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Decreasing suprapubic tube-related injuries: results of case series and comprehensive literature review.

Bowel-related injuries are known complications of suprapubic tube (SPT) catheterization placement. A literature review was conducted to determine identifiable risk factors for bowel injury. Results on the analysis Of 25 cases are presented along with a proposed algorithm to aid in choosing between open, percutaneous, and image-guided methods of placement.

Key Words: Suprapubic tube, percutaneous, complications, bowel injury.

Suprapubic tube catheterization (SPT) is a commonly performed technique for urinary diversion in select patient populations (see Table 1). However, an unusually high mortality rate (1.8%) for such a minor procedure has been reported (Ahluwalia et al., 2006). Suprapubic catheterization is superior to urethral catheterization with regards to patient satisfaction, comfort, incidence of urethral irritation and erosion, assessment of voiding, and ease of nursing care (Niel-Weise & Van den Broek, 2005; Sheriff et al., 1998).

Open placement of an SPT is considered the gold standard because it provides for direct vision, placement of a large catheter, and tacking of the bladder to the anterior abdominal wall to facilitate future catheter changes. Open placement, how ever, likely increases the cost of the procedure due to the surgical morbidity associated with general and spinal anesthesia.

Although infrequent, bowel perforation and obstruction are known complications of percutaneous SPT, occurring in approximately 0.3% to 2.7% of cases (Ahluwalia et al., 2006; Cronin et al., 2011; Flock, Litvak, & McRoberts, 1978; Sheriff et al., 1998). As a result of five recent cases of bowel injury related to percutaneous SPT placement at our institution, the literature was reviewed in an effort to provide physicians with guidance regarding risk-stratifying patients for open as opposed to percutaneous SPT placement.

Materials and Methods

A review of the literature was performed using PubMed. All available English language articles were identified using the search terms percutaneous, suprapubic tube, bowel injury, and complication of suprapubic tube. Articles reporting percutaneous SPT placement-related bowel injury were selected. Five bowel injury cases that recently occurred at our institution were added to the data analysis.

Data were obtained regarding the technique of SPT placement utilized, incurred bowel complications, timing of presentation of the complication, and underlying patient risk factors. Percutaneous SPT-related bowel injuries were stratified according to the Clavian classification of surgical complications (see Figure 1) (Dindo, Demartines, & Clavien, 2004).

Results

A comprehensive review of the literature demonstrated that after SPT placement, the most common complications in the peri-procedure setting were urosepsis, surgical site infection, surgical site bleeding, and catheter obstruction. Common post-procedure complications included catheter obstruction, urinary tract infection (UTI), catheter malposition, difficult catheter change, and SPT site infection/bleeding, some of which may be technique-related.

In addition to our five cases, 28 patients incurring bowel injury as a complication of percutaneous SPT placement were identified in a total of 18 articles or case reports (see Table 2). Two articles involving eight patients identified in the literature were excluded due to insufficient information (Ahluwalia et al., 2006; Sheriff et al., 1998), leaving 25 patients for review. Bowel injury complications presented both acutely after SPT placement (14/25, 56%) and later at the time of initial SPT change (11/25, 44%). Prior abdominal surgery (13/25, 52%), external beam radiation therapy (EBRT) (6/25, 24%), and a small/thick walled non-distensible bladder (4/25, 16%) were common factors noted in patients with SPT-associated bowel injury (see Figure 2). Only 8% of bowel injuries occurred in patients without risk factors. Of these 25 patients, three had Clavien Class II complications, 20 had Clavien Class IIIb complications, and two had a Clavien Class V complication.

Discussion

SPT placement is a commonly performed technique for urinary diversion in select patients. Indications for placement include acute urinary retention and inability to place a urethral catheter, urethral stricture disease, poor detrusor contractility, neurogenic bladder dysfunction, elderly patients with lower urinary tract symptoms in whom an indwelling urethral catheter is not a suitable alternative, and chronic bladder outlet obstruction (Niel-Weise & Van den Broek, 2005; Sheriff et al., 1998).

