Imaging-guided Percutaneous Large-Bore Suprapubic Cystostomy, a Safe Bladder Diversion Alternative AJIR

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1 CASE SERIES Imging-guided Percutneous Lrge-Bore Suprpuic Cystostomy, Sfe Bldder Diversion Alterntive Jesse Chen 1, Elliot Lndu 2, Noor Ahmd 2, Christopher Giordno 2, Jonthn Scheiner 2, Nchum Ktlowitz 3, Dvid Geller 2 1 Deprtment of Rdiology, 2 Deprtment of Interventionl Rdiology, 3 Deprtment of Urology, Stten Islnd University Hospitl, 475 Seview Avenue, Stten Islnd, NY, 10305, United Sttes Astrct Corresponding Author: Jesse Chen, Deprtment of Rdiology, Stten Islnd University Hospitl, 475 Seview Avenue, Stten Islnd, NY, 10305, United Sttes. E-mil: jessechen10@gmil.com Suprpuic ctheter plcement is common method of ldder diversion. To dte, there re limited reports descriing sfe plcement of lrge-ore (18 28 F) ctheters s smller ctheters often clog nd require upsizing procedures. We retrospectively evlute the imge-guided percutneous plcement of lrge-ore ctheters y interventionl rdiologists in our institution, totling 51 ctheters in 51 ptients over 5 yers. We successfully plced lrge-ore ctheter in 96% (49/51) of first ttempts with no post procedurl complictions. This dt demonstrtes tht percutneous plcement of lrge-ore suprpuic ctheters y interventionl rdiologists is sfe nd less-invsive ldder diversion lterntive to trditionl lind or open surgicl techniques. Keywords: Cystostomy, Lrge ore, Suprpuic Received: 19 June 2018 Accepted: 06 July 2018 Pulished: 17 July 2018 INTRODUCTION S uprpuic urinry ldder ctheters (SPCs) ply n importnt role in ptients requiring long-term ldder ctheteriztion nd/or diversion. Lrge Cochrne review nlyses hve demonstrted tht the use of SPC compred to trnsurethrl ctheteriztion decreses cteriuri, need for rectheteriztion, nd discomfort. [1] Ptients with trnsurethrl ctheters hve een shown to hve Access this rticle online Quick Response Code: Wesite: DOI: / significntly more hospitl visits compred to SPC ptients due to pin. [2] Eqully importnt, ptient preference of n SPC over trnsurethrl ctheter is lso documented due to its ese of mngement, decresed reltive discomfort, nd decresed rte of infections. [3] In the mjority of cses, the distended ldder displces the peritonel reflection superiorly llowing for uneventful lind insertion of such ctheters. However, there is reported 2.4% incidence of owel injury with lind technique, nd even under cystoscopic guidnce, 30-dy mortlity rte of 1.8% is reported. [3] Certin ptient risk fctors increse the risk for complictions including oesity, history of rdicl pelvic surgery, nd short distnce ( 11 cm) etween the symphysis puis nd umilicus. [4] The lst line lterntive of open surgicl plcement is less fvorle option s it is more invsive, requires generl nesthesi, nd crries further post-opertive risk nd cost. This is n open-ccess rticle distriuted under the terms of the Cretive Commons Attriution Non Commercil Shre Alike 4.0 License, which llows others to remix, twek, nd uild upon the work non commercilly, s long s the uthor is credited nd the new cretions re licensed under the identicl terms. Americn Journl of Interventionl Rdiology (10) 1

2 Plcement of reltively smll SPC (10 14 French) is commonly performed in the emergent setting for cute urinry retention when urethrl ctheteriztion is either impossile or contrindicted. The use of ultrsound ssistnce hs een descried in this emergency setting, including one series of 17 ptients with 100% success rte. [5] However, these ctheters re not optiml for prolonged, chronic dringe. Plcement of lrge-ore ctheter on initil cystostomy could preclude the need for repet procedures for ctheter upsizing. Initilly descried in 1989, ultrsound- nd fluoroscopicguided