Suprapubic trocar drainage of the bladder

A review of our cases of urinary obstruction due to prostatism, in which urethral catheter drainage had been used as a means of preliminary preparation for operation, revealed that the preoperative morbidity and mortality in patients who were otherwise good risks was relatively high, and that complications were not infrequent. Further study of this group showed that these undesirable occurrences were directly attributable to urinary sepsis, and that in every instance this was introduced or accentuated by some form of urethral instrumentation. For this reason we believed that a method of drainage other than the urethral catheter should be used, and therefore in the past two years we have substituted suprapubic trocar drainage for such patients.A series of thirty-two cases of patients with urinary retention due to benign hypertrophy and carcinoma of the prostate treated in this manner has been reviewed, and the results of this study analyzed.By this method of preoperative preparation, the routine care of patients with obstruction of the bladder outlet is greatly facilitated, the urinary tract infection which accompanies urethral drainage is largely eliminated, excellent decompression of the bladder can be maintained without the subjective discomfort so often attendant upon an inlying urethral catheter and complications are infrequent.As a result of our experience, we believe that suprapubic trocar drainage of the bladder is an entirely safe procedure, and that its use in acute and chronic urinary retention due to prostatic obstruction has substantially reduced the preoperative and postoperative morbidity and mortality of this disease.     

Impact of Percutaneous Suprapubic Tube Drainage on Patient Discomfort after Radical Prostatectomy

Background

Patients undergoing radical prostatectomy (RP) traditionally require urethral catheterization for adequate bladder drainage in the postoperative period. However, many patients have significant discomfort from the urethral catheter.

Objective

To describe a technique of percutaneous suprapubic tube (PST) bladder drainage after robotic-assisted laparoscopic radical prostatectomy (RALP) and to evaluate patient discomfort, complications, continence, and stricture rate after this procedure.

Design, setting, and participants

Two hundred two patients undergoing RALP were drained with a 14F PST instead of a urethral catheter. The PST was placed robotically at the conclusion of the urethrovesical anastomosis and secured to the skin over a plastic button. Beginning on postoperative day 5, patients clamped the PST, urinated per urethra, and measured the postvoid residual (PVR) drained by PST. The PST was removed when residuals were <30 cm³ per void. The control group consisted of 50 consecutive patients undergoing RALP with urethral catheter drainage.

Measurements

The primary end point was catheter-associated discomfort as measured with the Faces Pain Score-Revised (FPS-R). Secondary end points included use of anticholinergics, complications related to the PST, urinary continence, and urethral stricture.

Results and limitations

When compared with urethral catheter patients, PST patients had significantly decreased catheter-related discomfort on postoperative days 2 and 6 (p < 0.001). Anticholinergic medication was required by one PST and four urethral catheter patients (p < 0.001). Ten patients required urethral catheterization for PST dislodgement (n = 5) or urinary retention (n = 5). No patient has developed a urethral stricture at a mean follow-up of 7 mo.

Conclusions

PST provides adequate urinary drainage following RALP with less patient discomfort and no increased risk of urethral stricture.     

单纯尿管引流与管中管引流在幼儿尿道成形术中的疗效比较

目的:比较尿道下裂术后单纯硅胶尿管引流与管中管法引流两种引流方法的优缺点。方法:回顾性总结2009年3月至2013年9月361例行尿道成形术尿道下裂患者的临床资料,其中91例采用尿管引流(A组)尿液,270例采用管中管引流(B组)尿液。比较两组患者术后膀胱刺激征、尿瘘、尿道狭窄及尿道憩室发生率。结果:A组发生膀胱刺激征9例(9.89%),尿瘘19例(20.80%),尿道狭窄10例(10.90%),尿道憩室1例(1.09%)。B组发生膀胱刺激征29例(10.70%),尿瘘36例(13.30%),尿道狭窄15例(5.55%),尿道憩室6例(2.22%)。两组膀胱刺激征及尿道憩室发生率并无统计学差别(P0.05),尿管引流组尿瘘发生率高于管中管引流组(P0.05)。尿管引流组尿道狭窄发生率高于管中管引流组(P0.05)。结论:管中管法置管方式并不复杂,疗效优于单纯尿管引流法,值得进一步推广。     

自制尿道引流管在尿道下裂手术中的应用

目的观察自制尿道引流管在尿道下裂手术中的应用效果,探讨尿道下裂术后合适的引流方法。方法2001年1月至2006年1月,应用自制尿道引流管联合Foley导尿管引流修复74例尿道下裂,其中远端型尿道下裂(阴茎头、冠状沟、阴茎前1/3)22例,中段尿道下裂(阴茎中1/3)28例,近端型尿道下裂(阴茎阴囊交界、阴囊、会阴)10例,行一期尿道重建;尿道下裂术后尿道狭窄5例,尿道下裂术后尿瘘9例,行再次手术。结果74例患者术后获随访4个月~4年,3例拔导尿管后出现尿瘘,3例术后出现尿道狭窄,其中5例均已获二期手术治愈。其余67例一期治愈,无尿瘘和尿道狭窄发生。结论尿道引流管和Foley导尿管联合经尿道引流是一种尿道下裂术后有效、可行的引流方法。     

