Suprapubic Drainage

SUPRAPUBIC DRAINAGE, CLINICAL SKILLS LAB

INTRODUCTION:

When a patient is unable to empty the bladder normally, some kind of bladder drainage may be necessary.  Typically, this is a urethral catheter. However, long term urethral catheter can give rise to urethral discomfort, urethral erosions and penile discomfort in the male. Moreover, in some patients, it may not be possible to insert a urethral catheter e.g. because of  urethral stricture or prostatic enlargement.  In some patients who have contracture of the pelvis, the patients may not be able to abduct the legs.  It is also easier to change a suprapubic catheter as compared to a urethral catheter. For patients who require long term bladder drainage, it  is preferable to have a suprapubic catheter.

PROCEDURE:

The following steps are necessary in the insertion of suprapubic catheter:

(1)    Suitable medical indication.

(2)    Informed consent.

(3)    A full bladder.  The bladder may be filled by the patient’s own urine or the bladder may be filled with an indwelling urethral catheter, usually about 500 mls.  A full bladder will displace the abdominal contents, to reduce the risk of damage to the gut.

(4)    Local anaesthetic (1 or 2% Lignocaine) is injected at the site of insertion, usually 2 finger breaths above the symphysis pubis in the midline. The skin, subcutaneous tissue and the anterior bladder wall have to be infiltrated, usually with about 5 cc of the anaesthetic. 

(5)    In an obese patient, it may be necessary to confirm that the bladder is distended with an abdominal ultrasound. 

(6)    Skin incision is made with a size 11 blade.

(7)    A preliminary puncture may be made with a  21G needle to aspirate urine, also to send the urine for bacterial culture.

(8)    Most suprapubic catheters are of the peel away sheath type, before the catheter is introduced together with trocar.  Once the trocar is in the bladder, urine will come out.

(9)    The catheter is then inserted into the bladder.

(10) The trocar is then withdrawn, peeled away and removed. 

(11) The catheter is anchored in place by inflating with a balloon, usually about 5 cc of water or saline. The catheter can be anchored externally with a Silk sheath, for about a week until the suprapubic tract matures. 

COMPLICATIONS OF SPC INSERTION:

The most serious complication is that of injuries to the nearby organs, namely, the intestine or the rectum.  This can happen if the patient has previous surgery with the intestine adherent to the bladder.

FOLLOW-UP OF SPC:

Catheters in the body are usually for a limited time: the catheter can become blocked or  fragmented.  Therefore, the suprapubic catheters are usually changed every 3 weekly by deflating the balloon before removing, and inserting a new catheter.  If the patient has sensation, Lignocaine gel may help.

If the bladder is continuously empty over a number of months or years, the bladder can become contracted. Therefore, the catheter should be clamped for a few hours, e.g. from 8 am to 11 am, to allow the bladder to expand.  This will also allow the patient to have a trial of urination. If the patient can pass urine well with minimal residual urine (residual urine being measured by releasing the clamp), the suprapubic catheter may be removed. 

Written by:

Dr Clarence Lei Chang Moh, FRCS Urol, FEBU

Consultant Urologist

email: clarencelei@gmail.com

4 September 2013

robotics in urology

ROBOTICS IN UROLOGY

INTRODUCTION:

Prostatic surgery has become an important component of urologic surgery.  In USA, prostate cancer is the commonest cancer in men. In Malaysia, the incidence of prostate cancer is reported to be less, about 6th commonest cancer in men. The prostatic gland is located deep in the pelvis, behind the symphysis pubis.  Open radical prostatectomy has been technically difficult because of the confined space.  This has been revolutionised with the use of laparoscopic radical prostatectomy, assisted by the Da Vinci robot. 

DA VINCI ROBOTIC SURGERY:

Since the introduction of 2 Da Vinci robots in Malaysia around 2005 (1 in Hospital Kuala Lumpur and the other in Sarawak General Hospital), prostatectomy surgery has been much improved, especially with RALP, Robot Assisted Laparoscopic Prostatectomy.

The robot is actually a “slave robot”, controlled by the operating surgeon in a console. The console is typically placed in a big operating theatre, although theoretically the console can be located in a remote place. This idea was first envisaged to be used by the military and a remote surgeon can operate with the robot and a bedside assistant, at the battle field!

The robotic arms are therefore inserted into the pelvis. The many degrees of freedom allow the robot instruments to be used as if it is the surgeon’s operating hand. 

There is also magnification (about 10 times) and with 2 cameras to give rise to binocular vision.  In addition, the robotic transmission also removes any  tremors from the surgeon’s operating hand.

