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Suprapubic Bladder Drainage After Extraperitoneal Cystotomy

From the Division of Urogynecology and Reconstructive Pelvic Surgery, Good Samaritan Hospital, University of Cincinnati School of Medicine, Cincinnati, Ohio.

Address reprint requests to: Mickey M. Karram, MD Good Samaritan Hospital Seton Center 375 Dixmyth Avenue Cincinnati, OH 45220 E-mail: mickey-karram{at}trihealth.com

	Abstract

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Objective: To observe the effects of cessation of continuous bladder drainage after short-term catheterization in women who had extraperitoneal cystotomies.

Methods: The study population included 84 women, 78 of whom had retropubic urethropexies and six of whom had retropubic paravaginal repairs. Intentional cystotomy was done intraoperatively to assure ureteral patency, bladder integrity, and no inadvertent suture penetration into the bladder. All cystotomies were closed in two layers with 3-0 chromic suture. Suprapubic catheters were placed intraoperatively in all cases. In all women except four with gross hematuria, continuous bladder drainage was stopped and voiding trials were started within 24 hours after surgery. Suprapubic catheters were removed when women spontaneously voided 80% of total bladder volume.

Results: Suprapubic catheters were discontinued on average 4.1 days after surgery (range 2.7–14.1 days). Average bladder volume at initial clamping of the suprapubic catheter was 382 mL (range 224–510 mL). At this volume the integrity of the cystotomy should have been challenged appropriately. The women were observed for a minimum of 3 months with no immediate or long-term complications.

Conclusion: Extraperitoneal cystotomy in a nondependent portion of the bladder does not require continuous bladder drainage for more than 24 hours. This information should allow pelvic surgeons to be more liberal with intraoperative cystotomies if bladder integrity or ureteral patency needs to be confirmed.

Injuries to the urinary tract are more common in obstetric and gynecologic surgery than in any other type. In certain clinical settings, an intentional cystotomy can help when evaluating the urinary tract and defining anatomic boundaries during pelvic dissection. It can also assure that there is no inadvertent suture penetration of the bladder wall. Ureteral patency is observed by viewing urine or spillage of intravenous (IV) dye from each orifice. If ureteral patency is in question, retrograde passage of a ureteral stent can be done easily through a high cystotomy. Mismanagement or failure to diagnose a bladder or ureteral injury can cause pelvic abscess, hydronephrosis, renal failure, urinary ascites, or fistula formation. Thompson and Beningo¹ reported that 27% of women in whom recognition of ureteral injuries was delayed later lost kidneys.

Every gynecologic surgeon should be able to make an intravesical assessment and assure ureteral patency. It can be accomplished by intentional cystotomy or endoscopic evaluation of the lower urinary tract. Endoscopy in the form of cystoscopy or suprapubic teleoscopy is not universally taught to obstetricians-gynecologists. Cystoscopy privileges are not always easily obtained. During abdominal operations, cystotomy is often the most practical method of intravesical assessment. Although the bladder generally heals without incident, there is neither consensus nor data on how long to drain it postoperatively. Many authors categorized all cystotomies together, regardless of location, and recommended 5–10 days of continuous postoperative drainage.^2–5 Some have recommended bladder decompression until hematuria subsides.² If it is established that continuous prolonged drainage of a high cystotomy is not necessary, gynecologists might be more liberal with it for intravesical assessment, thereby decreasing the rate of undiagnosed lower urinary tract injury.

We retrospectively studied bladder drainage after 84 consecutive extraperitoneal cystotomy repairs. From those findings we make recommendations on length of continuous bladder drainage required after high extra-peritoneal cystotomy.

	Materials and Methods

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Between 1992 and 1998, we did intentional cystotomies for intravesical assessment in 92 women who had abdominal surgery. After 1998, suprapubic teleoscopy replaced intentional cystotomy as our method of choice for intravesical assessment and assurance of ureteral patency during selected abdominal procedures. All cystotomies were done by the same surgeon in the same institution. Seventy-eight women had open retropubic urethropexies and six had retropubic paravaginal repairs. Eight women who had intentional cystotomies during a procedure other than retropubic or paravaginal repair were excluded. A retrospective review was done from the medical records database and records from the Division of Urogynecology. Data retrieved from the records included urine color, urine volumes, voided volumes, and length of catheterization. Urine color was routinely documented as clear, blood-tinged, or grossly bloody. Those observations were made by an attending physician or fellow from the Division of Urogynecology. Intentional cystotomies were approximately 4–5 cm long in the extraperitoneal portion of the bladder dome. The bladder urothelium was inspected completely. Women were given 5 mL of IV indigo carmine, and ureteral patency was checked by watching for bilateral dye spillage.

A pediatric feeding tube or ureteral stent was passed retrograde to assure no ureteral injury in five women. One woman had a kinked ureter caused by suture placement during a paravaginal repair. Once the sutures were cut, the catheter was passed easily, and dye passed into the bladder. Two women had inadvertent penetration of permanent sutures through the urothelium of the bladder wall during Burch urethropexies. The sutures were removed and replaced with the bladder open.

