SURGEON'S WORKSHOP
PERCUTANEOUS SUPRAPUBIC CYSTOSTOMY USING BALLOON DILATION JOSEPH I,. CHIN, M.D. TtlOMAS W. D. SttORT, M.D. From the Division of Urology; University Hospital, University of Western Ontario, London, Ontario, Canada
:omy has traditionally been ~y troear pereutaneous insern operative procedure. The ge of the trocar insertion ¢ a small lumen catheter can :her methods of percutaneous •y diversion have been deined to achieve a large lumen lethod employs filiforms and other uses the Amplatz renal new method of percutaneous :omy is presented using the balloon dilator.* The main ; m e t h o d are (1) atraumatic tact in a single step, and (2) a large-sized permanent inTechnique may be performed under : combination of local anes,mous narcotic analgesia. In ~y position the patient is ed. The cystoseope or Foley per urethra, and the bladder rrigating fluid. An 18-gauge nserted two fingerbreadths :o the distended bladder. The awn leaving the sheath in m of the bladder puncture ld monitored eystoseopieally, La necessity provided urine is )m the angiocatheter. ldiford
tOl Y ~>~a~;~ . -;.~ ;
i
MARCH
1990
Drive,
,
Stouffville,
Ontario,
V O L U M E XXXV, N U M B E R 3
A 0.035-inch soft guide wire is threaded through the angioeatheter sheath into the bladder (Fig. 1A). A 5-ram transverse skin incision is made, and the balloon dilator catheter is threaded over the guide wire into the bladder and inflated to 30-F diameter using the LeVeen Inflator syringe (Medi-tech) (Fig. 1B). The balloon is deflated and withdrawn leaving the guide wire in place. A 26-F diameter Amplatz dilator is advanced into the bladder over the guide wire (Fig. 1C), followed by the 26-F diameter Amplatz grey working sheath over the dilator (Fig. 1D). The guide wire and Amplatz dilator are withdrawn, arid a 22-F Foley catheter is inserted through the open grey sheath into the bladder. After inflating the catheter balloon, the grey sheath is incised longitudinally as it is withdrawn so that it can be "'peeled off" the Foley catheter (Fig. 1E and F). The bivalved grey" sheath may, be resterilized and used for other s u p r a p u b i e cystostomy procedures. Catheter position may be confirmed cystoscopitally or with a cystogram. Comment: Percutaneous suprapubic cystostomy is less time-consuming, and entails less postoperative morbidity than open suprapubie eystostomy. In addition, it may be performed in the offiee or on high anesthetic risk patients with intravenous narcotic analgesia and local lidoeainc infiltration. The procedure presented here has the advantage of a one-step dilation of the tract. It is technieally easier and less traumatic than sequential dilation using filiforms and followers 26]
FmURE 1. (A) Guide wire ts threaded through 18-gauge angiocatheter sheath into bladde', dilator is advanced over guide wire and inflated to 30E (CO 26-F Amplatz dilator is advancec over guide wire. (D) 26-F grey sheath is inserted over Amplatz dilator into bladder. (E) Ampla guide wire are removed, and 22-F Foley catheter inserted through grey sheath and balloon i sheath is withdrawn as it is incised longitudinalh.! and "peeled o]]" the Foley catheter. (F) 22-F J in place. or the Amplatz dilating set. A much larger Foley catheter can be inserted than the trocar cystostomy sets commercially available. Inserting the Foley catheter through the grey Amplatz sheath ensures easy access into the bladder and avoids possible "buckling" at the rectus fascia or bladder wall level if the catheter was simply threaded over a guide wire or small Amplatz guide catheter. This procedure should not be attempted in patients with contracted small-capacity blad-
262
ders, those with prior lower a/: pelvic surger); and in extremely ol where full thickness dilation eanm plished. London, Ontario, Can References 1. Reiss If: Percutaneous suprapubic eysto~ Urology 15:294 (1980). 2. Klimberg I, and Wehle M: Pereutaneous prapubie eystostomy tube, Urolo~' 26:178 (191_ ,
UROLOGY
/
MARCH 1990 /
VOI.,UME XXXV, N U i'2~tJ
