Key points
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A suprapubic catheter (SPC) is a safe way to drain the urinary bladder when the urethra is inaccessible or needs to be avoided.
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There are several well-established methods of placing a SPC; a percutaneous approach is the minimally invasive way to establish bladder drainage in urgent and nonurgent settings.
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Several kits are now commercially available providing a straightforward means to place an SPC with some basic training.
Introduction
Suprapubic catheter (SPC) insertion is a urologic procedure performed for several reasons. In the event of bladder outlet obstruction caused by a urethral stricture or an enlarged prostate, it is a quick way to drain the bladder at the bedside thereby resolving patient discomfort from an overly distended bladder. At other times, an SPC is placed permanently as in the case of neurogenic bladder where the patient is unable to void and is at risk for urinary tract infections (UTIs) and upper urinary tract deterioration from a chronically distended bladder.
There are several methods by which the clinician may place an SPC depending on the indication. The options range from an open suprapubic cystostomy, transurethral using modified sounds, percutaneous using trocars, and the Seldinger technique. Each of these methods has various technical modifications. This article focuses on percutaneous SPC placement.
Introduction
Suprapubic catheter (SPC) insertion is a urologic procedure performed for several reasons. In the event of bladder outlet obstruction caused by a urethral stricture or an enlarged prostate, it is a quick way to drain the bladder at the bedside thereby resolving patient discomfort from an overly distended bladder. At other times, an SPC is placed permanently as in the case of neurogenic bladder where the patient is unable to void and is at risk for urinary tract infections (UTIs) and upper urinary tract deterioration from a chronically distended bladder.
There are several methods by which the clinician may place an SPC depending on the indication. The options range from an open suprapubic cystostomy, transurethral using modified sounds, percutaneous using trocars, and the Seldinger technique. Each of these methods has various technical modifications. This article focuses on percutaneous SPC placement.
Anatomy
The bladder is an ovoid-shaped muscular structure that is hollow and stretches quite easily because of its compliance properties. The maximum capacity of an adult bladder is about 500 mL, but it is not unusual for the patient in acute retention to have in excess of 1 L in the bladder. The bladder is anchored to the anterior abdominal wall by a fibrous chord called the urachus. The posterior surface of the bladder is lined with the parietal peritoneum. When the bladder is empty it remains within true pelvis ( Fig. 1 ), slightly above the level of the pubic symphysis; as it distends it elevates into the abdominal cavity pushing the peritoneum and its contents posteriorly ( Fig. 2 ), away from the abdominal wall. When fully distended, the bladder is palpable hence making it easier to perform a percutaneous SPC placement. With abdominal surgeries, especially in the lower abdomen, adhesions are formed and these planes are often violated, placing the patient at increased risk of bowel injury. In infants, the risk of bowel injury is much less because the bladder is located more cephalad than in the adult.
Preprocedure planning
If asked to place a SPC, it should be verified that urethral access was tried and failed multiple times. In a difficult to catheterize male patient, a trained urologist has several options before resorting to an SPC, including bedside urethral dilation after passing a guidewire into the bladder, or using a flexible cystoscopy to bypass any false passages under direct vision and leave a guidewire, which can then be used to pass a catheter.
Before placing an SPC, the clinician must not only understand pelvic anatomy, but must obtain an accurate clinical history from the patient regarding the nature of urinary problems and prior abdominal surgeries. The decision to proceed and the approach could depend on information obtained from patient history. Next, a careful examination of the abdominal wall, genitalia, and prostate should be done. Special attention should be paid to the patient’s body habitus because SPC placement becomes significantly more challenging in the morbidly obese. There is also increased risk of bowel injury if an SPC is attempted in patients with a higher body mass index. Look for signs of surgical scars, which may be evident if the patient has had surgery. If there is any abdominal or pelvic imaging available, such as computed tomography, ultrasound, or retrograde urethrogram, these should be reviewed for preprocedure planning. Next, laboratory studies should be reviewed for any evidence of coagulopathy before performing any invasive procedure. Some authors suggest providing the patient with a single dose of prophylactic antibiotic, preferably one that provides coverage against skin flora.
Indications
The indication for placing an SPC is simple: the patient is in retention and is unable to void or empty his or her bladder. The following are often cited indications for percutaneous SPC placement:
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Urinary retention, unable to catheterize the urethra secondary to strictures, false passages, prostate cancer, or benign prostatic hyperplasia
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Intractable urinary incontinence
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Traumatic disruption of the posterior urethra
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Neurogenic bladder leading to chronic retention or urinary incontinence
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Temporary urinary diversion secondary to urethral/pelvic surgery or severe genital infection or trauma
Contraindications
There are few absolute contraindications to placing an SPC. With all percutaneous SPC kits, the bladder must be distended and palpable to limit misplacement of the catheter and injury to the viscera. The issue of prior abdominal surgery may be overcome by using ultrasound guidance, which could determine if there is bowel interposition between the abdominal wall and the bladder. Coagulopathy should be corrected or the patient may be at risk of severe bleeding or hematuria with clot retention, which would render the newly placed catheter nonfunctional. Another relative contraindication is a prior history of pelvic radiation.
Patient preparation
Informed consent should be obtained from the patient. The procedure is painful in the awake patient, and adequate local anesthetic should be prepared, even for an obtunded patient. For a combative or agitated patient, sedation should be considered because the patient needs to be still while the procedure is being performed. Personal protective equipment, such as mask with protective shield and gowns, should be worn.
The patient should be in the supine position; excess body hair should be shaved off to permit proper visualization. The patient can then be prepared from the pubic symphysis to the umbilicus, and sterile towels or drapes are then placed to maintain a sterile field. At this time a separate sterile field on an overbed table or Mayo stand should be ready with all the necessary equipment. Most of the listed equipment may be found in a standard laceration kit. The following equipment is necessary before starting the procedure:
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SPC kit, opened and inspected ( Fig. 3 )
