British Journal of Urology (1976). 48, 119-121 0
Percutaneous Suprapubic Cystostomy after Spinal Cord Injury J . B . COOK
and
P. H. SMITH
Yorkshire Regional Spinal Injuries Unit, Pinderfields General Hospital, Wakefield
Suprapubic cystostomy was, for many years, the treatment of choice in the management of prostatic hypertrophy with retention of urine; for many patients it was the only treatment. Its use in patients following spinal cord injury was discussed by Thomson Walker (1917) and by Vellacott and Webb-Johnson (1919). The formal cystostomy had many disadvantages but these were largely overcome by the Riches technique (1943). Gradually, however, with the advent of latex catheters and antibiotic therapy the technique of intermittent catheterisation (Guttmann and Frankel, 1966) became more fashionable. It is, however, time-consuming and satisfactory only in those units with numbers of well-trained medical and nursing staff. The introduction of the Bard suprapubic catheter (the suprapubic angiocath, 1966, S. P. Bard-Davol Ltd) allowed us to reconsider the virtues of percutaneous suprapubic catheterisation (Smith, Cook and Robertson, 1969) in the hope that its use would save nursing and medical time and that the preservation of the integrity of the urethra would minimise both infective complications and the possibility of external sphincter spasm. We report our results in our first 43 patients treated with either the Bard catheter or with a Braun peritoneal dialysis catheter which is somewhat more rigid and has proved more reliable.
Method Suprapubic cannulae were inserted into adult male paraplegic patients at the time of admission to the Spinal Injuries Unit after allowing the bladder to distend so that it was palpable. The cannula was inserted half-way between the umbilicus and the symphysis in the midline and angled at 45" to the vertical as suggested by Riches (1943). The procedure was carried out by a member of the medical staff and the bladder allowed to drain freely into a drainage bag whilst the patient was immobilised in bed. Any cannula which blocked or became displaced was replaced when the bladder filled. This has presented no difficulty. If satisfactory micturition had not been established by the time of mobilisation the cannula was removed and an intermittent catheterisation regime adopted because the patients commonly found the cannula inconvenient when mobilised. Smith, Cook and Robertson (1969) reported the use of the Bard supracath for suprapubic drainage of the paralysed bladder in 12 patients who had not previously been catheterised. Of the 12 patients, 6 maintained sterile urine throughout the course of suprapubic catheterisation, I for as long as 30 days. This method was used in a further 6 patients but there was difficulty because of mechanical blockage of the catheter by kinking. It was decided to continue suprapubic drainage using a more rigid but equally fine (9 Charriere) catheter. The Braun peritoneal dialysis catheter (distributed by Armour Pharmaceuticals Ltd) was chosen. The method was used only in male paraplegics, some having had previous urethral catheterisation. Antibiotics and urinary antiseptics were not used until clinical urinary infection had 119
120
BRITISH JOURNAL 01- UROLOGY
Table I Duration of Suprapubic Drainage and Life of each Catheter Type of catheter
I'a t ien ts Duration of suprapubic drainage (average-days) Life of each catheter (average-days)
Supracatli
Dialysis
Both
18
23
41
24
57
45
II
26
-
Table I1 Urine Infection after Suprapubic Drainage Type of catheter
v-
-7
PCtticn 15
Ui ine 5terile throughout Ihidtion (avei age-days) Ui ine infected Onset of infection (dveiage-days)
Supracath
Dialysis
in 9 (50"i) in
23 10 ( 4 3 " 3 49 13 (57",,) 27
9 (50",,) 33
Total 41 19 (46",,) 38 22 (54",,) 30
supervened and no instillation was made into the bladder. The urine was scanned bacteriologiciilly a t weekly intervals. A significant infection was taken to be either more than 105 organisms per nil o r 5 cells per high-power field and a positive culture. Bladder emptying was checked by aspiration with a syringe and by 2-film intravenous urograms done a t weekly intervals.
