If a patient has retention of urine, and you cannot pass a catheter, you will have to drain his bladder from his abdomen. As it distends, it rises up above his pubis and strips the peritoneum off his abdominal wall. This allows you to drain it without going through his peritoneal cavity. Most surgeons have their own favourite ways of doing this. We describe several alternatives: a syringe and needle is best for immediate emergency use; and a thin plastic tube passed through a trocar and cannula is best if drainage has to be continued for more than a few days. The track round a thin tube is less easily infected, although the tube itself is more readily blocked by clots.
EMERGENCY SUPRAPUBIC PUNCTURE (''SPP') INDICATIONS (1) Acute obstruction with a full bladder, such as that from an enlarged prostate, a bladder stone, or a stricture when catheterization has failed. (2) Rupture of the urethra (68.3, 68.5).
CONTRAINDICATIONS (1) An empty bladder. This method is therefore contraindicated, if the patient has extravasation of urine. (2) A carcinoma of the bladder causing retention. A track may form, which is very distressing. So feel for a craggy rectal or suprapubic mass before you do a suprapubic puncture.
CAUTION ! (1) For a blind suprapubic puncture, his bladder must be distended and palpable. If it is not, wait for it to fill, or do a formal cystostomy. (2) The classical site for drainage is half-way between his pubis and the upper limit of bladder dullness. If you are going to remove his prostate later, do the cystostomy (drainage) as high as you can, so that you can open his abdomen below it later, without entering the cystostomy track. If he has a stricture, so that you will not be operating through his abdomen, the site of the cystostomy is less important.
A NEEDLE AND SYRINGE. Scrub and put on sterile gloves. Mount a 0.9 or 1 mm needle on a 20 or 50 ml syringe, preferably with a three-way tap. Check the outline of his bladder. Insert the needle 2[nd]3 cm above his symphysis pubis, and advance it towards his lower sacrum. Aspirate as much urine as you can, and advance the needle a little as you do so.
CAUTION ! Use this method once or twice only, then try catheterization. If this fails proceed to the other methods.
A LUMBAR PUNCTURE NEEDLE is the least satisfactory of any of the methods here. It is however an emergency method which a night sister can use.
Find a 0.9 or 1 mm lumbar puncture needle and stillette, or a long exploring needle of the same length. Have these ready in sterile packs or boil them. You will also need an intravenous drip set, and spirit swabs; a container for his urine, such as a measuring jug, or a urine bag; gauze and adhesive strapping.
Lay him down, swab his suprapubic area, and insert the needle 2 or 3 cm above his pubis. Push it downwards. It will enter his bladder for almost its full length. Withdraw the stylet. Urine will escape. If his urine is tinged with blood, withdraw it a little, it may have touched his trigone. Connect it to the bag of a drip set, or a bottle.
CAUTION ! The needle must be a long one. If you use a small one, his bladder will pull itself out of the needle as it contracts down behind the pubis. In emergency you may be able to use the needle of a drip set, but it is too short, and is completely impracticable if he is fat. The danger with any needle, and especially that from a drip set, is that it easily slips out when he turns over in bed, so that his urine extravasates.
Fig. 23-6 SUPRAPUBIC PUNCTURE WITH A TROCAR and plastic tube[md]''SPP'. A, inserting the trocar. B, inserting the tube. C, the tube in place. D, and E, anchoring the tube. F, alternatively, make the tube into a loose knot and tie it to the patient. G, if his peritoneum is tethered by the scar of a previous operation, the trocar may traverse his peritoneal cavity, with the risk of damaging his gut. Kindly contributed by Neville Harrison.
USING A POLYTHENE TUBE. The description here applies to retention due to a stricture, but it can also be used for obstruction due to an enlarged prostate.
Use a hydrocoele trocar and cannula, and 1.5 metres of plastic tube of external diameter about 2.5 mm, with lateral drainage holes cut in the first 5 cm. Or, use a Gibbon's catheter. Make an identification mark 15 cm from the tip. A small scalpel blade, a skin needle and suture, local anaesthetic.