Anterior urethral valve as a cause of end-stage renal disease

Although posterior urethral valves are predominant as a cause of obstructive uropathy in children, anterior urethral valves may also appear as the underlying etiologic factor in end-stage renal disease that results from obstruction. Two cases are presented of anterior urethral valve patients that were admitted with end-stage renal disease. The first case was successfully treated with diverticulectomy and urethral reconstruction in preparation for renal transplantation. The second case, however, had been on cystostomy drainage for 6 years and also had a contracted bladder. A more extensive lower urinary tract reconstruction was delayed. Children with poor stream and recurrent infections should be evaluated carefully and anterior urethral valve or diverticula should be considered in differential diagnosis of obstructive lesions.     

A scrotal graft technique for the repair of prostatic-cutaneous fistulas

Three patients who had a prostatic urethral fistula into the presacral space and perineal urinary drainage after rectal resection or vascular injury with rectal sloughing were treated successfully by a transperineal, extraurethral scrotal inlay flap.     

Experitoneal bladder perforation due to in-dwelling urethral catheter successfully treated by urethral drainage: a case report

Perforation of the bladder related to long-term indwelling urethral catheter is a rare and serious complication. A 85-year-old man with an indwelling urethral catheter presented severe hematuria, abdominal pain with rebound tenderness and muscular tension over the suprapubic area after the exchange of the urethral catheter. Computed tomography and cystogram revealed experitoneal bladder perforation due to indwelling catheter. Three weeks after the indwelling urethral catheter had been placed, the perforation was closed. In most cases, laparotomy and suprapubic cystostomy are performed. We describe the case of experitoneal bladder perforation successfully treated by urethral drainage.     

Optical internal urethrotomy as the treatment of choice for primary stricture of the urethra

Seventy-five patients with primary urethral strictures were treated by optical urethrotomy with catheter drainage for 7 days. Good results were obtained in 66% of cases, which were all post-traumatic in nature; 34% had to undergo further procedures such as dilatation or repeat internal urethrotomy.     

Reconstructive surgery for trauma of the lower urinary tract

Blunt external trauma is the most common cause of injuries of the lower urinary tract. Minor injuries often heal uneventfully with catheter drainage. Penetrating traumas are best treated with primary repair. Delayed reconstruction of urethral disruption injuries is safe and effective in the majority of cases, but immediate realignment is an attractive, minimally invasive alternative. Pelvic MR imaging and urethral ultrasound are important ancillary staging studies for evaluating patients who require complex urethral reconstruction.     

Management of extraperitoneal ruptures of bladder caused by external trauma

We reviewed 105 cases of extraperitoneal bladder rupture admitted to our hospitals from 1959 to 1985. Primary suturing of the rupture was performed in 65 patients, and catheter drainage alone without suturing of the rupture was performed in 34. The incidence of blunt trauma causing the rupture of gross hematuria on admission, and of associated injuries was similar in both groups. There was a higher incidence of women older than sixty years in the group managed by catheter drainage alone, and a higher incidence of laparotomy for associated intra-abdominal injuries and a higher mortality rate in the group treated by primary suturing. There were three early complications in the group treated by suturing (hematuria with clot retention 2, sepsis contributing to death 1) and four early complications in the conservatively treated group (hematuria with clot retention 1, pseudodiverticulum with bone spike in its floor 1, persistent urinary fistula 1, and sepsis contributing to death 1). There were two late complications in 42 patients followed in the group treated by suturing (urethral stricture 1, frequency and dysuria 1), and three late complications in 14 patients followed in the conservatively treated group (hyperreflexic bladder 2, urethral stricture and vesical calculi 1). Catheter drainage alone for extraperitoneal rupture from external trauma was simple, quick to perform, and appealing in the multiple-injured patient. Although the early and late complication rates were higher in the conservatively managed group, there was no statistically significant difference from the group treated by primary suturing.     