Minimally invasive alternatives have been developed, such as the Lowsley retractor, percutaneus punch, and Bonnano, Rutner, Stamey, and Sofflex devices. Two of the more commonly performed minimally invasive techniques, the Staney procedure and use of the Lowsley tractor, were recently highlighted (Bullman, 2011). These percutaneous devices can be utilized under local anesthesia/intravenous sedation in a cost-effective and safe manner in patients with significant co-morbid medical conditions. Despite the low risk associated with this procedure, the use of ultrasound or fluoroscopy to guide catheter placement, as well as Trendelenburg positioning, has been proposed to decrease the risk of organ injury (Aguilera, Choi, & Durham, 2004; Ahluwalia et al., 2006; Bonanno, Landers, & Rock, 1970; Cromie & Lake, 1978; Cronin et al., 2011; Flock et al., 1978; Lingard & Foote, 2005; Mond & Lee, 1994).

A variety of complications have been reported after percutaneous SPT placement. In 1978, Flock and colleagues published their initial experience with SPT placement in 250 individuals. They noted a low minor complication rate of 1.6% and a bowel injury rate of 0.4% (Flock et al., 1978). Ahluwalia et al. (2006) described a 10% intra-operative complication rate, 2.4% risk of bowel injury, and a mortality rate of 1.8% in 219 patients. An additional review by Sheriff et al. (1998) reported a 10% intraoperative complication rate, 2.7% rate of bowel injury, and a 0.8% mortality rate in patients with neurogenic bladders. The difference in mortality rates between the Ahluwalia and Sheriff's series may reflect that the latter patient population was significantly younger (mean age 73 years vs. 37.5 years) and had less co-morbid conditions.

Additional complications have been reported after percutaneous SPT placement, including intraperitoneal extravasation, extraperitoneal extravasation, infection, ureteral obstruction, catheter obstruction or dislodgement, hematuria, hernia, bowel obstruction, subcutaneous emphysema, urosepsis, and bladder penetration with associated rectal, vaginal, or uterine injury (Dangle, Tycast, Vasquez, Geary, & Chehval, 2010; Heit, 1997; Lobel & Sand, 1997; Vaidyanathan, Soni, Singh, & Hughes, 2006). Such complications may result in significant morbidity, even mortality, and thus, efforts have been made to improve the safety of SPT placement.

Modifications in technique, such as patient positioning, bladder distention, image-guidance with ultrasound, and fluoroscopy, have been reported as methods to decrease the risk of complication (Ahluwalia et al., 2006; Cronin et al., 2011; Flock et al., 1978; Sheriff et al., 1998). Placing the patient into a Trendelenburg position uses gravity to displace bowel away from the bladder. In patients with prior abdominal/pelvic surgery or EBRT, this may not be possible secondary to adhesions and scarring. Distention of the bladder is limited in many patients as well. Only those patients with a patent urethra and a non-contracted bladder are amenable to this approach.

Efforts to successfully place larger catheters to prevent obstruction and dislodgment have focused on the placement of urethral sounds to juxtapose the anterior bladder wall against the anterior abdominal wall (Bonanno et al., 1970; Cromie & Lake, 1978; Lingard & Foote, 2005). This approach requires a patent urethra and is not advisable in individuals with small capacity, contracted bladders, and in whom bladder distention is not possible. Despite the advantages offered by this technique, it still has limitations of a percutaneous approach, and trapping of the bowel can still occur.

Cho, Doo, Yang, Song, and Lee (2010) evaluated the impact of bladder distension on bowel displacement. In their study, computerized tomography (CT) scans of 226 patients with bladder distension greater than 6 cm above the symphysis pubis were reviewed to assess the proximity of bowel loops to the potential SPT tract. Bowel was identified in the path of the proposed SPT tract in 40.9% of those patients with and only 8.3% of those without a history of prior pelvic surgery. Obesity, history of pelvic surgery, and a short distance (< 11 cm) between the symphysis pubis and umbilicus correlated significantly with bowel presence within the proposed SPT tract (Cho et al., 2010).

The use of ultrasound and fluoroscopy guidance has been advocated as methods to evaluate bladder distention, assess for overlying loops of bowel, and visualize catheter placement (Aguilera et al., 2004; Cronin et al., 2011; Mond & Lee, 1994). Ultrasound-assisted percutaneous SPT placement in the emergency room by knowledgeable emergency room physicians has been demonstrated to be a safe and effective method for emergent bladder decompression. A study out of UCLA (Aguilera et al., 2004) demonstrated no complications following ultrasound-guided placement of Stamey percutaneous cystostomy catheters in 17 consecutive patients requiring emergent bladder decompression. The authors noted that obesity creates an acoustic barrier that can limit visualization (Aguilera et al., 2004). In addition, pressure on the ultrasound probe over the lower abdominal wall may interfere with visualization of bowel loops, and individuals with contracted bladders may not achieve sufficient bladder distention for adequate visualization.