With magnification, the surgeon is therefore about to preserve more structures. In particular, the nerve on the posterior lateral aspect of both sides of the prostate are preserved, giving rise to better potency and urinary continence as compared to open surgery.

OTHER USES OF THE ROBOT:

As the robot is very expensive (more than RM10 million per robot), the robot can also be used for other pelvic surgery, e.g. gynaecologic, colorectal.  It may also be used for surgery of the upper tract, e.g. pyeloplasties and partial nephrectomy.  This allows intracorporeal suturing to be used with relative ease as compared to pure laparoscopic surgery. 

DISADVANTAGE OF THE ROBOT:

The robot is expensive to purchase.  In addition, each use of the robotic instrument is computerised and is expensive. The robot also needs to be “docked” to the patient. i.e. to be prepared and the robotic laparoscopic pots and instruments need to be inserted and this often takes time in the beginning.

Written by:

Dr Clarence Lei Chang Moh, FRCS Urol, FEBU

Consultant Urologist

email: clarencelei@gmail.com

4 September 2013

Obstructive Uropathy

OBSTRUCTIVE UROPATHY

INTRODUCTION:

Obstructive uropathy refers to the impairment of  renal function as a result of obstruction of the urinary tract.  Obstructive uropathy should be avoided as this is a reversible cause of kidney failure.

CAUSES OF OBSTRUCTIVE UROPATHY:

Obstructive uropathy can be due to obstruction of the urinary tract at any part but typically in the tubular part, namely, the ureter and the urethra. 

The causes of ureteric obstruction may include intraluminal causes, e.g. a stone or extraluminal causes e.g. enlarged lymph nodes or pelvic organs e.g. the uterus, cancer cervix.

The causes of bladder outlet obstruction could include enlarged prostate, urethral stricture or occasionally a urethral stone. 

Diagram urinary tract:

DIAGNOSIS:

Diagnosis of the obstructive uropathy would involve uro-radiology, namely, KUB, ultrasound, CT and CT scan. When intravenous contrast cannot be used, a MRI may occasionally be done without contrast to delineate the urinary tract better.  Ureterography, percutaneous or retrograde, can also be done.

TREATMENT:

The treatment of obstructive uropathy depends on the underlying cause. If the underlying cause is due to a stone, the stone will need to be removed as a matter of urgency. If it is due to an underlying malignancy, e.g. a lymphoma, cancer cervix, iatrogenic ureteric injuries, this has to be treated in an appropriate manner. 

The kidney can be drained, e.g. with a drainage tube. This may be an external drain, e.g. a percutaneous nephrostomy inserted under ultrasound and fluoroscopic guide.  if the patient is well enough to go to operating theatre, it may be possible to insert an indwelling ureteric stent. 

Written by:

Dr Clarence Lei Chang Moh, FRCS Urol, FEBU

Consultant Urologist

email: clarencelei@gmail.com

4 Sept 2013

Testicular Torsion

TESTICULAR TORSION

Any child or young man who presents with acute testicular pain is considered to have testicular torsion, until proven otherwise.  The etiological factor seems to be a congenital predisposition of the testis to a horizontal lie rather than the normal vertical lie.  The testis is twisted upon itself, giving rise to vascular strangulation. Depending on the degree of torsion, the torsion has to be relieved, usually within 6 hours to avoid testicular infarct. In real life practice, testicular torsion is often missed and often a subject of medico-legal negligence against the attending doctor and the surgeon.

Emergency surgery consists of scrotal exploration, untwisting the torsion and fixing the testicle with 3 sutures.  The fixation also has to be done for the contralateral testis.  However, if the testis is infarcted, the testis is best removed and consent has to be taken preoperatively for this as well.

However, only 50% of children and young men presenting with acute testicular pain are due to torsion.  The differential diagnosis is often that of inflammation e.g. epididymo-orchitis from viral infection especially mumps.  Urinary tract infection (in children with underlying UTI, urogenital tract abnormalities) and in young adults with other infections (e.g. TB, STD) can also present acutely with testicular pain.  However, upon taking a detailed history, they may be found to have an insidious onset, including constitutional symptoms e.g. fever, mumps in a close family member or in the school.

Emergency investigations can occasionally help to rule out torsion and this includes emergency Doppler ultrasound of the testis, epididymis and spermatic cord to trace the blood supply. In some medical centres, emergency isotope study can also confirm the vascularity of the testis.  When in doubt, it is always better to list the patient for emergency exploration.

Dr Clarence Lei Chang Moh, FRCS Urol

Consultant Urologist

email: clarencelei@gmail.com

10^th September 2013

Enclosures: Two sets of operative photographs indicating (a) testicular torsion infarcted and testicle removed, (b) testicular torsion twisted intraoperatively and salvaged.