PERCUTANEOUS SUPRAPUBIC CYSTOSTOMY USING BALLOON DILATION JOSEPH I,. CHIN, M.D. TtlOMAS W. D. SttORT, M.D. From the Division of Urology; University Hospital, University of Western Ontario, London, Ontario, Canada
:omy has traditionally been ~y troear pereutaneous insern operative procedure. The ge of the trocar insertion ¢ a small lumen catheter can :her methods of percutaneous •y diversion have been deined to achieve a large lumen lethod employs filiforms and other uses the Amplatz renal new method of percutaneous :omy is presented using the balloon dilator.* The main ; m e t h o d are (1) atraumatic tact in a single step, and (2) a large-sized permanent inTechnique may be performed under : combination of local anes,mous narcotic analgesia. In ~y position the patient is ed. The cystoseope or Foley per urethra, and the bladder rrigating fluid. An 18-gauge nserted two fingerbreadths :o the distended bladder. The awn leaving the sheath in m of the bladder puncture ld monitored eystoseopieally, La necessity provided urine is )m the angiocatheter. ldiford
tOl Y ~>~a~;~ . -;.~ ;
i
MARCH
1990
Drive,
,
Stouffville,
Ontario,
V O L U M E XXXV, N U M B E R 3
A 0.035-inch soft guide wire is threaded through the angioeatheter sheath into the bladder (Fig. 1A). A 5-ram transverse skin incision is made, and the balloon dilator catheter is threaded over the guide wire into the bladder and inflated to 30-F diameter using the LeVeen Inflator syringe (Medi-tech) (Fig. 1B). The balloon is deflated and withdrawn leaving the guide wire in place. A 26-F diameter Amplatz dilator is advanced into the bladder over the guide wire (Fig. 1C), followed by the 26-F diameter Amplatz grey working sheath over the dilator (Fig. 1D). The guide wire and Amplatz dilator are withdrawn, arid a 22-F Foley catheter is inserted through the open grey sheath into the bladder. After inflating the catheter balloon, the grey sheath is incised longitudinally as it is withdrawn so that it can be "'peeled off" the Foley catheter (Fig. 1E and F). The bivalved grey" sheath may, be resterilized and used for other s u p r a p u b i e cystostomy procedures. Catheter position may be confirmed cystoscopitally or with a cystogram. Comment: Percutaneous suprapubic cystostomy is less time-consuming, and entails less postoperative morbidity than open suprapubie eystostomy. In addition, it may be performed in the offiee or on high anesthetic risk patients with intravenous narcotic analgesia and local lidoeainc infiltration. The procedure presented here has the advantage of a one-step dilation of the tract. It is technieally easier and less traumatic than sequential dilation using filiforms and followers 26]
FmURE 1. (A) Guide wire ts threaded through 18-gauge angiocatheter sheath into bladde', dilator is advanced over guide wire and inflated to 30E (CO 26-F Amplatz dilator is advancec over guide wire. (D) 26-F grey sheath is inserted over Amplatz dilator into bladder. (E) Ampla guide wire are removed, and 22-F Foley catheter inserted through grey sheath and balloon i sheath is withdrawn as it is incised longitudinalh.! and "peeled o]]" the Foley catheter. (F) 22-F J in place. or the Amplatz dilating set. A much larger Foley catheter can be inserted than the trocar cystostomy sets commercially available. Inserting the Foley catheter through the grey Amplatz sheath ensures easy access into the bladder and avoids possible "buckling" at the rectus fascia or bladder wall level if the catheter was simply threaded over a guide wire or small Amplatz guide catheter. This procedure should not be attempted in patients with contracted small-capacity blad-
262
ders, those with prior lower a/: pelvic surger); and in extremely ol where full thickness dilation eanm plished. London, Ontario, Can References 1. Reiss If: Percutaneous suprapubic eysto~ Urology 15:294 (1980). 2. Klimberg I, and Wehle M: Pereutaneous prapubie eystostomy tube, Urolo~' 26:178 (191_ ,
UROLOGY
/
MARCH 1990 /
VOI.,UME XXXV, N U i'2~tJ