Fluoroscopic guidance has been shown to be useful in percutaneous SPT placement in the interventional radiology literature. In a series of 549 percutaneous SPT placements under fluoroscopic guidance, the authors noted a minor complication rate of 7.2% at insertion and 4.8% on catheter exchange with a major complication rate of 0.3%. The minor complications included hemorrhage (3.3%), pain (1%), urinary tract infection (UTI) (1%), and urine leak (1.8%). Only one patient experienced a small bowel injury for a small bowel perforation rate of 0.3%. No mortalities were reported in their series (Cronin et al., 2011).

A variety of techniques have been employed for placement of suprapubic tubes. Each technique has advantages, disadvantages, as well as different complication rates, which may be pertinent to patient selection (see Table 3). Analysis of the literature revealed that risk factors for the complications of bowel injury during percutaneous SPT placement include a small capacity or thickwalled neurogenic bladder, patients with a bladder that cannot be adequately distended, history of prior abdominal/pelvic EBRT, and/or surgery. Thickwalled, small-capacity bladders can be diagnosed through history, physical, cystoscopy, ultrasound, and urodynamics. Percutaneous SPT-related bowel injury has a bimodal presentation, and may manifest symptoms and signs of bowel injury at either the time of SPT catheter insertion or following the initial catheter change.

History, physical examination, laboratory data, and radiologic imaging are useful adjuncts for diagnosis of bowel injury (see Figure 3). Based on the literature and our institutional experience, consideration of open SPT placement is proposed for high-risk patients. Additionally, the use of ultrasound and/or fluoroscopy, the Trendelenburg position, and bladder distension during percutaneous SPT placement may help to decrease the incidence of bowel injury in this population (see Figure 4).

As part of a quality assurance project in our division, a decision-making algorithm was developed in an attempt to identify patient risk factors and methods to decrease the risk of SPT-related bowel injury in our institution. The algorithm was presented to members of our division of urology and adopted into practice (see Figure 4).

Nursing awareness regarding potential complications of suprapubic tube placement and the presenting signs and symptoms is critical. Nurses have an important role in caring for patients who undergo placement of suprapubic tubes. This not only involves strict attention to post-operative complications but also patient education to facilitate the transition to management at home. Post-operatively, the patient should be monitored for fever; changes in the location and nahtre of pain; lack of urinary drainage, which could represent catheter obstruction or dislodgement; urinary tract infection; and changes in color, consistency, or presence of particulate matter in the urine, which may be indicative of stool, stone debris, urinary tract infection, and dehydration (Ahluwalia et al., 2006). Proper care of suprapubic tubes, wound care, securing the catheter to prevent dislodgement, and monitoring of urine output are all key elements of patient education by nursing (Bullman, 2011). The urologist often does the first suprapubic tube change approximately four to six weeks after placement. Subsequent changes can be delegated to trained nursing staff. Although the majority of SPT-related bowel injuries present early after placement or at the time of the first SPT change, some present later, and nurses will often be the recipients of phone calls regarding the presence of feculent material in the urine or from the SPT site. Thus, awareness of this complication will help nursing staff prompt patients to seek immediate evaluation. In addition to the short-term issues related to SPT placement, there are long-term risks, including bladder stones and development of bladder cancer. Therefore, it is important for patients to understand the need for follow-up cystoscopic examinations and renal ultrasound every five years post-placement (Vaidyanathan, Soni, Hughes, Singh, & Oo, 2011)

Conclusion

Prior abdominal surgery, abdominal/pelvic EBRT, and a small/thick-walled non-distensible bladder are risk factors for percutaneous SPT-associated bowel injury and are present in 92% of bowel injury cases. Consideration of open or image-guided percutaneous SPT placement in patients with small capacity or thick-walled neurogenic bladders, those in whom the bladder cannot be distended adequately, prior abdominal/pelvic EBRT, and/or surgery is advocated (see Figure 4). If the patient's ASA score is greater than or equal to 3, percutaneous image-guided approaches should be used. If percutaneous SPT is planned, Trendelenburg positioning and the use of ultrasound and/or fluoroscopy at the time of SPT placement is supported by the literature review.