plcement of lrge-ore SPC (18 French or lrger) y interventionl rdiologists hs een shown to e sfe nd effective lterntive insertion method without requiring generl nesthesi. [6] In our study, we descrie single institution s experience plcing lrge-ore SPC (18 28 French) within the interventionl rdiology (IR) deprtment including the technicl success rte nd complictions. MATERIALS AND METHODS Approvl for this retrospective review ws otined from the hospitl s Institutionl Review Bord. The study ws HIPAA complint nd informed consent ws wived. Ptient dt collection dominl wll nd to displce interposing owel loops. A sfe window ws confirmed through comintion of ultrsound, fluoroscopy, nd on occsion, pre procedurl CT. A 5 French, 7 cm needle/trocr ssemly (Yueh needle, Cook Medicl, Bloomington, IN) ws susequently dvnced into the ldder under ultrsound guidnce. Alterntively, 21 g micropuncture set ws used. Once urine ws spirted ck, smll volume of diluted contrst ws dministered through the outer sheth to confirm intrvesiculr positioning under fluoroscopic guidnce (Figure 1). The inner stylet ws removed nd inch Ampltz guidewire (Boston Scientific, Mrlorough, MA) ws dvnced into the ldder under fluoroscopic guidnce (Figure 1). The Yueh sheth ws removed nd the trct ws serilly dilted to dvnce 10 mm, 15 cm lloon ctheter system (Brd, Covington, GA) which ultimtely dilted the sucutneous trct nd cystostomy to 30 French under fluoroscopic control (Figure 1c). A 30F peel-wy sheth ws dvnced over the lloon, the lloon ws deflted nd removed, nd lrgeore Foley ctheter (usully 26 French) ws directed into the urinry ldder through the peel-wy sheth (Figure 1d). With the sheth then removed, smll mount of diluted contrst ws dministered through the ctheter to confirm plcement. The retention lloon ws then distended with sterile wter under fluoroscopic control. Our institution s dicttion dtse ws serched for ll suprpuic ctheter insertions performed y the deprtment of IR over 5-yer period from Jnury 1, 2012, to Decemer 31, A totl of 51 consecutive primry lrge-ore SPC insertions were performed. The electronic medicl record for these ptients ws reviewed to strct dt regrding gender, ge, indiction, ptient comoridities, ctheter dimeter, nesthetic provided, nd oth intropertive nd susequent in-house complictions. Technique All procedures were done y one of four full-time ttending stff interventionl rdiologists rnging from 1 to 20 yers of experience. The first 5 cses were performed conjointly etween the IR nd urology deprtments. Once comfortle with the technique, IR performed ll susequent procedures without ssistnce. Our institutionl Picture Archiving nd Communiction System were reviewed efore ll insertions for ny crosssectionl imging tht would demonstrte pelvic ntomy nd sfe window for percutneous insertion. Once in the IR suite, n initil ultrsound ws performed to evlute for ldder distention. If not lredy distended, the urinry ldder ws filled with cc norml sline through pre-existing trnsurethrl ctheter to pproximte the ldder nd nterior c d Figure 1: A 70-yer-old mle with urinry retention from BPH undergoing percutneous imge-guided suprpuic ctheteriztion. () Fluoroscopic ppernce of 7 cm Yueh needle within the distended ldder. Opcifiction of the ldder following injection of smll mount of Cysto-Conry contrst confirms needle tip position. () Fluoroscopic ppernce of inch Ampltz guidewire threded into the ldder, with expected coiled ppernce. (c) Fluoroscopic ppernce of 30F lloon pssed over the guidewire to dilte the cystostomy. (d) Fluoroscopic ppernce of 30F peel-wy sheth within the ldder. A lrge-ore ctheter is dvnced through the sheth nd its retention lloon inflted. Americn Journl of Interventionl Rdiology (10) 2

