1. Overview 1.1 Background Cystostomy is the general term for the surgical creation of an opening into the bladder; it may be a planned component of urologic surgery or an iatrogenic occurrence. Often, however, the term is used more narrowly to refer to suprapubic cystostomy or suprapubic catheterization. In a setting where an individual is unable to empty his or her bladder appropriately and urethral catheterization is either undesirable or impossible, suprapubic cystostomy offers an effective alternative. Cystostomy for the purpose of suprapubic catheterization may be performed in 2 ways, as follows: Via an open approach, in which a small infraumbilical incision is made above the pubic symphysis Via a percutaneous approach, in which the catheter is inserted directly through the abdominal wall, above the pubic symphysis, with or without ultrasound guidance or visualization through flexible cystoscopy This article focuses on the percutaneous approach because this method can potentially be performed in outpatient, bedside, or urgent care settings. 1.2 Anatomy The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the retropubic space (of Retzius). The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to neighboring structures by reflections of the pelvic fascia and by true ligaments of the pelvis. The body of the bladder receives support from the external urethral sphincter muscle and the perineal membrane inferiorly and the obturator internus muscles laterally (see the image below).
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1. Overview
1.1 Background
Cystostomy is the general term for the surgical creation of an opening into the bladder; it may be a planned
component of urologic surgery or an iatrogenic occurrence. Often, however, the term is used more narrowly to
refer to suprapubic cystostomy or suprapubic catheterization. In a setting where an individual is unable to empty
his or her bladder appropriately and urethral catheterization is either undesirable or impossible, suprapubic
cystostomy offers an effective alternative.
Cystostomy for the purpose of suprapubic catheterization may be performed in 2 ways, as follows:
Via an open approach, in which a small infraumbilical incision is made above the pubic symphysis
Via a percutaneous approach, in which the catheter is inserted directly through the abdominal wall, above the
pubic symphysis, with or without ultrasound guidance or visualization through flexible cystoscopy
This article focuses on the percutaneous approach because this method can potentially be performed in
outpatient, bedside, or urgent care settings.
1.2 Anatomy
The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue.
It is separated from the pubic symphysis by an anterior prevesical space known as the retropubic space (of
Retzius). The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to neighboring
structures by reflections of the pelvic fascia and by true ligaments of the pelvis.
The body of the bladder receives support from the external urethral sphincter muscle and the perineal membrane
inferiorly and the obturator internus muscles laterally (see the image below).
1.3 Indications
At least 4 situations exist in which suprapubic cystostomy is considered:
Acute urinary retention in which a urethral catheter cannot be passed (eg, because of prostatic enlargement
secondary to benign prostatic hyperplasia or prostatitis, urethral strictures or false passages, or bladder neck
contractures secondary to previous surgery)
Urethral trauma
Management of a complicated lower genitourinary tract infection
Requirement for long-term urinary diversion (eg, because of neurogenic bladder)
Acute urinary retention without urethral catheterization
For a patient who is difficult to catheterize transurethrally, various steps are suggested before suprapubic
cystostomy is performed (see the image below).[1]
Failure to pass a urethral catheter may result from a false passage created by multiple attempts at urethral
catheterization or from urethral stricture disease. After a reasonable attempt at catheterization has been made,
including use of a coudé catheter, and if a urologist is not available to perform a flexible cystoscopy with
potential catheter placement over a wire, a suprapubic cystostomy is reasonable.
Urethral trauma
In the setting of urethral trauma, functional bypass of the urethra may be required because of the possibility of
urethral disruption. Urethral disruption is usually associated with pelvic fractures or saddle-type injuries and
should be suspected when the triad of (1) blood at the urethral meatus, (2) inability to urinate, and (3) a palpably
distended bladder is observed. The urethral injury should be addressed by a urologist; however, a suprapubic
cystostomy may be a valuable measure for emergency drainage of the bladder.
Complicated lower genitourinary infection
In a complicated infection of the lower genitourinary tract with associated urinary retention (eg, acute bacterial
prostatitis), bladder drainage with suprapubic cystostomy should be considered.
Another indication for suprapubic catheter placement is Fournier's gangrene, which often necessitates multiple
genitourinary debridement procedures and, potentially, skin grafting. If a urethral catheter impedes wound care
and surgical management of this complicated, dangerous disease, consider a suprapubic cystostomy to divert
urine from these surgical sites.
Long-term urinary diversion
Suprapubic catheterization may also be considered as an option in patients who require long-term urinary
diversion. The British Association of Urological Surgeons issued practice guidelines suggesting that clinicians
should consider whether a suprapubic catheter would be preferable to an urethral catheter for patients who
require a long-term indwelling catheter.[2]
A suprapubic catheter may be considered in patients with neurogenic bladder secondary to spinal cord
injuries, stroke, multiple sclerosis, neuropathy, or detrusor sphincter dyssynergia who are unable to void and
who are unable or unwilling to perform clean intermittent catheterization.[3, 2]
Patients who undergo phallic reconstruction or fistula repair[1] may also require longer-term urinary diversion. In
a retrospective study that included more than 10 years of follow-up data from 179 predominantly male patients
with spinal cord injuries, similar rates of urinary tract infections, bladder and renal calculi, and renal function
preservation were reported for those managed with urethral catheters and those managed with suprapubic
catheters.[4]
In this study,[4] urethral strictures, urethral fistulas, and scrotal abscesses were found only in the urethral catheter
group; 3 patients with urethral strictures and 3 patients with urethral-cutaneous fistulas switched to suprapubic
catheters as a result of these complications. Catheter-specific complications included erosion associated with
urethral catheters and leakage around the suprapubic catheter site and from the urethra.
1.4 Contraindications
Percutaneous suprapubic cystostomy is absolutely contraindicated in the following circumstances:
The bladder is not distended, is not easily palpable, or cannot be localized with ultrasonographic assistance