitoneal
• Patients with a history of pelvic cancer or pelvic radiation therapy
 A history of pelvic cancer or irradiation will increase the risk of adhesions, anatomic distortion, and
scarring
• Uncooperative patients
 Attempts at suprapubic cystostomy increase the risk of peritoneal and/or bowel perforation
• Patients who have urinary tract infections
 Urine leakage in patients with a urinary tract infection may result in bacteremia, peritonitis, and/or
sepsis.
• Any extremity contractures, physical alterations, spinal deformities, truncal obesity, or other conditions
that would preclude the patient from lying supine and inhibit bladder palpation are also relative
contraindications to performing a percutaneous cystostomy.
Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019
• Povidone iodine or chlorhexidine solution EQUIPMENT FOR
• Sterile gloves SUPRAPUBIC
• Percutaneous cystostomy catheter kit
•
CATHETERIZATION
Foley catheter, 14 to 16 French
• 60 mL catheter-tipped syringe
• 10 mL syringes
• 24 to 25 gauge spinal needle, 3 inches long
• #11 surgical scalpel blade on a handle
• 3–0 nylon suture
• Needle driver
• Local anesthetic solution, with or without epinephrine
• 4×4 gauze squares
• 25 gauge needle, 1 inch long
• 18 gauge needle
• Urine meter or urine leg bag
• Sterile towels
• Sterile drapes
• Tincture of benzoin
• 2 inch tape
• Ultrasound machine (recommended)
• Sterile ultrasound gel
• Sterile ultrasound transducer cover
• Curvilinear abdominal or phased-array transducer for adults
• Linear transducer for children

Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019

 PATIENT PREPARATION

1. As with all procedures, the risks and benefits of suprapubic bladder catheterization should be discussed
with the patient and/or their representative. Obtain an informed consent and place it in the medical record.
2. Place the patient supine. Clean any dirt and debris from the abdominal wall. Shave the lower abdomen if
the patient is hirsute
3. Identify the bladder by palpation, percussion, and/or ultrasonography.
4. Apply povidone iodine or chlorhexidine solution to the lower abdomen, from the umbilicus to the pubis,
and allow it to dry.
• Consider the administration of parenteral analgesics, sedatives, or procedural sedation (as this is a
painful procedure)
5. Anesthetize the abdominal wall. Fill a 10 mL syringe with local anesthetic solution. Apply a 24 to 25 gauge
spinal needle onto the syringe. Identify the insertion site in the midline and 4 to 5 cm above the pubic
symphysis. The use of ultrasound to verify the bladder location and to ensure that no loops of bowel are
present between the abdominal wall and bladder is recommended.

Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019

6. Make a skin wheal with the local anesthetic solution at the insertion site.
7. Insert the spinal needle at a 60° to 70° angle to the skin and aimed caudally
• Advance the needle through the sub-cutaneous tissue, rectus sheath, and retropubic space while
simultaneously aspirating and injecting 5 to 10 mL of local anesthetic solution
• A loss of resistance will be felt as the spinal needle transverses the rectus sheath and enters the
retropubic space.
• Continue to aspirate while advancing the spinal needle until the bladder is entered and urine fills the
syringe.
• The bladder appears to tent as the needle pierces its anterior wall when ultrasonographic guidance is
used. Note the needle direction and depth of insertion required to enter the bladder.

It is important to ensure that the needle enters and is advanced in the midline. This area is avascular.
If the needle is paramedian it may traverse the rectus muscles and inferior epigastric vessels, resulting
in significant hemorrhage

Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019

 The Seldinger technique with a peel-away sheath

A. The finder needle is inserted 60° to 70° to the skin and

advanced into the bladder
B. The syringe has been removed and the guidewire inserted
through the needle
C. The needle has been removed. The dilator and peel-away
sheath are inserted over the guidewire as a unit and into the
bladder
D. The dilator and guidewire are removed.
E. The peel-away sheath remains through the skin and into the
bladder
F. A Foley catheter is inserted through the peel-away sheath
and into the bladder
G. Urine is aspirated from the bladder. The cuff on the catheter
has been inflated
H. The arms of the peel-away sheath are pulled upward and
apart to remove the sheath
I. The cuff is lodged against the dome of the bladder
OBTURATOR TECHNIQUE
• The obturator technique is a derivative of the trochar technique.
• The spinal needle was previously used to infiltrate local
anesthetic solution and locate the urinary bladder. This
maneuver allows the operator to determine both the depth and
angle needed for bladder entry.
• Make a 3 to 4 mm stab incision in the midline and 4 to 5 cm
above the pubic symphysis through the skin wheal of local
anesthetic solution with a #11 scalpel blade. Place the tip of the
obturator catheter unit in the skin incision

A. The obturator is within the catheter. The system is inserted 60°

to the skin and advanced into the bladder.
B. The cuff is inflated.
C. The obturator is removed while the catheter remains within the
bladder.
D. The catheter has been pulled upward and the collecting tube is
attached to the catheter.
Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019
 ULTRASOUND GUIDANCE

A. The anterior bladder wall is tenting as the needle tip is about to penetrate the wall.
The remainder of the needle is not visible within the tissues.
B. The needle is within the bladder. (Courtesy of Andrew Shedd, MD.)