Objectives:

1. Describe indications for suprapubic tube catheterization (SPT) placement.

2. Discuss the prevalence of injuries resulting from SPT as discovered in dais literature review.

3. Identify alternatives for catheter placement that may alleviate or reduce suprapubic tubing injuries.

References

Aguilera, P.A., Choi, T., & Durham, B. A. (2004). Ultrasound-guided suprapubic cystostomy catheter placement in the emergency department. The Journal of Emergency Medicine, 26(3), 319-321.

Ahluwalia, R.S., Johal, N., Kouriefs, C., Kooiman, G., Montgomery, B.S., & Plail, R.O. (2006). The surgical risk of suprapubic catheter insertion and long-term sequelae. Annals of the Royal College of Surgeons of England, 88(2), 210-213.

Ahmed, S.J., Mehta, A., & Rimington, P. (2004). Delayed bowel perforation following suprapubic catheter insertion. BMC Urology, 4(1), 16.

Bonanno, P.J., Landers, D.E., & Rock, D.E. (1970). Bladder drainage with the suprapubic catheter needle. Obstetrics & Gynecology. 35(5), 807-813.

Bullman, S. (2011). Ins and outs of suprapubic catheters--A clinician's experience. Urologic Nursing, 31(5), 259-263.

Cho, K.H., Doo, S.W., Yang, W.J., Song, Y.S., & Lee, K.H. (2010). Suprapubic cystostomy: Risk analysis of possible bowel interposition through the percutaneous tract by computed tomography. Korean Journal of Urology, 51(10), 709-712.

Cromie, W.J., & Lake, M.H. (1978). The Lowsley cystotomy. Urology, 11(1), 78.

Cronin, C.G., Prakash, P., Gervais, D.A., Hahn, P.F., Arellano, R., Guimares, A., & Mueller, P.R. (2011). Imaging-guided suprapubic bladder tube insertion: Experience in the care of 549 patients. American Journal of Roentgenology, 196(1), 182-188.

Cundiff, G., & Bent, A.E. (1995). Suprapubic catheterization complicated by bowel perforation. International Urogynecology journal, 6(2), 110-113.

Dangle, P.P., Tycast, J., Vasquez, E., Geary, B., & Chehval, M. (2010). Suprapubic cystostomy: A bizarre complication of catheter migration causing ureteric obstruction. Canadian Urological Association Journal, 4(5), E127-E128.

Dindo, D., Demartines, N., & Clavien, P.A. (2004). Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of Surgery, 240(2), 205.

Flock, W.D., Litvak, A.S., & McRoberts, W.J. (1978). Evaluation of closed suprapubic cystostomy. Urology, 11(1), 40-42.

Goldblum, D., & Brugger, J.J. (1999). Bowel obstruction caused by dislocation of a suprapubic catheter. Surgical endoscopy, 13(3), 283-284.

Hebert, D.B., & Mitchell, G.W. (1983). Perforation of the ileum as a complication of suprapubic catheterization. Obstetrics & Gynecology, 62(5), 662-664.

Heit, M. (1997). Infectious peritonitis complicating suprapubic catheter removal. International Urogynecology Journal, 8(1), 47-49.

Liau, S.S., & Shabeer, U.A. (2005). Laparoscopic management of cecal injury from a misplaced percutaneous suprapubic cystostomy. Surgical Laparoscopy Endoscopy & Percutaneous Techniques, 15(6), 378-379.

Lingard, C., & Foote, A.J. (2005). Suprapubic catheterisation: A retrospective comparison of two insertion systems. Australian and New Zealand Journal of Obstetrics and Gynaecology, 45(1), 74-76.

Lobel, R.W., & Sand, P.K. (1997). Incisional hernia after suprapubic catheterization. Obstetrics & Gynecology, 89(5), 844-846.

Mond, D.J., & Lee, W.J. (1994). Fluoroscopically guided suprapnbic cystostomy in complex urologic cases. Journal of Vascular and Interventional Radiology, 5(6), 911-914.

