Further experience with suprapubic drainage by trocar catheter JAMES M. INGRAM, M.D.

Tampa, Florida

In 1972 a preliminary report described the use of a large-bore (Nos. i2 and i6 Fr.) vinyl catheter, which contained a steel trocar within its lumen, in repair of cystourethrocele in 86 patients. Further experience in an additional 158 patients undergoing cystourethrocele repair, and a variety of other gynecologic procedures, is now evaluated. The prototype of a sharp, beveled, cutting-edge trocar tip proved to increase substantially the ease of insertion. Problems of design and production of the catheter were encountered and corrected. Two points of technique, (I) insertion of the catheter prior to the surgical procedure and (2) use of the two-hand method, are advocated. The trocar catheter was found to be a simple, practical, and safe instrument for suprapubic bladder drainage.

A L T H o u G H suprapubic bladder drainage has been advocated for over a hundred years in urologic surgery, its acceptance by gynecologists has been slow and reluctant. Both Hippocrates and Galen forbade incision of the body of the bladder with the aphorism "cuy vesica persecta ... lethale" (to cut through the bladder is lethal) . This dogma was regarded as inviolable for 15 centuries, until the late Renaissance Period/ and its influence still lingers today. However, resistance to the transurethral catheter was sharpened by the studies of Kass 2 in 1956 and by Beeson's:1 landmark editorial "The case against the catheter'' in 1958. In the 8 years since Hodgkinson and Hodari 4 reported the use of suprapubic drainage with the Malecot catheter a myriad of instruments and methods for suprapubic cystotomy, by both transvesical and percutaneous routes, has appeared."- 1 ~ The advocates of suprapubic drainage are agreed upon its multiple advantages, but no

single method or instrument has gained universal favor. The one dominant trend has been a growing dissatisfaction with the smaller bore catheters because of frequent obstruction. In an effort to achieve a maximum diameter of the lumen with a minimum of external diameter, a suprapubic vinyl catheter, which contained a stainless steel trocar within its lumen, was developed in 1970. The thin vinyl wall provided a much wider lumen than that of the conventional latex catheter. A preliminary study of the use of this catheter* in 86 patients undergoing repair of cystourethrocele was made 2 years ago. 13 The objective of this report is the evaluation of further use of the catheter in 158 patients undergoing a wider variety of gynecologic procedures. Materials and methods

The catheter. In 96 patients, the catheter which was 'previously describedB was used (Fig. 1). During the latter part of the study, in 62 patients, only the No. 16 Fr. catheter was employed, and the prototype model of a sharp, beveled, cuttingedge trocar tip (Fig. 2) was substituted for the rounded needle-point tip, in order to facilitate insertion with less pressure. Technique. Several modifications were added to the original technique of insertion. In all patients

From the Department of Obstetrics and Gynecology, College of Medicine, University of South Florida. Presented by invitation at the Eighty-fifth Annual Meeting of the American Association of Obstetricians and Gynecologists, Hot Springs, Virginia, September 4-7, 1974. Reprint requests: Dr. fames N. Ingram, Department of Obstetrics and Gynecology, College of Medicine, University of South Florida, Tampa, Florida 33620.

*Manufactured by Aloe Medical Division (Argyle) of Sherwood Medical Industries, St. Louis, Missouri.

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Fig. 1. The vinyl catheter contains a steel trocar within its lumen. The movable retention ring may be sutured or cemented to the skin. The retention balloon is inflated through a rubbercapped inflation port. A twist-cap irrigation port occupies the opposite side. The dark line is radiopaque.

Table I. Procedures Vaginal hysterectomy and repair of cystourethrocele and rectocele Vaginal hysterectomy and repair of cystourethrocele and rectocele (with scar of previous laparotomy) Vaginal hysterectomy and repair of cystourethrocele Vaginal hysterectomy and colpectomy Colpectomy for prolapse of the vagina Repair of prolapse of the vagina Marshall-Marchetti-Krantz urethropexy Radical vulvectomy and lymphadenectomy Vulvectomy Total