Turner-Warwick urethroplasty and urethral stricture Results in 60 patients

Sixty patients with urethral strictures at the bulbous and membranous levels were treated with Turner-Warwick urethroplasty. Initially, there were significant difficulties with restenosis of either the proximal or distal stoma following the first-stage urethroplasty. Use of nitrofurazonehydrocortisone (Furacin-Hc) urethral suppositories practically eliminated recurrent stomal stenosis after the first stage. Several additional modifications were made in the original technique; these included placement of urethral sutures prior to scrotal mobilization and abandonment of the suprapubic cystotomy for drainage at the second stage of the procedure. These modifications increased the chances of achieving a successful result while facilitating the actual surgery and improving the patients' comfort. The over-all success rate was approximately 90 per cent. Patients with urethral stricture surgery subsequent to prostatectomy had problems with urinary control, but not so if prostatectomy was done after the first stage of urethroplasty. It appears that the Turner-Warwick urethroplasty is a good one, and predictably good results can be expected on selected patients with urethral strictures.     

Recent traumatic lesions of the male anterior urethra. Apropos of 17 cases

Seventeen cases of anterior urethral injuries are presented. The authors define the management of these lesions: emergency IVP and suprapubic catheter drainage; after three to five days, retrograde and voiding urethrography and surgical repair: end to end anastomosis when the rupture is complete (8 cases with 7 good results, 1 fair result), in case of partial rupture, surgical repair should be preferred (2 cases with 2 good results); the other alternatives, urethral catheter (2 cases), or suprapubic catheter drainage with delayed treatment of stricture (3 cases), appeared to be less comfortable, contusions must be treated conservatively.     

The female urethral diverticula: apropos of 21 cases

PURPOSE: Our goal is to study the clinical, radiological and therapeutic particularity of the female urethral diverticula via a retrospective study of 21 cases. PATIENT AND METHODS: Twenty one females, with a mean age of 37 years (range 15 to 62 years) presenting an urethral diverticula, were treated between 1988 and 2000. Clinical examination made diagnosis in all cases. Cystorethrography shown a direct image of diverticula in 100% of cases and intravenous Pyelography in only 24% of cases. The urethral diverticula was excised via a transvaginal approach in all cases. RESULTS: Eighteen patients had favourable immediate outcome. Three patients presented an urethrovaginal fistula treated surgically in one case and by bladder drainage in one case. The last patient refused treatment and she was lost to follow-up. After a median follow-up of 54 months (range 18 to 120) only three patients have some urinary urgency that was treated by anticholinergics. CONCLUSION: Female urethral diverticula is a rare disease, the diagnosis is easy and only surgical excision gives good results.     

Surgical Treatment of 31 Complex Traumatic Posterior Urethral Strictures Associated with Urethrorectal Fistulas

Background

Urethrorectal fistulas (URF) in patients with complex posterior urethral strictures are rare and difficult to repair surgically. There is no widely accepted standard approach described in the published literature.

Objective

The aim of this study was to describe the outcomes of various operative approaches for the repair of URFs in patients with complex posterior urethral strictures.

Design, setting, and participants

From January 1985 to December 2007, 31 patients (age: 6–61 yr; mean: 28.4) with URFs secondary to posterior urethral strictures were treated using a perineal or combined abdominal transpubic–perineal approach.

Interventions

A simple perineal approach was used in 4 patients; a transperineal inferior pubectomy approach was used in 18 patients; and a combined transpubic–perineal approach was used in 9 patients. A bulbospongiosus muscle and subcutaneous dartos pedicle flaps were interposed between the repaired rectum and urethra in 22 patients. The combined transpubic–perineal approach used either a gracilis muscle flap (one patient) or a rectus muscle flap (eight patients).

Measurements

Suprapubic catheterisation was used for bladder drainage, and a urethral silicone stent was left indwelling for 4 wk.

Results and limitations

One-stage repair was successful in 4 patients (100%) using the perineal approach, in 16 of 18 patients (88.9%) using the transperineal–inferior pubectomy approach, and in 7 of 9 patients (77.8%) using the transpubic–perineal approach. Recurrent urethral strictures developed in two cases; one patient required regular dilation, and the other patient was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent URFs developed in two additional patients.

Conclusions

Surgical approaches for the treatment of URFs associated with complex urethral strictures should be based on a number of considerations including the location of the URF, its aetiology, the length of the urethral strictures, and a history of previous unsuccessful repairs. These results demonstrate that the transperineal–inferior pubic approach may be appropriate as a first-line procedure.     

Is there a difference in outcome when treating traumatic intraperitoneal bladder rupture with or without a suprapubic tube?

