Indications and preoperative preparation
High cystostomy is performed strictly according to specific clinical indications. These include the presence of stones in the organ cavity, various neoplastic lesions, the need for adenomectomy (surgical removal of prostate adenoma), as well as traumatic injuries to the urinary bladder.
Before the procedure begins, the patient is placed on the operating table in the supine position. A crucial condition is the elevated position of the pelvis. This position is necessary so that abdominal organs shift upward due to gravity, freeing up the working space in the suprapubic region. The operation is performed under general anesthesia.
Surgical access technique
Surgical access is achieved by performing a lower midline laparotomy. The skin incision line runs strictly along the midline of the abdomen above the pubic symphysis.
Dissection of the anterior abdominal wall tissues is performed layer by layer:
- First, the surgeon dissects the skin and subcutaneous adipose tissue.
- Then, the linea alba (linea alba) is exposed and incised.
- The edges of the rectus abdominis muscles are carefully retracted to the sides, taking care not to damage the muscle fibers.
- The next step is the incision of the transversalis fascia.
After this, the preperitoneal space is opened. At this point, the surgeon must act exclusively bluntly: the preperitoneal adipose tissue along with the peritoneal reflection is carefully mobilized in the cranial direction (upward). It is precisely this technique that allows the anterior wall of the urinary bladder to be exposed while preserving the integrity of the peritoneum and without entering the peritoneal cavity.
Exposure and opening of the organ lumen
After mobilizing the adipose tissue, the surgeon visually identifies the anterior wall of the urinary bladder. Its characteristic distinguishing features are a specific pinkish color and the presence of longitudinally arranged blood vessels (veins).
For reliable fixation of the organ, two temporary catgut sutures are placed on its wall to serve as stay sutures. They are positioned closer to the dome of the bladder at a distance of about 2–3 cm from each other.
Before opening, the bladder cavity must be emptied. This is done either using a pre-inserted catheter or by puncture. The incision of the wall itself is performed with a scalpel strictly between the placed temporary stay sutures. The direction of the incision is longitudinal, from top to bottom. During tissue dissection, it is extremely critical to be cautious and avoid accidental detachment of the mucosal layer from the muscular layer of the bladder wall.
Options for completing the surgical intervention
Depending on the goals of the operation and the clinical situation, the completion can follow one of three scenarios:
- Cystotomy (Cystotomia) with primary closure. If the patient does not require subsequent drainage of the cavity, the wound of the urinary bladder wall is closed tightly. A reliable two-layer suture is used for this purpose.
- Cystostomy (Cystostomia) with fistula formation. A special rubber drainage tube is inserted into the organ cavity. Strict requirements apply to the tube: it must have an obliquely cut working end and additional side openings for adequate outflow. The bladder wound is closed with interrupted sutures in two layers (a two-layer suture) right up to the rubber drain itself. The tube is positioned in the upper corner of the wound.
- High section exclusively for urinary diversion. In this case, after placing the temporary stay sutures, a purse-string suture is immediately placed on the anterior wall. The lumen is opened precisely in the center of this purse-string suture, after which a drainage tube is inserted inside.
At the final stage of the operation, layer-by-layer closure of the anterior abdominal wall wound is performed down to the left-in drain.
Briefly: answers to topical questions
Which arteries supply blood to the urinary bladder?
Blood supply to the urinary bladder is provided by branches of the internal iliac artery (a. iliaca interna). The following vessels participate in the blood supply to the organ:
- Superior vesical artery (a. vesicalis superior) — one or two branches arising from the unliterated part of the umbilical artery (a. umbilicalis), which supply blood to the dome of the urinary bladder.
- Inferior vesical artery (a. vesicalis inferior) — arises directly from the anterior trunk of the internal iliac artery and supplies blood to the base of the urinary bladder.
What is the innervation of the urinary bladder?
The urinary bladder is innervated by:
- superior and inferior hypogastric nerve plexuses;
- pelvic splanchnic nerves;
- pudendal nerve.
Parasympathetic innervation originates from the sacral spinal cord segments S2–S4 via the pelvic splanchnic nerves to parasympathetic ganglia in the bladder wall. Sympathetic innervation originates from the lower thoracic and upper lumbar spinal cord segments Th12, L1, L2.
What is the patient's position on the operating table during a cystotomy called?
During a cystotomy, the patient is supine, with the pelvis elevated. This position is used to shift abdominal organs upward.
To which lymph nodes does lymph drainage from the urinary bladder occur?
Lymph drainage from the urinary bladder goes to regional iliac and sacral lymph nodes. Lymph is directed to the following groups of nodes:
- Iliac lymph nodes — located along the internal and external iliac arteries.
- Sacral lymph nodes — located on the anterior surface of the sacrum.
In women, the lymphatic vessels of the urinary bladder also form direct connections with the vessels of the uterus and vagina, being located at the base of the broad ligament of the uterus.
To remember the essence of the approach, use the "Three P's" rule: Pelvis elevated, Pongitudinal incision, Preperitoneal adipose tissue (mobilized upward along with the peritoneum).
Class and exam questions
Why must the patient's pelvis be elevated during cystotomy?
This is necessary for the upward displacement of abdominal organs due to gravity, which facilitates the extraperitoneal approach to the urinary bladder and reduces the risk of peritoneal injury.
How to visually distinguish the anterior wall of the urinary bladder in the surgical wound?
It has a characteristic pinkish hue and prominent longitudinally running veins.
What is the difference between cystotomy and cystostomy?
During cystotomy, the bladder wound is closed tightly with a two-layer suture, whereas during cystostomy, a fistula is formed by leaving a rubber drainage tube in the organ cavity for urinary diversion.
What technical error is important to avoid when dissecting the bladder wall?
When performing an incision with a scalpel, it is necessary to avoid detachment of the mucosa from the muscular layer of the wall.
What else to study on this topic
- Topography of the preperitoneal space and peritoneal reflection.
- Technique of applying a two-layer suture to the urinary bladder wall.
- Features of forming a purse-string suture during urinary diversion.
- Surgical anatomy of the linea alba in the lower third.
- Requirements for drainage tubes during cystostomy and their care.
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