Mongiu, A.K., Helfand, B.T., & Kielb, S.J. (2009). Small bowel perforation during suprapubic tube exchange. Canadian Journal of Urology, 16(1), 4519-4521.

Moody, T.E., Howards, S.S., Schneider, J.A., & Rudolf, L.E. (1977). Intestinal obstruction: A complication of percutaneous cystostomy. A case report. The Journal of Urology, 118(4), 680.

Morse, R.M., Spirnak, J.P., & Resnick, M.I. (1988). Iatrogenic colon and rectal injuries associated with urological intervention: report of 14 patients. Journal of Urology, 140(1), 101-103.

Niel-Weise, B.S., & Van den Broek, P.J. (2005). Urinary catheter policies for short-term bladder drainage in adults. Cochrane Database System Review, 3, CD004203.

Noller, K.L., Pratt, J.H., & Symmonds, R.E. (1976). Bowel perforation with suprapubic cystostomy Report of two cases. Obstetrics and Gynecology, 48(1, Suppl.), 67S-69S.

Parikh, A., Chapple, C.R., & Hampson, S.J. (2008). Suprapubic catheterisation and bowel injury. British Journal of Urology, 70(2), 212-213.

Pieretti, R.V., & Pieretti-Vanmarcke, R.V. (1995). Combined abdominal and posterior sagittal transrectal approach for the repair of rectourinary fistula resulting from a shotgun wound. Urology, 46(2), 254-256.

Sheriff, M.K., Foley, S., McFarlane, J., Nauth-Misir, R., Craggs, M., & Shah, P.J. (1998). Long-term suprapubic catheterisation: Clinical outcome and satisfaction survey. Spinal Cord, 36(3), 171-176.

Simpson, R.R. (2001). An unusual cause of small bowel obstruction: The misplaced suprapubic catheter. The Journal of Urology, 165(6), 1998-1998.

Tompkins, A.J., Travis, M., Watne, R.E., Lasser, M., & Ellsworth, P. (2014). Decreasing suprapubic tube-related injuries: Results of case series and comprehensive literature review. Urologic Nursing, 34(1), 9-17. doi: 10.7257/1053-816X.2014.34.1.9

Vaidyanathan S., Soni B., Hughes P., Singh G., & Oo T. (2011). Preventable long-term complications of suprapubic cystostomy after spinal cord injury: Root cause analysis in a representative case report. Patient Safety in Surgery, 5, 27-34.

Vaidyanathan, S., Soni, B.M., Singh, G., & Hughes, P.L. (2006). Fatality due to septicemia and hemorrhage in a patient with spinal cord injury and ischemic heart disease with the need for long-term catheter drainage. Advances in Therapy, 23(2), 354-358.

Witham, M.D., & Martindale, A.D. (2002). Occult transfixation of the sigmoid colon by suprapubic catheter. Age and Ageing, 31(5), 407-408.

Wu, C.C., Su, C.T., & Lin, A.C. (2007). Terminal ileum perforation from a misplaced percutaneous suprapubic cystostomy. European Journal of Emergency Medicine, 14(2), 92-93.

Andrew J. Tompkins, MD, is a Urologic Resident Surgeon, Rhode Island Hospital, Providence, RI.

Michelle Travis, NP, is a Nurse Practitioner, VA Medical Center, Providence, RI.

Reed E. Watne, is a Student, Brown University, Providence, RI.

Michael Lasser, MD, is Medical Director of Robotic Surgery, Atlantic Coast Urology, Neptune, NJ.

Pamela Ellsworth, MD, FAAP, FACS, is a Urologist, University Urological Association, Providence, RI.

Tompkins, A.J., Travis, M., Watne, R.E., Lasser, M., & Ellsworth, P. (2014). Decreasing suprapubic tube-related injuries: Results of case series and comprehensive literature review. Urologic Nursing, 34(1), 9-17. doi:10.7257/ 1053-816X.2014.34.1.9

Table 1.
Common Indications for Suprapubic Tube

Symptomatic elevated post-void residual and inability to perform clean
intermittent catheterization (CIC)

Urethral erosion with chronic indwelling urethral catheter

Traumatic urethral disruption

Temporary diversion following certain urologic/gynecologic procedures

Table 2.
Literature Review of Suprapubic Tube-Related Bowel Complications

                        Patient Age, Gender,
Authors                   and Risk Factors            Technique