Results The results are shown in Tables I and 11. I t was found (Table 1) that the average life of the peritoneal dialysis catheter was 26 days as compared with 1 1 days for the Bard supracath. Using the dialysis catheter, it was possible to maintain suprapubic drainage for an average of 8 weeks with a range from 4 to 19 weeks. The proportion of patients maintaining sterile urine throughout the period o f suprapubic drainage (Table I I ) was marginally less with the more rigid (peritoneal) catheter, 43 as compared with 50'1,;with the supracath. However, when the duration of suprapubic drainage was Laken into account, it was clear that the peritoneal dialysis catheter was a considerable advance in that it was possible to maintain sterility for a n average of 7 weeks without antibiotics o r urinary antiseptics. Those patients who developed infected urine during the course of suprapubic drainage (Table 1 I ) included some who had previous urethral catheterisation, 1 with a urethral fistula and ;I number 'I,,
PERCUTANEOUS SUPRAPUBIC CYSTOSTOMY AFTER SPINAL CORD INJURY
121
whose suprapubic catheter had been manipulated for bladder pressure recording. Of those whose urine was sterile at the time of first suprapubic catheterisation, but who later developed infection, it was possible to maintain sterility for an average of 4 weeks. Discussion The results of suprapubic drainage of the paralysed bladder by means of a fine catheter in 41 male paraplegic patients are encouraging. The initial problem of blockage by mechanical kinking of the catheter has been greatly reduced by the use of a stronger peritoneal dialysis catheter. More than 40% of patients maintained a sterile urine for an average of 7 weeks without the use of antibiotics or urinary antiseptics. It is difficult to compare these results with those of intermittent catheterisation since the criterion usually quoted with reference to intermittent catheterisation is the state of the urine on discharge from hospital, when a variety of treatments may have been given subsequent to intermittent catheterisation.
Summary
The results of treatment of urinary bladder paralysis with small calibre (9 Charriere) suprapubic drainage in 41 male patients are described. It was found that suprapubic drainage could be maintained for an average of 8 weeks and that the urine in 43% of patients remained sterile for an average of 7 weeks. This technique merits further trial, both in the paraplegic patient and in normal patients requiring catheterisation because of obstruction of the lower urinary tract.
References GUTTMANN, L. and FRANKEL, H. (1966). The value of intermittent catheterisation in the early management of traumatic paraplegia and tetraplegia. Paraplegia, 4, 63-84. RICHES,E. W. (1943). The methods and results of treatment in cases of paralysis of the bladder following spinal injury. British Jortrrzal qf’ Surgery, 31, 135-147. SMITH,P. H., COOK,J. B. and ROBERTSON, W. G. (1969). Stone formation in paraplegia. Paraplegia, 7 , 77-85. THOMPSON WALKER, J . W. (1917). The bladder in gunshot and other injuries of the spinal cord. Lancet, I , 173-179. P. N. and WEBB-JOHNSON, A. E. (1919). Spinal injury with retention of urine, the avoidance of VELLACOTT, catheterisation. Lancet, 1, 733-737.
The Authors J. €3. Cook, MD, FRCP, Consultant in Neurology. P. H . Smith, FRCS, Consultant in Urology.
Percutaneous Suprapubic Cystostomy after Spinal Cord Injury J . B . COOK
and
P. H. SMITH
Yorkshire Regional Spinal Injuries Unit, Pinderfields General Hospital, Wakefield
Suprapubic cystostomy was, for many years, the treatment of choice in the management of prostatic hypertrophy with retention of urine; for many patients it was the only treatment. Its use in patients following spinal cord injury was discussed by Thomson Walker (1917) and by Vellacott and Webb-Johnson (1919). The formal cystostomy had many disadvantages but these were largely overcome by the Riches technique (1943). Gradually, however, with the advent of latex catheters and antibiotic therapy the technique of intermittent catheterisation (Guttmann and Frankel, 1966) became more fashionable. It is, however, time-consuming and satisfactory only in those units with numbers of well-trained medical and nursing staff. The introduction of the Bard suprapubic catheter (the suprapubic angiocath, 1966, S. P. Bard-Davol Ltd) allowed us to reconsider the virtues of percutaneous suprapubic catheterisation (Smith, Cook and Robertson, 1969) in the hope that its use would save nursing and medical time and that the preservation of the integrity of the urethra would minimise both infective complications and the possibility of external sphincter spasm. We report our results in our first 43 patients treated with either the Bard catheter or with a Braun peritoneal dialysis catheter which is somewhat more rigid and has proved more reliable.
