If a patient must have his urine diverted but his bladder is not distended, you cannot do a blind suprapubic puncture, so you have to do an open one. This can happen as the result of extravasation of urine due to trauma or a stricture. A similar operation is needed for the removal of a stone from the bladder (23.15).
OPEN SUPRAPUBIC CYSTOSTOMY TEMPORARY [s7]OPEN CYSTOSTOMY ANAESTHESIA. (1) Local anaesthesia (A 5.4). (2) Ketamine (A 8.2).
INDICATIONS. (1) The need to divert a patient's urine, when his bladder is not sufficiently distended, or clear in outline, for a blind cystostomy, as with most cases of extravasation of urine. (2) Rupture of the bladder (68.2). (3) The treatment of clot retention. (4) As a necessary step in a urethroplasty. (4) As a permanent measure for an impassable stricture of the urethra, which is so high up (as in the membranous urethra), that a urethrotomy, which would be preferable, is impossible.
CONTRAINDICATIONS. Avoid doing a suprapubic cystotomy if a patient has carcinoma of his bladder (common in areas where Schistosoma haematobium is endemic), or is suspected of having it, because it may lead to a permanent and distressing urinary fistula.
METHOD. Make a midline vertical suprapubic incision. A 5 cm incision is adequate unless he is fat. Divide his linea alba, and retract his rectus muscles. Use your forefinger, covered with a gauze swab, to push the cellular tissue and peritoneum upwards, away from the anterior surface of his bladder. Dissect the loose fatty tissue away from in front of it.
Recognize his bladder by its characteristic pale appearance with some tortuous blood vessels. Aspirate it first, unless it is impalpable (as with trauma causing extravasation). Insert stay sutures, superiorly and inferiorly, at the proposed ends of your vertical bladder incision. They will make useful retractors when it sinks into his pelvis. Take urine for culture, open his bladder with a longitudinal 5 cm incision, and explore it.
If you are going to leave a suprapubic catheter in place, pass a Malecot, de Pezzer, or Foley catheter into his bladder through a separate stab incision above or to the side of the main one. Make it a snug fit and hold it in place with a purse string suture (many surgeons pass it through the main wound).
Close the main bladder incision with 2 layers of 2/0 or 1/0 chromic catgut sutures. Close the wound with the catheter emerging through a long, oblique, mid-line track. Extend the wound proximally if necessary. If it is likely to be infected by contaminated urine, as it may be if you are operating for extravasation, insert a retropubic drain.
See also Section 23.10 on extravasation of urine, especially if you have to continue suprapubic drainage more than a month.
CAUTION ! Make sure the suprapubic catheter emerges high, so that the track closes easily, and will not interfere with an approach to the bladder later.
PERMANENT [s7]OPEN CYSTOSTOMY INDICATIONS. Some impassable urinary obstruction: a very tight stricture, or prostatic hypertrophy where catheterization has failed, and he is too ill for surgery. Where surgery is even reasonably good, a permanent cystotomy should rarely be necessary.
METHOD. Pass a Foley, a Malecot, or a de Pezzer catheter suprapubically by the method just above, or that in Section 23.6, using a trocar and cannula. If necessary, he can go home with the catheter leading into a bag, or closed with a spigot, which will need to be released 4-hourly. The bag will need cleaning and replacing after 2 weeks.
Change his catheter monthly. If you use an introducer, you should have no difficulty replacing his catheter, once a track has been established after the first 10 or 14 days. Replacing it earlier may be almost impossible. If you leave it in for longer, phosphatic encrustation, both inside and out, will make it difficult and painful to remove. A high fluid intake and acidifying his urine will minimize encrustation. The leak round the tube should not be too inconvenient. To leave him with a ''hole' is distressing, because he will be wet all the time.
He faces the certainty of infection, and the probability of an early death.