119

9 6 4 2 5 7 4 2 158

undergoing vaginal repair, the bladder was inflated to palpable size (400 to 600 c.c.) and the catheter introduced prior to, and not following, the operation. When dealing with total procidentia or with prolapse of the vaginal vault, the inflated bladder was rotated upward and held firmly by the assistant's hand against the abdominal wall during insertion of the catheter. In patients who had scars of previous laparotomy, the trocar catheter was inserted lateral to the vertical scar or superior or inferior to a transverse scar. The use of the suprapubic catheter \·vas felt to be contraindicated in t\""10 patients, both of whom had undergone previous laparotomies, which were followed twice by repair of recurrent incisional hernias. The two-hand technique of insertion (Fig. 3), with the operator in a sitting position, was employed without exception. The Foley drainage tube and bag were used, and were considered preferable

to siphonal drainage. Clamping of the drainage tube was begun on the third postoperative day, as before. Clinical use. During the 2 year period from January, 1972, through January, 1974, the trocar catheter was employed in 158 operations performed by 14 gynecologists at the University-affiliated hospitals. The procedures perfoqned are listed in Table I. Identical procedures, with the exception of radical vulvectomy, done during the same period of time with the use of transurethral catheters, were used as controls. Culture and microscopic examination of the urine were done only if fever exceeded 100.4° F. after the day of operation. In both the study and the control groups, 56 per cent of the patients received prophylactic antibiotics, beginning the day before or on the day of surgery. Results

The established and previously described advantages of suprapubic drainage by any method were again observed in this series of patients. Postoperative morbidity (temperature of 100.4° F. or greater for any 2 days except for the day of surgery) was reduced from 43 per cent in the control group to 21 per cent in the study group. The procedures other than vaginal repair were considered too small in number to be of statistical value. "Significant urinary tract infection," as defined by Mattingly, Moore, and Clark 14 (colony count of 100,000 per cubic centimeter and presence of .1 0 or more white blood cells per high-powered field), was used as the criterion for urinary infection.

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I

I

I

Fig. 3. The two-hand technique of insertion, with the forearms resting on the pelvis, acting as a fulcrum, and the operator seated, pulling the trocar catheter downward a nd toward him, is applicable to any type of suprapubic: ca theter.

I'

Fig. 2. The needle-pointed trocar tip is shown on the left. On the right is the prototype of a sharp, beveled, cuttingedge trocar tip.

Eighteen per cent of all patients with suprapubic drainage were found to have urinary infection, as compared with 42 per cent with the use of transurethral catheters. In 94 per cent of the 28 positive cultures obtained from suprapubic catheters, the organism was either E. coli or Klebsiella. By contrast, the 66 positive cultures obtained from transurethral ca theters revealed these two bacteria in 57 per cent, the remainder consisting largely of Proteus, Pseudomonas, and Enterococcus. The a verage time of satisfactory postoperative voiding remained at 5.4 days. Unlike other studies, we have not found that suprapubic drainage leads to earlier postoperative voiding. The catheter was removed as early as 3 days and as late as 24 days following surgery. Careful observation during longterm use revealed no tissue reaction to the vinyl material. There were no perforations of the bladder base or bowel and there was no known entry of the catheter into the urethra.

Complications. As in the previous study, the problems encountered were chiefly those of design or construction of the catheter. Among the earlier patients in the current series, there were nine instances of leakage of the balloon and pulling out of the catheter, all with the No. 12 Fr. catheter. One patient developed a small urinary extravasation a nd perivesical cellulitis when the catheter was pulled out of the bladder but remained in the abdominal wall. She responded promptly to Foley catheter drainage and antibiotic therapy. Leakage of the catheter at the site of connection to the drainage tube occurred in 16 patients in the early pa rt of the series. Use of the catheter was discontinued for 3 months until the balloon and catheter end were redesigned, and production methods corrected . Hematuria occurred in 21 per cent of the patients. It was largely transient, and disappeared spontaneously, but, in eight patients using the No. 12 Fr. catheter, was of sufficient degree to cause tempora ry obstruction. The over-all incidence of hematuria was identical with the use of the No. 12 or 16 Fr. ca theter, and did not increase with the use of the cutting edge trocar. Distention of the bladder to its maximum capacity was found to be the most imporant factor in prevention of hematuria. Comment

Among members of our staff, as in many others, there is a continuing reluctance, particularly after years of use of the transurethral catheter, to change to suprapubic drainage, in spite of its many ad-

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vantages. Of a total of 609 procedures for correction of stress urinary incontinence which were studied concurrently with this investigation, suprapubic cystotomy was used in 152 patients, or 26 per cent. Consideration of the years-in-practice of those gynecologists who prefer suprapubic drainage is of interest. With the exception of those performed by the author, suprapubic cystotomy was employed only by gynecologists who had finished their training within the last 12 years, or by residents. For the most part, the advantages of suprapubic drainage appear to be utilized by those more recently trained, or still in training. Although routine preoperative and postoperative urine cultures were not done in this study, our observations of the cultures which were performed coincide with those of Hodgkinson and Hodari, 4 Mattingly, Moore, and Clark, 14 and Beeson. 3 Suprapubic drainage is not an aseptic method, but it is associated with a much lower incidence of urinary infection and with bacteria less resistant to therapy. The high incidence of Proteus, Pseudomonas, and Enterococcus in the control group is characteristic of infection secondary to urethral instrumentation. Had routine postoperative cultures been performed, the infection rate probably would have been higher in both groups because of the detection of asymptomatic infection. In 1969, Hodgkinson 15 first compiled his "Ten commandments of trocar cystotomy." After a test of 5 years, they remain the valid surgical principles of the cystotomist. It would be improper to suggest that there be twelve commandments; however, two additional points of technique, which have evolved from this and the previous study, are proposed. 1. Introduction of any type of suprapubic cathe-