PURPOSE: Primary bladder repair with a suprapubic tube is considered to be effective for managing intraperitoneal bladder injury. We compared the outcomes of suprapubic tube placement and no suprapubic tube for this injury. MATERIALS AND METHODS: We reviewed the charts of 31 men and 3 women with a mean age of 28.5 years who required emergency operative repair without a cystogram of traumatic bladder injury from 1992 to 1997. Patient characteristics, mechanism of injury, associated injuries, and short and long-term complications were reviewed. RESULTS: Penetrating and blunt trauma occurred in 28 (82%) and 5 (15%) patients, respectively, while 1 had spontaneous bladder rupture. After primary bladder repair the bladder was drained with a suprapubic tube in 18 cases (53%) and a urethral catheter only in 16 (47%). There were no significant differences between the 2 groups with respect to mechanism of injury, patient age, location of injury in the bladder, coexisting medical illnesses, stability in the field or emergency room, or the bladder repair technique. The 18 patients treated with a suprapubic tube had an associated injury that resulted in 2 deaths, while 13 of the 16 treated with urethral catheter drainage only had an associated injury and 1 died. Urological and nonurological complications in the suprapubic tube versus urethral catheter only group developed in 28 and 33 versus 19 and 19% of the cases, respectively (p <0.05). Followup ranged from 1 month to 4 years. No significant long-term morbidity was noted in either group. CONCLUSIONS: These data indicate that intraperitoneal bladder injuries may be equally well managed by primary bladder repair and urethral catheter drainage only versus suprapubic tube drainage.     

Long-Term Results of Internal Urethrotomy

Purpose

A retrospective analysis was done of long-term results of internal urethrotomy to evaluate risk factors of stricture recurrence.

Materials and Methods

Followup studies were performed of 937 patients with urethral strictures treated with internal urethrotomy. Of the patients 357 were treated at Mainz University between 1977 and 1989 (mean followup 4.6 years) and 580 were treated at Bonn University between 1974 and 1986 (mean followup 3.2 years).

Results

Strictures recurred in 96 of 357 (26.9 percent) and 260 of 580 (44.8 percent) patients, respectively. Risk factors for recurrence were etiology (post-transurethral resection and inflammation), stricture longer than 1 cm. and postoperative catheter drainage for longer than 3 days.

Conclusions

Urethroplasty should be considered in patients at high risk for stricture recurrence and with more than 1 treatment failure after urethrotomy.     

Direct vision internal urethrotomy. A prospective study of 81 primary strictures treated with a single urethrotomy

The post-operative treatment of urethral strictures as well as the criteria of success have varied considerably. In order to find a solution to this problem, we undertook a prospective evaluation of 81 men treated for their first urethral stricture with a single urethrotomy. Fifty-one patients with a stricture 5 mm or less in length were catheterised post-operatively for 3 days. Patients with strictures longer than 5 mm were catheterised for 3 weeks (14 patients) or 6 weeks (16 patients). All were followed up for a minimum of 24 months. The stricture recurred in 33 patients (41%). We found that 3 days' catheter drainage was sufficient for patients with short strictures. Whether strictures measuring more than 5 mm might be treated similarly needs further investigation.     

Surgical technique and results of primary repair in recent urethral injuries: a review of 49 consecutive cases.

Late results after primary repair in 49 recent urethral injuries of the urethra treated through a perineal approach by sutures of realignment with splinting, and suprapublic and perineal drainage were assessed by measuring urethral flow, urethrography, urine analysis and other examinations. In 15 straddle injuries the results were excellent. Of 34 injuries associated with pelvic fracture 50% had satisfactory results. 12% had marked, but tolerable difficulties in micturition. Important details of operative technique are mentioned. A preference for primary repair in comparison with early cybstostomy and delayed reconstruction of the urethra is confirmed.     

Non-operative treatment of the ruptured bladder.

Open surgical drainage is not necessary in all patients with bladder rupture. Two patients with an extraperitoneal rupture and 1 with an intraperitoneal rupture were successfully managed with urethral catheter drainage only. Our rationale and specific criteria for this treatment are presented. We believe that in selected patients urethral catheter drainage is a safe, simple and effective method of treating the ruptured bladder.     

A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL COMPARING SUPRAPUBIC WITH URETHRAL CATHETERIZATION IN RECTAL SURGERY

Background : Bladder drainage is necessary for several days following rectal surgery. Urethral catheterization has long been known to be associated with significant morbidity. Therefore a prospective randomized trial was performed to determine if this morbidity could be decreased by suprapubic catheterization. Methods : One hundred and thirty-seven patients undergoing rectal surgery were prospectively randomized to either suprapubic or urethral catheterization. Results : After exclusions, 108 patients were analysed. Of the 49 patients with suprapubic catheters there was 14% morbidity, and of the 59 patients with urethral catheters there was 32% morbidity. Significant bacteriuria was halved with suprapubic catheterization. Patient acceptability of suprapubic catheterization was high, and there was no increased morbidity in any of the areas studied. Conclusions : This study suggests that suprapubic catheterization has advantages over urethral catheterization with decreased bacteriuria, and greater patient acceptability. However, the significance of decreased bacteriuria is not clear and therefore we can only say suprapubic catheter drainage is comparable to urethral catheter drainage.