Epitystostomy of the bladder: indications, course of operation, complications

In cases of violation of the physiological process of urination - in the absence of the possibility to ensure the emptying of the patient's bladder by means of urethral catheterization - an epicystostomy is performed. That is, bypassing the urethra, through the abdominal wall directly into the bladder establish a special urinary system - cystostomy, which works on the principle of drainage and, unlike the ureteral catheter, can be used for a long time.

Indications for the procedure

In the list, including the main indications for the suprapubic bladder drainage (epitsistostomii), are noted:

• ischuria -  acute and chronic urinary retention  in patients with prostatic hyperplasia (adenoma) or adenocarcinoma;[1]
• violation of urination in cases of traumatic damage to the urinary organs;
• condition after surgery, for example, removal of a urethral polyp, expansion of a sclerotic bladder neck or its transurethral resection;
• acute urological infections with obstruction of the urethra;
• dysfunction of the urinary organs in injuries of the spinal cord with the development of lower paraparesis or paralysis; [2], [3]
• urethral strictures with bladder stones;
• severe cases of  neurogenic bladder ;
• congenital uropathy, for example, infravesical obstruction syndrome.

The use of modified trocar epicystostomy in the surgical treatment of hypospadias in children is described. [4]

Preparation

If epitsistostomiya planned, then its holding is appointed after an appropriate examination and all diagnostic procedures. In urgent cases - in acute ischuria - special preparation of the patient is not required, and all necessary studies are carried out after the installation of a cystostomy.

When carrying out this procedure, the appropriate tools for epicystostomy are used: a pointed scalpel, surgical scissors and tweezers, syringes, a trocar.

A specially equipped sterile set for an epicystostomy is used, consisting of a trocar, a catheter (Foley or Pezzzer), a guide needle (introducer), a clamp, a skin fixative, a urinal. There are various modifications of such kits from different manufacturers.

Technique of the epicystostomy

According to the type of surgical intervention, an operation to create a stoma (artificial hole) can be performed as an open epicysticostomy or as a less invasive trocar epicysticostomy. [5]

With an open epicystostomy, which implies the need for long-term urinary diversion, epidural or general anesthesia is used and an operation technique with wide access to the bladder is used — with all the peritoneum undercut 50 mm below the navel in the vertical direction and abducted, and the surgeon pulls up the bladder and makes an incision in its wall through which a drainage catheter is inserted into the bladder. After this, the incision of the bladder wall incision (simultaneous fixing the position of the catheter in the stoma) and the entire surgical wound is performed.

The suprapubic cystostomy is a common procedure used to treat acute urinary retention after unsuccessful urethral catheterization and when there is a need for long-term catheterization. This procedure is more effective, has less complications than urethral catheterization or open epitsistostomy.[6], [7]

When an epicystostomy of the bladder is necessary for a limited period of time, a suprapubic trocar epicysticostomy is performed under local anesthesia. In order for this intervention to proceed normally, the bladder must be full, for which a small amount of fluid is given to the patient before the operation. If this is not possible, the bladder fills with air.

During this operation, 30 mm above the pubic bone of the abdominal wall and the underlying bladder are punctured with a trocar stylet, a catheter is inserted into the resulting small opening under ultrasound guidance through the trocar tube. [8]If a Foley catheter is used and equipped with a balloon, the catheter is fixed inside the orifice by inflating it. After the trocar is removed, the drainage tube passing through the stoma is fixed on the skin surface.

An inguinal approach for installing a cystostomy tube in the bladder with minimal soft tissue dissection is described. [9]

Contraindications to the procedure

The main contraindications to the conduct of an epicystostomy, urologists consider a malignant tumor of the bladder, acute inflammation of the ureter, abnormal localization of the bladder, dysfunction of its sphincters, the presence in a patient of a fracture of the pelvic bones, adhesions in the lower abdominal cavity, as well as a high degree of abdominal obesity and marked reduction of abdominal obesity and pronounced reduction of abdominal obesity.

Complications after the procedure

Possible postoperative effects are manifested in the form of pain, irritation of the skin around the artificial fistula, seam divergence, bleeding, infection of tissues at the site of the catheter with the formation of purulent discharge and fever.

Complications after an epicystostomy procedure include:

• catheter falling out of the stoma or blocking it;
• urine leakage, as well as its entry into the intra-abdominal space;
• spasm of the bladder and urethra;
• hematuria; [10]
• secondary infection of the bladder through epicystic with the development of cystitis; [11]
• described the case of acute purulent cavernitis and prostatitis in a patient with diabetes mellitus after epicysticostomy; [12]
• bowel injury was reported in 2.2% of patients. [13]

Care after the procedure

In the first week after the procedure, when a sterile gauze cloth is applied in the area of the cystostomy, the skin is antiseptic; further use of water with soap will be sufficient.

Any actions to change the dressing and to handle the catheter tube are carried out only with clean hands (in the first month it is better with sterile gloves), since the observance of hygiene rules plays a very important role in the prevention of complications.

Each patient receives detailed instructions from the urologist for the care after the procedure, in particular:

• the need for timely emptying of the urinal and its weekly replacement;
• replacing the catheter itself every one to two months (depending on the type of catheter);
• regarding proper wearing of the urinal (fixing it below the level of the bladder - on the outer surface of the thigh, and at night - on the bed, below the position of the body).

People with epicystic are advised to take a shower more often; limit alcohol consumption and drink less strong tea, coffee and soda water, which can irritate the bladder mucosa. But in order to avoid stagnant processes, it is recommended to drink at least one and a half liters of pure water throughout the day.

Reviews

Reviews of some patients after this operation indicate the possibility of intense pain at the site of installation of cystostomy, hyperemia and swelling of the skin, as well as discharge of turbid urine and the appearance of an unpleasant odor. With all the problems associated with transferred epitsistostomii, you should immediately contact your urologist.