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April 1, 1975 Obstet. Gynecol

ter should be performed only prior to the procedure, with the patient well anesthetized, in deep Trendelenburg position, and with the bladder distended to an easily palpable size. This is the most practical time that the cystotomy can be done by aseptic technique. Deep anesthesia, Trendelenburg position, and an easily palpable bladder are the best prophylaxis against bowel perforation. The remote possibility of breaking down a cystourethrocele repair by excessive bladder pressure is eliminated. 2. Regardless of the instrument employed, the use of the two-hand technique, with the forearms resting on the pubis, acting as a fulcrum, and with the operator in a sitting position, pulling the instrument downward and toward him, offers optimal control of the force of insertion and minimal chance of perforation of the bladder base. It is regrettable that the opportunity did not present to use this catheter with Wertheim hysterectomy. As pointed out by van Nagell, Penny, and Roddick, 16 and others, suprapubic drainage is particularly useful when there is prolonged delay m return to normal bladder function. In this second study, a more simple method of introduction of a large (No. 16 Fr.) suprapubic catheter has been devised. Experience \Vith the trocar catheter has increased-both in number and in variety of operative procedures. Two additional facets of technique, applicable to any suprapubic instrument, have been evolved in its use. In our experience, the trocar catheter has proved to be satisfactory. The true test of any method or any instrument comes not at home, however, but only when it leaves its parent institution and becomes useful and practical in the hands of others.

REFERENCES

1. Cumston, C. G.: Trans. Am. Urol. Assoc. 6: 304, 1912. 2. Kass, E. H.: Trans. Am. Assoc. Physicians 69: 56, 1956. 3. Beeson, P. B.: Am. J. Med. XXIV: I, 1958. 4. Hodgkinson, C. P., and Hodari, A. M.: AM. J. OnSTET. GYNECOL. 96: 773, 1966. 5. Bonnano, P. J., Landers, D. E., and Rock, D. E.: Obstet. Gynecol. 35: 807, 1970. 6. Kariher, D. H., Fernandez, I. A., Trombetta, G. C., and Amstey, M. S.: Obstet. Gynecol. 35: 401, 1970. 7. Hofmeister, F. J., Martens, W. E., and Strebel, R. L.: AM. J. 0BSTET. GYNECOL. 107: 767, 1970. 8. Robertson, J. R.: Obstet. Gynecol. 41: 624, 1973. 9. Wilson, E. A., Sprague, A. D., and van Nagell, ]. R.,

Jr.: AM. J. OasTET. GYNECOL. 115: 991, 1973. 10. Sharpe, J. R., and Ingram, J. M.: J. Urol. 110: 340, 1973. 11. Peloso, 0. A., Wilkinson, L. H., and Floyd, V. T.: Arch. Surg. 106: 568, 1973. 12. Goldberg, B. B., and Meyer, H.: Pediatrics 51: 70, 1973. 13. Ingram, .f. M.: AM . .J. 0BSTET. GYNECOL. 113: 1108, 19~2. 14. Mattingly, R. F., Moore, D. E., and Clark, D. 0.: AM. ]. 0BSTET. GYNECOL. 114: 732, 1972. 15. Hodgkinson, C. P.: AM. J. 0BSTET. GYNECOL. 105: 62, 1969. 16. van Nagel!, J. R., Jr., Penny, R. M., Jr., and Roddick, ]. W., Jr.: AM. J. OasTET. GYNECOL. 113: 849, 1972.