Method Suprapubic cannulae were inserted into adult male paraplegic patients at the time of admission to the Spinal Injuries Unit after allowing the bladder to distend so that it was palpable. The cannula was inserted half-way between the umbilicus and the symphysis in the midline and angled at 45" to the vertical as suggested by Riches (1943). The procedure was carried out by a member of the medical staff and the bladder allowed to drain freely into a drainage bag whilst the patient was immobilised in bed. Any cannula which blocked or became displaced was replaced when the bladder filled. This has presented no difficulty. If satisfactory micturition had not been established by the time of mobilisation the cannula was removed and an intermittent catheterisation regime adopted because the patients commonly found the cannula inconvenient when mobilised. Smith, Cook and Robertson (1969) reported the use of the Bard supracath for suprapubic drainage of the paralysed bladder in 12 patients who had not previously been catheterised. Of the 12 patients, 6 maintained sterile urine throughout the course of suprapubic catheterisation, I for as long as 30 days. This method was used in a further 6 patients but there was difficulty because of mechanical blockage of the catheter by kinking. It was decided to continue suprapubic drainage using a more rigid but equally fine (9 Charriere) catheter. The Braun peritoneal dialysis catheter (distributed by Armour Pharmaceuticals Ltd) was chosen. The method was used only in male paraplegics, some having had previous urethral catheterisation. Antibiotics and urinary antiseptics were not used until clinical urinary infection had 119
120
BRITISH JOURNAL 01- UROLOGY
Table I Duration of Suprapubic Drainage and Life of each Catheter Type of catheter
I'a t ien ts Duration of suprapubic drainage (average-days) Life of each catheter (average-days)
Supracatli
Dialysis
Both
18
23
41
24
57
45
II
26
-
Table I1 Urine Infection after Suprapubic Drainage Type of catheter
v-
-7
PCtticn 15
Ui ine 5terile throughout Ihidtion (avei age-days) Ui ine infected Onset of infection (dveiage-days)
Supracath
Dialysis
in 9 (50"i) in
23 10 ( 4 3 " 3 49 13 (57",,) 27
9 (50",,) 33
Total 41 19 (46",,) 38 22 (54",,) 30
supervened and no instillation was made into the bladder. The urine was scanned bacteriologiciilly a t weekly intervals. A significant infection was taken to be either more than 105 organisms per nil o r 5 cells per high-power field and a positive culture. Bladder emptying was checked by aspiration with a syringe and by 2-film intravenous urograms done a t weekly intervals.
Results The results are shown in Tables I and 11. I t was found (Table 1) that the average life of the peritoneal dialysis catheter was 26 days as compared with 1 1 days for the Bard supracath. Using the dialysis catheter, it was possible to maintain suprapubic drainage for an average of 8 weeks with a range from 4 to 19 weeks. The proportion of patients maintaining sterile urine throughout the period o f suprapubic drainage (Table I I ) was marginally less with the more rigid (peritoneal) catheter, 43 as compared with 50'1,;with the supracath. However, when the duration of suprapubic drainage was Laken into account, it was clear that the peritoneal dialysis catheter was a considerable advance in that it was possible to maintain sterility for a n average of 7 weeks without antibiotics o r urinary antiseptics. Those patients who developed infected urine during the course of suprapubic drainage (Table 1 I ) included some who had previous urethral catheterisation, 1 with a urethral fistula and ;I number 'I,,
PERCUTANEOUS SUPRAPUBIC CYSTOSTOMY AFTER SPINAL CORD INJURY
121
whose suprapubic catheter had been manipulated for bladder pressure recording. Of those whose urine was sterile at the time of first suprapubic catheterisation, but who later developed infection, it was possible to maintain sterility for an average of 4 weeks. Discussion The results of suprapubic drainage of the paralysed bladder by means of a fine catheter in 41 male paraplegic patients are encouraging. The initial problem of blockage by mechanical kinking of the catheter has been greatly reduced by the use of a stronger peritoneal dialysis catheter. More than 40% of patients maintained a sterile urine for an average of 7 weeks without the use of antibiotics or urinary antiseptics. It is difficult to compare these results with those of intermittent catheterisation since the criterion usually quoted with reference to intermittent catheterisation is the state of the urine on discharge from hospital, when a variety of treatments may have been given subsequent to intermittent catheterisation.
Summary
The results of treatment of urinary bladder paralysis with small calibre (9 Charriere) suprapubic drainage in 41 male patients are described. It was found that suprapubic drainage could be maintained for an average of 8 weeks and that the urine in 43% of patients remained sterile for an average of 7 weeks. This technique merits further trial, both in the paraplegic patient and in normal patients requiring catheterisation because of obstruction of the lower urinary tract.
References GUTTMANN, L. and FRANKEL, H. (1966). The value of intermittent catheterisation in the early management of traumatic paraplegia and tetraplegia. Paraplegia, 4, 63-84. RICHES,E. W. (1943). The methods and results of treatment in cases of paralysis of the bladder following spinal injury. British Jortrrzal qf’ Surgery, 31, 135-147. SMITH,P. H., COOK,J. B. and ROBERTSON, W. G. (1969). Stone formation in paraplegia. Paraplegia, 7 , 77-85. THOMPSON WALKER, J . W. (1917). The bladder in gunshot and other injuries of the spinal cord. Lancet, I , 173-179. P. N. and WEBB-JOHNSON, A. E. (1919). Spinal injury with retention of urine, the avoidance of VELLACOTT, catheterisation. Lancet, 1, 733-737.
The Authors J. €3. Cook, MD, FRCP, Consultant in Neurology. P. H . Smith, FRCS, Consultant in Urology.