Ahluwalia et al.,       Not reported            Cystoscopic bladder
2006"                                           distention with
                                                visual guidance

Ahmed, Mehta, &         86m, pelvic surgery     Lawrence Add-a-Cath
Rimington, 2004         and EBRT                trocar with
                                                ultrasound guidance

Cronin et al., 2011     History midline         Fluoroscopic and
                        laparotomy              US guided SPT in
                                                interventional
                                                radiology

Cundiff & Bent, 1995    62f, TAH-BSO, pelvic    Trendelenburg,
                        prolapse, and SUI       bladder filled to
                        procedures              400cc, Rutner
                                                catheter through
                                                stab incision with
                                                cystoscopy

Flock, Litvak, &        History of prior        Lowsley tractor in
McRoberts, 1978         lower abdominal         bladder and cut down
                        surgery                 onto tip and Foley
                                                delivered into
                                                bladder

Flock, Litvak, &        Neurogenic bladder      Lowsley tractor in
McRoberts, 1978                                 bladder and cut down
                                                onto tip and Foley
                                                delivered into
                                                bladder

Goldblum & Brugger,     78m, retention          Cystofix SPT with
1999                                            cystoscopic guidance

Hebert & Mitchell,      37f, open CCY'and       Following total
1983                    Marshall-Marchetti-     abdominal
                        Krantz procedure        hysterectomy,
                                                bladder filled to
                                                400cc and Argyle
                                                Ingram SPT placed
                                                percutaneously

Hebert & Mitchell,      57f, G5P3 and           Cysto-Trocath placed
1983                    uterine prolapse        through urethra,
                                                into bladder and out
                                                SP incision
                                                following total
                                                vaginal hysterectomy

Liau & Shabeer, 2005    72f, MS                 Percutaneous SPT

Mongiu, Helfand, &      88f, PV sling, AUS      Cystoscopic assisted
Kielb, 2009             SP approach             SPT

Moody, Howards,         69m, Bilroth II         Percutaneous Bonanno
Schneider, & Rudolf,    gastrojejunostomy,      SPT
1977                    s/p TURP with
                        retention

Morse, Spimak, &        65m, urinary            Punch SPT
Resnick, 1988           retention

Noller, Pratt, &        35f, G10P5              Transurethral Davis
Symmonds, 1976                                  sound, 16 French
                                                foley

Noller, Pratt, &        72f, cystocele,         Bladder filled to
Symmonds, 1976          enterocele,             400 cc, chest tube
                        perineorrhhaphy         trocar SPT with 14
                                                French foley

Parikh, Chapple, &      82f, pelvic surgery     SPT placed with
Hampson, 2008           and EBRT                Nottingham
                                                introducer under
                                                general anesthesia

Parikh, Chapple, &      92f, pelvic EBRT        SPT placed with
Hampson, 2008                                   Nottingham
                                                introducer under
                                                general anesthesia

Pieretti & Pieretti-    7mos m, bladder         Percutaneous Stamey
Vanmarcke, 1995         exstrophy, retention    SPT

Sheriff et al.,         Most patients with      Cystoscopic bladder
1998 *                  neurogenic bladder      distention with
                                                visual guidance
                                                using "Add-a Cath"
                                                or Nottingham
                                                introducer

Simpson, 2001           76m, acute retention    Percutaneous SPT

Tompkins, Travis,       86f, PV sling and       Percutaneous SPT
Watne, Lasser, &        cystocele
Ellsworth, 2014
(current article)

Tompkins, Travis,       63f, neurogenic         Van Buren sound and
Watne, Lasser, &        bladder, abdominal      cut down onto sound
Ellsworth, 2014         surgery                 and catheter pulled
(current article)                               into bladder with
                                                cystoscopy

Tompkins, Travis,       70m, APR, EBRT          Bladder distention,
Watne, Lasser, &        posterior urethral-     trocar SPT and 16
Ellsworth, 2014         pelvic fistula          French Foley placed
(current article)                               using peel away
                                                sheath--cystoscopy--
                                                posterior cystotomy
                                                noted

Tompkins, Travis,       85m, EBRT for           Van Buren sound and
Watne, Lasser, &        prostate cancer         cut down onto sound
Ellsworth, 2014                                 and catheter pulled
(current article)                               into bladder with
                                                cystoscopy