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Discussion DR. C. PAuL HoDGKINSON, Detroit, Michigan. As mentioned by Dr. Ingram, it was 8 years ago, and before this Association, when we reported our 3 year experience with suprapubic cystostomy for bladder drainage in gynecologic patients. Now I can confess that presentation of that report \vas made only after great circumspection. In preparing the report meticulous care was taken to mention every incident which might have been considered a complication. After well over 1,000 suprapubic cystostomies, I believe we might have been somewhat overzealous, because transient siightiy pinkish urine was reported as hematuria. Experience has shown that hematuria is seldom of clinical significance and Dr. Ingram's incidence of 24 per cent is an acceptable figure. I have no quarrel with the two-handed technique for insertion recommended by Dr. Ingram; with his catheter, I believe this is a good idea. His recommendation that the catheter be inserted at the beginning of the operation holds for vaginal procedures, but I doubt if he would follow this recommendation for abdominal procedures. His observation that suprapubic cystotomy is usually adopted by younger gynecologists is interesting, but I noted that he excluded himself from this classification. There are certain attributes for the "hardware" for suprapubic cystostomy which are important. ( 1) The functional tip of the catheter should be so constructed as to prevent migration into the inner urethra; this eliminates all straight catheters regardless of composition or caliber. ( 2) The catheters should be sufficiently flexible so that they will not kink when acutely flexed. (3) The catheters should securely adapt to the drainage tubing to prevent disengagement. ( 4) The catheter material should be relatively inert so as to not cause local tissue reaction. None of the commercially available catheter systems which I have tested fulfill a!! of these criteria. Except for silicone rubber, plastic catheters when sharply flexed at the skin level kink and sometimes fractures. Most plastic catheters insecurely attach to the drainage tubing and 10 per cent of Dr. Ingram's patients experienced leakage at the connection site. Although I have not had extensive experience with Dr. Ingram's catheter (he kindly sent me five sets to try), with the standard Foley catheter 15 per cent of patients previously tested experienced drainage difficulties. With the bladder empty and the superior and inferior surfaces of the bladder in apposition, apparently the Foley tip tended to migrate into the inner urethra to produce symptoms of obstruction. The Teflon, Bonnano, rat-tailed catheter has a n1en1ory curve built into the distal end and an inner diameter of 2 mm. The curved end effectively has prevented urethral migration and seldom have I had difficulty with obstruction. Kinking at the skin level and disengagement of the

Suprapubic drainage by trocar catheter

889

Table I. Department of Obstetrics and Gynecology, The Roosevelt Hospital-College of Physicians and Surgeons, Columbia University, New York, New York: abdominal hysterectomy Total number

106

Prophylactic antibiotics Urinary tract infection

39

No prophylaxis Urinary tract infection

67 25 (37.3%)

(0.026%)

Table II. Department of Obstetrics and Gynecology, The R.oosevelt Hospital--College of Physicians and Surgeons, Columbia University, New York, New York: vaginal hysterectomy Total number

21

Prophylactic antibiotics Urinary tract infection

4 0

No prophylaxis Urinary tract infection

(0%)

17 10 (58.8%)

Table Ill. Department of Obstetrics and Gynecology, The Roosevelt Hospital-College of Physicians and Surgeons, Columbia University, New York, New York: abdominal hysterectomy

I

Catheterization time (hr.)

antiI No anti-~ Nobiotics, I

I,;~::~:;~;, I No. of patients Mean Standard deviation Median *T test; P

tract mfection

urinary tract infection

42 27.17*

25 30.44*

18.51

< 48

14.77

< 24

Anti-

I

I ';:::::;,~' I tract. infectwn

Antibiotics, urinary tract infection

38 44.08

"~ 4J

48.46

< 48

25

= 0.511.

rather complicated catheter parts have been the major deficiencies I have observed with this catheter. A final appraisal: none of the commercially available catheter sets I have tested for suprapubic cystostomy has been mechanically superior to the simple No. 12 soft rubber Malicot and all are considerably more expensive. Lately I have been interested in the mechanicai efficiency of drainage bag systems. Those commercially available have been developed to conform to the needs of urologists. To adequately drain urine contaminated by large blood clots, drainage tubing has been standard-

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April I, 197:i Am.

Table IV. Department of Obstetrics and Gynecology, The Roosevelt Hospital-College of Physicians and Surgeons, Columbia University, New York, New York: vaginal hysterectomy

I

Catheterization time (hr.)

No antibiotics, no urinary tract infection

No. of patients Mean Standard deviation Median

7 126.57*

85.67 < 168

I No

antibiotics, urinary tract infection 10 183.50*

88.44 .::r>rl in hio;;:._ -M;1ttinulv ------···-.---··--- thio;;: ............. -~------~-;

d11r-llr>o;;: ~---~·--·J

nf ~·

nno;;:tnnPr~.......... . 1'""'~'''1

tivc patimts. He does not believe there is such a thing. We do usc a skin incision on all patients in inserting the catheter. Thcst' are matched controls as far as the procedures are concerned. The study of minary tract infection that we have made is only those of patients who are febrile. Thr chief thrust of this paper was to test thP instrument. Admittedly, as an afterthought, I wish we had donr routine cultures on all of these patients. The 18 per cent of positive culturPs which wP obtained probably is coincidental but is roughly equal to the incidence of asymptomatic urinary tract infPction, which was reportPd by Dr. ~1attingly in his studies when he cultured patients on admission to the hospital for vaginal surgery.