Longitudinal position Transverse position

Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019

 AFTERCARE
• No specific care is required after performing a suprapubic bladder
aspiration.
• Microscopic hematuria can occur following the procedure
although gross hematuria is uncommon
• The patient may complain of mild pain or soreness in the
suprapubic area
• This can be relieved with acetaminophen or nonsteroidal anti-
Securing the catheter inflammatory drugs

• The patient, if discharged, should be given specific instructions to

return immediately if they develop gross hematuria, abdominal
pain, fever, nausea, vomiting, or an infection at the puncture site.

Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019

 COMPLICATION

1. Bowel perforation
• Perforation of the bowel can be prevented by ensuring that the bladder is distended by palpation, percussion, or ultrasonography.
• Intraperitoneal perforation is more common in patients with ascites, a distended abdomen, or prior abdominal surgery
2. Catheter migration
3. Catheter misplacement
4. Intraabdominal visceral injury
• Through-and- through perforation of the bladder can injure the rectum, vagina, and/ or uterus
5. Infectious complications include abdominal wall cellulitis, abdominal wall abscess, sepsis, and peritonitis.
6. Hematomas of the abdominal wall, bladder wall, and pelvis are usually self- limited and require no treatment.
7. Uncontrolled hemorrhage
• Vascular injury are the major complications of a suprapubic cystostomy catheter placement. Gross hematuria is common and
transient

Other minor complications are associated with the length of indwelling catheter time and include bleeding, infections (e.g., cellulitis and
abscesses), kinking, and stone formation

Reichman,E.F; Reichman’s Emergency Medicine Procedure;3 rd ed; 2019

 SISTOSTOMI & PUNKSI BULI-BULI
(No. ICOPIM: 5-572)
1. TUJUAN
1.1. Tujuan pembelajaran umum
 Setelah mengikuti sesi ini peserta didik memahami dan
mengerti tentang anatomi, topografi, histologi, fisiologi
dan biokimia dari sistem saluran kemih bagian bawah
 menegakkan diagnosis dan pengelolaan retensio urin
 melakukan punksi aspirasi dan sistotomi suprapubik
1.2. Tujuan pembelajaran khusus
Setelah mengikuti sesi ini peserta didik akan memiliki kemampuan
untuk:
 Mampu menjelaskan anatomi, topografi, dan fisiologi saluran
kemih bagian bawah
 Mampu melakukan anamnesis, pemeriksaan fisik dan pemeriksaan
penunjang pada pasien retensio urin
 Mampu melakukan identifikasi kandung kemih melalui
pemeriksaan fisik
 Mampu memberi penjelasan kepada penderita dan keluarga,
(informed consent) mengenai tindakan punksi aspirasi supra pubik
dan sistotomi suprapubik beserta resiko dan komplikasi yang
mungkin terjadi
 Mampu menjelaskan tehnik punksi aspirasi kandung kemih dan
tindakan sistostomi suprapubik dan penanganan komplikasinya
 Mampu melakukan perawatan paska tindakan punksi aspirasi
suprapubic dan sistotomi supra pubik
2. POKOK BAHASAN / SUB POKOK BAHASAN
3. WAKTU METODE
• Anatomi, topografi, histologi, fisiologi dan biokimia dari sistem
A. Proses pembelajaran dilaksanakan melalui metode:
saluran kemih
1)  small group discussion
• Etiologi, macam, diagnosis dan rencana pengelolaan retensio
2)  peer assisted learning (PAL)
urin
3)  bedside teaching
• Tehnik operasi punksi asiprasi suprapubic dan sistostomi beserta
4)  task-based medical education
komplikasinya
B. Peserta didik paling tidak sudah harus mempelajari:
• Work-up penderita retensio urin
1)  bahan acuan (references)
• Perawatan penderita pra operatif dan pasca operasi
2)  ilmu dasar yang berkaitan dengan topik pembelajaran
3)  ilmu klinis dasar
4. MEDIA C. Penuntun belajar (learning guide) terlampir
1. Kuliah
D. Tempat belajar (training setting): ruang kuliah
2. Workshop / Pelatihan
3. Small group discussion
4. Belajar mandiri

5. ALAT BANTU PEMBELAJARAN

Internet, telekonferens, dll.
PENUNTUN PEMBELAJARAN
TEHNIK ASPIRASI SUPRAPUBIS
PENUNTUN PEMBELAJARAN
KETERAMPILAN TEHNIK ASPIRASI SUPRAPUBIS

NO. LANGKAH/ KEGIATAN KASUS

MENJALIN SAMBUNG RASA 1 2 3
1 Sapalah klien atau keluarganya dengan ramah dan perkenalkan diri anda, serta tanyakan keadaannya.