Infiltrate the site of puncture with local anaesthetic solution in the midline at the chosen site. Continue to infiltrate down to his bladder; when you get there, confirm it is distended by aspirating a few millilitres of urine into the syringe.
Make a nick in his skin with a scalpel blade. With your left hand on the dome of his bladder to steady it, push the trocar into it with a steady turning movement towards his lower sacrum. If his bladder is lax, compress it with the edge of your hand. You will feel it ''give' as urine gushes out. Push the plastic tube down the cannula to well beyond the 15 cm mark, and withdraw the cannula. Some urine will escape and relieve his distension. Carefully withdraw the tube to the 15 cm mark, and secure it to his skin with a monofilament stitch tied several times round the tube, as in Fig. 23-6. Alternatively, apply pieces of strapping, as in Fig. 65-8.
CAUTION ! (1) Beware of suprapubic scars[md]if his peritoneum is adherent to his abdominal wall, you may injure his gut. Or, less seriously, the trocar may traverse his peritoneal cavity, and some urine may leak into it, to cause a mild local sterile peritonitis. (2) Puncture his abdominal wall in the direction of his lower sacrum. If you push the trocar too caudally you may enter his retropubic space and fail to enter his bladder. If you push it too cranially, you may enter his abdomen and possibly injure his gut.
Drain the urine into a plastic urine bag, or bottle. Make sure he has a daily fluid intake of at least 3 litres daily[md]a generous fluid intake is the best way of preventing or clearing infection.
If he has a stricture, drain it for about a week before you attempt to dilate it. After doing so, clip off the tube with artery forceps. You can estimate his residual urine by measuring the volume which drains through the tube, after he has passed urine. If there is no residual urine you have succeeded.
If there are no complications, he may be able to leave hospital in 24 to 48 hours, complete with his drainage system. Don't try bouginage for at least a week, then try it gently at weekly or two-weekly intervals. A few strictures will remain impassable[md]see Section 23.9.
If instrumentation fails and he is unable to pass urine about the 5th day, try again at the 10th day. If this fails again, an operation will be necessary.
48 hours after you have removed the tube the puncture site may be difficult to find.
A MALECOT OR de PEZZER CATHETER, A TROCAR, AND AN INTRODUCER. Under local anaesthesia stab his bladder through his abdominal wall with a sharp scalpel. Make an incision that is wide enough to let the catheter through. Thread a Malecot or de Pezzer catheter over a straight introducer (as in Fig. 23-1), and push it through the stab wound. Withdraw the introducer. Anchor it with monofilament stitched to his skin and tied several times round the tube.
CAUTION ! (1) The catheter must project well into his bladder. If it does not project far enough, it may be pulled out as his bladder contracts. (2) It must not project too far, or it will touch his trigone, and cause discomfort.
DIFFFICULTIES [s7]WITH EMERGENCY SUPRAPUBIC CYSTOTOMY Other difficulties include extravasation of the urine into the suprabpubic space, followed by spreading cellulitis, injury of the prostate, perforation of the bladder wall into the rectum, urinary peritonitis, and perforation of the large or small gut. See also ''Difficulties with retention' Section 23.5.
If there is heavy or prolonged BLEEDING, suspect a bladder tumour, or damage to his bladder neck. Abandon the procedure.
If the TUBE BLOCKS, flush it through with saline from a syringe. It is more likely to block if there is too long a length inside his bladder, hence the importance of the 15 cm mark.
Fig. 23-7 OPEN SUPRAPUBIC CYSTOSTOMY. A, avoid using a Pfannensteil incision. B, a midline incision. The cystostomy tube should emerge half-way between a patient's umbilicus and his symphysis. C, in a midline incision part his rectus muscles to reveal the criss-cross fibres of his bladder. D, open his bladder between stay sutures. E, and F, close his bladder and abdomen, being careful to leave an oblique track, that will be less likely to leak when the catheter is withdrawn. After Blandy J, ''Operative Urology', Figs. 8.14 to 8.24. Blackwell Scientific Publications, with kind permission.