Tompkins, Travis,       85m, EBRT for           Bladder distention,
Watne, Lasser, &        prostate cancer,        trocar SPT and 16
Ellsworth, 2014         APR, AAA                French Foley placed
(current article)                               using peel away
                                                sheath--cystoscopy

Witham & Martndale,     75m, hx CVA             Percutaneous SPT
2002                                            under general with
                                                cystoscopy

Wu, Su, & Lin, 2007     71 m, neurogenic        Percutaneous SPT
                        bladder

Authors                             Diagnosis and Outcome

Ahluwalia et al.,      3 out of 219 patients had bowel injury (2.4%)
2006"

Ahmed, Mehta, &        10 days post-SPT--peritonitis, feculent
Rimington, 2004        drainage--exploratory laparotomy--small
                       bowel penetration--small bowel resection

Cronin et al., 2011    Small bowel injury (0.3%)

Cundiff & Bent, 1995   POD 3--abdominal distention and loss bowel
                       sounds--SPT pierced muscularis of ileum

Flock, Litvak, &       Enterovesical fistula 3.5 weeks postop with
McRoberts, 1978        1 st catheter change--healed with Foley and
                       removal of SPT

Flock, Litvak, &       Intraperitoneal extravasation of irrigation fluid
McRoberts, 1978        16 days post-procedure--exploratory laparo
                       tomy demonstrated peritoneum violation and
                       antimesonteric perforations in the ileum

Goldblum & Brugger,    6 days post-SPT, peritonitis--exploratory
1999                   laparoscopy--catheter wrapped around
                       jejunum--no bowel resection

Hebert & Mitchell,     19 days post-SPT--peritonitis--exploratory
1983                   laparotomy--ileum perforation--small bowel
                       resection

Hebert & Mitchell,     3 days post-SPT--feculent drainage--
1983                   cystogram--exploratory laparotomy--ileum
                       perforation--primary repair

Liau & Shabeer, 2005   3 months post-SPT--feculent drainage--
                       exploratory laparoscopy--catheter in cecum
                       --primary repair

Mongiu, Helfand, &     8 months post-SPT--feculent drainage--
Kielb, 2009            catheter in ileum

Moody, Howards,        10 days post-SPT- signs of bowel
Schneider, & Rudolf,   obstruction--exploratory laparotomy--atretic
1977                   segment of ileum and mesentery punctured
                       by SPT--small bowel resection

Morse, Spimak, &       Peritonitis--exploratory laparotomy--rectal
Resnick, 1988          perforation--diverting colostomy

Noller, Pratt, &       5 days postop drainage around SPT c/w
Symmonds, 1976         bowel contents--exploratory laparotomy--
                       small bowel penetration--small bowel
                       resection

Noller, Pratt, &       2 weeks postop brown discharge--
Symmonds, 1976         ileocutaneous fistula--conservative
                       management

Parikh, Chapple, &     9 months post-SPT--drainage of stool--
Hampson, 2008          cystogram--enterovesical fistula to small
                       bowel -exploratory laparotomy--small bowel
                       resection

Parikh, Chapple, &     12 hours post-SPT drainage of intestinal con
Hampson, 2008          tents--exploratory laparotomy SPT passed
                       through small bowel--small bowel resection

Pieretti & Pieretti-   2 months post-SPT -
- abdominal pain/
Vanmarcke, 1995        distention--posterior bladder wall perforation,
                       distal ileal obstruction

Sheriff et al.,        5 out of 185 patients had bowel injury (2.7%)
1998 *

Simpson, 2001          10 days post-SPT--abdominal pain/
                       distention--exploratory laparotomy--incar
                       cerated loop small bowel beneath intraperi
                       toneally exposed SPT--no bowel resection

Tompkins, Travis,      8 months post-SPT, catheter change required
Watne, Lasser, &       cysto, dilation, and manipulation--abdominal
Ellsworth, 2014        distention--exploratory laparotomy catheter
(current article)      penetrated bowel--patient died post
                       operatively

Tompkins, Travis,      2 months post-SPT--abdominal pain, N/V--
Watne, Lasser, &       CT demonstrated SPT through small bowel--
Ellsworth, 2014        exploratory laparotomy--small bowel
(current article)      resection