2 Berikan informasi umum pada klien atau keluarganya tentang tindakan aspirasi supra pubis, tujuan dan
manfaat aspirasi suprapubis untuk keadaan klien
3 Berikan penjelasan dengan bahasa awam pada klien atau keluarganya tentang:
-  jenis alat yang akan dipakai,
-  dimana tempat akan dilakukan aspirasi
-  bagaimana cara aspirasi suprapubis
-  jelaskan kemungkinan risiko dalam tindakan, tetapi beri jaminan bahwa bahaya itu
kemungkinannya sangat kecil, karena anda sudah mahir melakukan dan anda memakai alat yang
tepat dan steril.
4 Berikan jaminan pada klien atau keluarganya tentang kerahasiaan yang diperlukan klien

5 Jelaskan tentang hak-hak klien pada klien atau keluarganya, misalnya tentang hak untuk menolak
tindakan aspirasi suprapubis
6 Mintalah kesediaan klien untuk dilakukan tindakan aspirasi suprapubis
MELAKUKAN PERSIAPAN ALAT DAN BAHAN 1 2 3
7 Periksa dan letakkanlah semua alat dan bahan pada tempatnya

MENYIAPKAN PENDERITA 1 2 3
8 Sebelum tindakan dilakukan, sebaiknya melihat terlebih dahulu darah rutin
(trombosit, PT, PTT, waktu perdarahan)
9 Sebelum tindakan mintalah pasien untuk minum air yang banyak

10 Pasien berbaring dengan posisi terlentang

11 Pastikan kandung kemih berisi penuh dengan cara melakukan perkusi di daerah
supra pubis atau dengan bantuan USG bila tersedia
12 Pasanglah urine bag collector untuk mengantisipasi miksi spontan

MELAKUKAN PERSIAPAN DIRI 1 2 3

13 Lakukanlah cuci tangan asepsis

14 Pasanglah sarung tangan steril pada kedua tangan

15 Pemeriksa berdiri di samping kanan pasien

MELAKUKAN ASPIRASI SUPRAPUBIS 1 2 3
16 Bersihkan dan lakukanlah desinfeksi daerah supra pubis dengan povidone iodine

17 Tutuplah daerah sekitar suprapubis dengan doek steril sehingga daerah yang terbuka hanyalah yang dibutuhkan
untuk melakukan tindakan aspirasi suprapubis.
18 Tentukan titik tempat melakukan punksi yaitu pada garis tengah 0,5–1 cm cm diatas simpisis pubis

19 Bila perlu dilakukan anastesi lokal di daerah tindakan dengan krim anastesi topikal. Tunggulah kira-kira 5 menit,
agar penderita tidak merasa sakit ketika tindakan aspirasi.
20 Dengan menggunakan jarum no 23 G dilakukan aspirasisedalam 3 cm dengan posisi jarum membentuk sudut
10 – 20 dari garis tegak lurus.
21 Sewaktu jarum suntik mencapai jaringan subkutan, plunger spoit ditarik untuk membuat tekanan negatif

22 Perlahan-lahan masukkan jarum lebih dalam sambil melakukan aspirasi (jarum masuk ke dalam kandung kemih
ditandai dengan keluarnya urin ke dalam spuit). Bila urin sudah keluar, tusukan dihentikan.
23 Setelah jumlah urin cukup, jarum dicabut sambil menekan tempat tusukan dengan kasa steril.

24 Bukalah doek yang terpasang

25 Urin yang diperoleh kemudian dimasukkan ke dalam botol steril untuk pemeriksaan urin
SETELAH PEMASANGAN SELESAI 1 2 3
Lakukanlah dekontaminasi sarung tangan dengan memasukkan tangan yang masih
26 bersarung tangan ke dalam baskom berisi larutan khlorin 0,5%, gosokkan kedua tangan
untuk membersihkan bercak-bercak cairan/duh tubuh yang menempel pada sarung tangan.
27. Lepaskanlah sarung tangan dan masukkan ke dalam tempat sampah medis

28. Lakukan cuci tangan asepsis

29. Lakukanlah perpisahan dengan pasien

PERAWATAN PASKA TINDAKAN 1 2 3

30 Komplikasi dan penatalaksanaannya

31 Perawatan luka operasi

32 Perawatan selang kateter dan kantong urine (sistotomi suprapubic)

TERIMA KASIH
DAFTAR CEK PENUNTUN BELAJAR PROSEDUR OPERASI
DAFTAR TILIK