Cystotomies were closed in two layers by using 3-0 chromic suture. The first layer was closed with a continuous nonlocking suture that approximated the bladder urothelium. The second layer was closed with a continuous imbricating stitch through the muscularis. Women had suprapubic placement of a 12-French urethral Foley catheter with a 5-mL balloon. The catheter was placed in the bladder through the extraperitoneal cystotomy and brought out through a separate incision in the skin. After the bladder was closed, the incision was not evaluated for watertightness.

Urine color assessed on the morning after surgery was categorized as clear, blood-tinged, or grossly bloody, by gross viewing of the catheter tubing and bag. Urine was categorized as clear if there was no evidence of blood in the bag or tube. Blood-tinged was defined as pink-colored urine or blood in clear urine. Grossly bloody urine was defined as red-colored urine throughout the bag and tubing.

Women with clear or blood-tinged urine on the first postoperative day had voiding trials initiated by clamping of the suprapubic catheter. Women with grossly bloody urine were maintained on continuous drainage until the urine became blood-tinged or clear. Women were followed up after surgery at 2 weeks, 6 weeks, and 3 months.

	Results

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Eighty-four cystotomies were reviewed as described. The urine assessed on the morning of the first postoperative day was clear in 42 women, blood-tinged in 38, and grossly bloody in four. In women with clear or blood-tinged urine, their suprapubic catheters were clamped on postoperative day 1. All four women with grossly bloody urine were maintained on continuous drainage until their urine was blood-tinged or clear, an additional 24 hours in two women and 48 hours in the other two.

Average bladder volume on the first day of clamping was 382 mL, which was determined by adding the amount of urine voided to the postvoid residual. At that volume, integrity of the cystotomy should have been challenged appropriately. Suprapubic catheters were removed when women voided 80% of their total bladder volume on two consecutive voids. This was an average of 4.1 (2.7–14.1) days after surgery. Three of 84 women (3.6%) had to have transurethral Foley catheters inserted after removal of their suprapubic catheters because of urinary retention or voiding dysfunction. No women developed a vesicocutaneous fistula or any other immediate or long-term complication with this system of bladder drainage and early catheter removal.

	Discussion

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We found that high extraperitoneal cystotomies heal efficiently when closed appropriately. It has been stated empirically that bladder cystotomies require a minimum of 5–10 days of continuous bladder drainage.^2–5 There has also been some suggestion that if the urine is still blood-tinged, continuous drainage should be done.^2,3 The results of this study challenge those concepts. Although all women in this study had suprapubic catheters in place for an average of 4.1 days, with the exception of the four women with gross hematuria, their cystotomies were challenged within 24 hours when catheters were clamped to test for voiding efficiency. We acknowledge that the major weaknesses of this study were the subjective nature of establishing urine color and that the conclusions are based on the assumption that bladder integrity was appropriately challenged at an average bladder volume of 382 mL per clamping. If that assumption is accepted, our data indicate that in women with clear or blood-tinged urine in whom voiding efficiency is anticipated, catheter removal is possible as early as 24 hours after surgery. That is useful information for pelvic surgeons who are not trained or equipped to do cystoscopic or suprapubic endoscopic evaluation of the urinary tract. Gynecologic surgeons should not be concerned with making small extraperitoneal cystotomies to ensure ureteral patency and evaluate possible bladder injury or stitch penetration of the bladder wall. Previously, most women had unnecessarily prolonged continuous bladder decompression after extraperitoneal cystotomies. In our setting, the bladder appeared to heal efficiently after as little as 1 day of continuous drainage. We believe that it is important to differentiate cystotomies by location as intraperitoneal or extraperitoneal. Intraperitoneal cystotomies in dependent portions of the bladder will require prolonged drainage because of the constant irritation of the closure sites by urine. However, these cases of extraperitoneal cystotomy healed with minimal continuous postoperative drainage. Another limitation of this review was that conclusions were based solely on postoperative observations.

	Footnotes

 
PII S0029-7844(00)00912-1

Received October 21, 1999. Received in revised form March 21, 2000. Accepted April 13, 2000.

	References

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1. Thompson JD, Beningo BB. Vaginal repair of ureteral injuries. Am J Obstet Gynecol 1971;111:601–10.[Medline]

2. Eisenkop SM, Richman R, Platt LD, Paul RH. Urinary tract injury during Cesarean section. Obstet Gynecol 1982;60:591–6.[Abstract/Free Full Text]

3. Spirnak JP, Resnick MI. Intraoperative consultation for the bladder. Urol Clin North Am 1985;3:439–46.

4. Penalver MA. Urinary tract injuries. In: Hurt GW, ed. Urogynecologic surgery. Gaithersburg, Maryland: Aspen Publishers, 1992: 169–76.

5. Wall LL, Norton PA, DeLancy J. Urinary tract injury in gynecologic surgery. In: Wall LL, Norton PA, DeLancy J, eds. Practical urogynecology. Baltimore: Williams & Wilkins, 1993:332–50.

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by KARRAM, M. Articles by GOLDWASSER, S. Search for Related Content PubMed PubMed Citation Articles by KARRAM, M. Articles by GOLDWASSER, S.