Suprapubic catheter insertion technique
The procedure uses an introducer consisting of a trocar and a special sheath. The procedure includes the following steps:
- The instrument is inserted along the midline of the abdomen toward the urinary bladder. The optimal tilt is about 40 degrees from the vertical axis. Advancement continues until urine is obtained.
- The trocar is removed, and the catheter itself is advanced through the remaining sheath to approximately its midpoint.
- The retention balloon is inflated within the urinary bladder cavity. Afterward, the catheter is gently pulled outward until the balloon abuts the inner wall of the organ.
- The sheath is removed or peeled away.
Quality control: To definitively confirm the correct placement of the drainage, a contrast medium is injected under fluoroscopy. If the patient has complex pelvic anatomy (due to congenital anomalies or scars from previous surgeries), CT guidance is indicated.
Non-deflating balloon issue
The main reason why a urinary catheter balloon cannot be deflated is the obstruction of the internal channel by accumulations of detritus. There are several ways to resolve this, each with its own specific features:
- Restoring channel patency. This is the safest and most optimal method. It involves passing a hydrophilic or rigid guidewire (0.018-inch in size) into the channel. If the pathway cannot be cleared, the sharp tip of the guidewire can be used to puncture the balloon itself.
- Percutaneous puncture. Performed transabdominally with a 22-G needle under ultrasound guidance. For convenience, the catheter is gently pulled via the urethra.
- Transrectal puncture. Also performed under ultrasound guidance, but requires mandatory antibiotic administration for infection prophylaxis.
- Overinflation (Overinflation). This method aims to rupture the balloon using excessive pressure; however, it is associated with serious risks: rupture of the urinary bladder wall or leaving rubber fragments in its cavity is possible.
- Injection of solvents. The use of aggressive liquids to dissolve the balloon material risks causing chemical cystitis.
Note: When using puncture techniques, the goal is not always achieved on the first attempt, and a series of punctures may be required.
Percutaneous cystolithotripsy (PCCL)
Percutaneous cystolithotripsy (Percutaneous cystolithotripsy) is a method of stone fragmentation and removal used when the transurethral approach or open surgery is unfeasible.
Indications for PCCL:
- Urethral strictures preventing instrument passage.
- Conditions following urinary bladder augmentation (enlargement) surgery.
- Neurogenic bladder dysfunction.
- Pediatric practice (narrow urethra in children makes safe extraction of stone fragments via the classical route impossible).
Technical features: The procedure combines elements of suprapubic cystostomy placement and percutaneous nephrolithotomy (PCNL). First, access to the bladder cavity is established over a guidewire. Then, the puncture tract is dilated, and a rigid rigid sheath 30-F in diameter is placed into it. It is through this wide working sheath that stone fragmentation and fragment extraction are performed.
Prostate interventions
Prostate and seminal vesicle interventions can be categorized by the type of access.
Transrectal access is usually performed on an outpatient basis under local anesthesia (patient lying on the left side). The main risks here are rectal bleeding and severe infectious complications. Transperineal access has a minimal risk of infections; however, the procedure itself is extremely painful and therefore requires general anesthesia or deep sedation.
Types of procedures:
- Drainage of prostate and perirectal abscesses.
- Seminal vesiculography.
- Local therapy: brachytherapy, cryotherapy, laser ablation, or high-intensity focused ultrasound (HIFU).
Prostate biopsy: This is the most common procedure performed to rule out malignancy. Historically, it was performed transrectally under ultrasound guidance. However, due to the high rate of infection, modern medicine is transitioning to transperineal grid-guided biopsy (grid template-guided). With specialized equipment, the biopsy can also be performed under MRI guidance. It is important to remember that prostatic stenting has high morbidity, and balloon dilation of the prostate is recognized as ineffective.
Briefly: answers to topical questions
What complications can occur during suprapubic catheter placement?
The primary described complication during suprapubic catheter placement is bowel perforation.
The frequency of this condition directly depends on the chosen imaging guidance method during the procedure:
- Bowel perforation — when the catheter is placed under fluoroscopic guidance, the frequency of this complication is 0.3%.
- Bowel perforation — when cystoscopic assistance is used, this rate is significantly higher at 2.4–2.7%.
No other specific complications for this procedure are described in the provided materials.
What instruments and equipment are needed to perform percutaneous cystolithotripsy (PCCL)?
To perform percutaneous cystolithotripsy (percutaneous cystolithotripsy, PCCL), instruments for puncture access and stone fragmentation are required.
The required equipment list includes:
- Guidewire — used to obtain initial access to the urinary bladder cavity.
- Dilating instruments — used to expand the puncture tract, similar to percutaneous nephrolithotomy.
- Rigid sheath (rigid sheath) — placed into the formed tract, has a 30-F size, and serves as the working channel for fragmentation and subsequent stone removal.
What are the reasons why a urinary catheter balloon cannot be deflated?
The main reason why a urinary catheter balloon cannot be deflated is mechanical obstruction of the fluid outflow pathways.
In clinical practice, the following factor is distinguished:
- Obstruction of the balloon channel by detritus — the accumulation of debris blocks the lumen, making standard emptying impossible.
To solve this problem, methods such as overinflation, solvent injection, restoring channel patency with a rigid guidewire, or ultrasound-guided percutaneous balloon puncture are used.
Class and exam questions
Why is imaging guidance important during suprapubic catheter placement?
The use of fluoroscopy with contrast allows precise confirmation of catheter position, while fluoroscopic guidance generally reduces the risk of accidental bowel perforation to 0.3%. For complex anatomy, CT is additionally used.
What is the danger of overinflating a non-deflating balloon?
This method can lead to damage and rupture of the urinary bladder wall itself, as well as leaving detached balloon fragments in the organ cavity.
Why is the access approach for prostate biopsy changing?
Traditional transrectal access is associated with an increasing rate of severe infectious complications, which is why transperineal biopsy is now preferred.
What else to study on this topic
- Detailed technique of percutaneous cystolithotripsy (PCCL)
- Comparison of transabdominal and transrectal access for balloon puncture
- Navigation principles in grid template-guided transperineal prostate biopsy
- Complications following prostatic stent placement
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