Tompkins, Travis,      Peritonitis postoperatively--exploratory
Watne, Lasser, &       laparotomy--SPT traversed a portion of small
Ellsworth, 2014        bowel that was adherent to anterior bladder
(current article)      wall--small bowel resection

Tompkins, Travis,      2 weeks after SPT change--feculent
Watne, Lasser, &       drainage--exploratory laparotomy--SPT in
Ellsworth, 2014        loop of small bowel--small bowel resection
(current article)

Tompkins, Travis,      1 year post-SPT and 20 days following SPT
Watne, Lasser, &       change--feculent drainage--CT
Ellsworth, 2014        demonstrated Foley in bladder with tip eroded
(current article)      through posterior bladder into loop of bowel--
                       patient comfort measures only

Witham & Martndale,    First catheter change 3 months postop--
2002                   feculent drainage--exploratory laparotomy--
                       tip of catheter in sigmoid--primary repair

Wu, Su, & Lin, 2007    2 months post-SPT first change, feculent
                       material--exploratory laparotomy--SPT in
                       terminal ileum--small bowel resection

* Excluded from data analysis secondary to no individual patient
medical/surgical history reported.

Notes: m = Male, f = Female, y = year old, G10P5 = gravida 10 para 5,
SPT = suprapubic tube, US = ultrasound, UTI = urinary  tract
infection, CT = computerized tomography, XRT = external beam radiation
therapy, CCY = laparoscopic cholecystectomy,  MS = multiple sclerosis,
TURP = transurethral resection of prostate, TAH-BSO = total abdominal
hysterectomy bilateral salpin-go oophorectomy, SUI = stress urinary
incontinence, CVA = cerebral vascular accident, PV = pubovaginal, AUS
= artificial uri-nary sphincter, APR = abdominal perineal resection,
AAA = abdominal aortic aneurism.

Table 3.
Advantages/Disadvantages of Suprapubic Tube
Placement Tecniques

Technique        Advantages                  Disadvantages

Percutaneous     Bedside procedure,          Small catheter prone to
(i.e., Stamey)   smaller catheter may        obstruction, dislodged
                 improve comfort.            easily, blind procedure,
                                             difficult to place in
                                             thick walled bladder.

Lowsley          Bladder tented up to        Requires patient urethra,
Tractor          abdominal wall, larger      requires sedation/
                 catheter size possible,     anesthesia, often
                 less risk of obstruction.   performed blind.

Open             Direct vision, bladder      Requires anesthesia.
                 sutured to abdominal wall
                 assisting with straight
                 tract formation, does not
                 require patent urethra.

Figure 1.
Clavian Classification of Surgical Complications

Grade I:   Any deviation from the normal post-operative course without
           the need for pharmacological treatment or surgical,
           endoscopic, and radiological intervention.

           * Allowed therapeutic regimens are drugs as antiemetics,
             antipyretics, analgesics, diuretics, electrolytes, and
             physiotherapy.

           * Wound infections opened at bedside.

Grade II:  Requiring pharmacological treatment with drugs other than
           for class I complications, including blood, and total
           parenteral nutrition are also included.

Grade III: Requiring surgical, endoscopic, or radiological
           intervention.

           * Grade IIIa: Intervention not under general anesthesia.

           * Grade IIIb: Intervention under general anesthesia.

Grade IV:  Life-threatening complication, including central nervous
           system (CNS) complications, requiring IC/ICU management.

           * Grade IVa: Single-organ dysfunction (including dialysis).

           * Grade IVb: Multi-organ dysfunction.

Grade V:   Death of a patient.

Source: Dindo, Demartines, & Clavien, 2004.

Figure 2.

Bowel Injury Following Percutaneous Suprapubic Tube
Catheterization (SPT)

Prior Abdominal Surgery                  54%
External Beam Radiation Therapy (EBRT)   21%
Small/Thick-Walled Bladder               17%
No Risk Factor                            8%

Note: EBRT = external beam radiation therapy

Note: Table made from pie chart.
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Title Annotation:CNE SERIES/ADVANCED CLINICAL PRACTICE
Author:Tompkins, Andrew J.; Travis, Michelle; Watne, Reed E.; Lasser, Michael; Ellsworth, Pamela
Publication:Urologic Nursing
Article Type:Clinical report
Date:Jan 1, 2014
Words:4509
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