3 Follow-up of ptients ws limited to the sme dmission for inptient procedures nd follow-up phone cll within 1 week of dischrge for outptient procedures. Ptient demogrphics RESULTS From Jnury 2012 to Decemer 2016, 51 lrge-ore suprpuic ctheters were inserted in 51 ptients (46 mles, 5 femles) mong them 49 of 51 were single stge procedure. The men ge ws 67.3 yers, rnging from 22 to cses were performed s outptient procedures, nd the remining 41 cses were performed s inptient procedures. One cse ws performed with generl nesthesi due to ptient preference. The indictions for suprpuic ctheteriztion re listed in Tle 1. Outcomes Technicl success ws defined s single-step plcement of the SPC in the ldder s plnned. Of the 51 cses performed, technicl success ws chieved in 49 procedures, for 96% success rte. No mjor complictions occurred ccording to the Society of IR Clinicl Prctice Guidelines. [7] For the first unsuccessful cse, there ws immedite clinicl suspicion of the ctheter eing mlpositioned outside of the urinry ldder on completion of the procedure. The ptient ws tken directly to computed tomogrphic (CT), nd CT cystogrm confirmed the ctheter ws positioned within the spce of Retzius (Figure 2). The ptient ws susequently tken ck to the IR suite for uneventful removl of the mlpositioned ctheter nd successful plcement of new 26F SPC. Tle 1: Indictions for suprpuic ctheteriztion Indiction Count Neurogenic ldder (stroke, spinl 16 trum) BPH w/urinry retention 12 Urethrl stricture/injury 8 Penile trum 6 Fournier s Gngrene/necrotizing 3 fsciitis Vulvr cncer 2 Prostte cncer 1 Hypospdis 1 Bldder injury during owel surgery 1 Chronic urinry clculi 1 Totl 51 Tle 2: The distriution of lrge ore ctheter sizes plced on first ttempt Initil ctheter size Count Totl 49 In the second unsuccessful cse, the ldder ws ccessed uneventfully. However, fter lloon dilttion of the dominl wll trct, the 30-French trocr sheth ws unle to e dvnced into the ldder. After severl ttempts to dvnce the sheth, extr luminl contrst extrvstion incresed so 14-French pigtil dringe ctheter ws esily plced insted. The ptient ws rought ck the next dy for uneventful ctheter upsizing to 26F ctheter. The distriution of ctheter sizes plced on the first ttempt is listed in Tle 2. There were no in-house complictions for the 41 inptient procedures. Four of our ptients susequently expired in the sme dmission: Two from sepsis in the setting of Fournier s gngrene, one from sepsis from overwhelming ed sores, nd one from withdrwl of cre in the setting of prolonged ventiltor dependence fter diffuse urn injury. The plcement of n SPC, however, hd no identifile contriutory role to the cuse of deth for ny ptients. On telephone follow-up for outptient procedures, there were no reported complictions. Long-term follow-up for these ptients ws in urology clinic. Figure 2: A 37-yer-old mle with diffuse genitl urn injury following motor vehicle collision underwent suprpuic ctheteriztion. () Axil nd () sgittl postprocedurl computed tomogrphic cystogrm imges demonstrte the inflted Foley ctheter lloon in the spce of Retzius (white rrows) DISCUSSION Suprpuic ctheters re commonly used for oth temporry nd long-term urinry dringe. Suprpuic cystostomy is indicted when trnsurethrl ctheteriztion is contrindicted or techniclly impossile. The trditionl pproch of suprpuic ctheteriztion is with n open dominl incision under generl nesthesi. Some urologists prefer this method s it provides ressurnce tht no owel is hrmed during the procedure. However, the invsiveness nd length of the surgery, the post procedurl pin, the need for nesthesi, nd the cost to oth the ptient nd the hospitl re ll resons to pursue sfe nd efficient lterntive. Americn Journl of Interventionl Rdiology (10) 3

4 While percutneous plcement is techniclly simple, the risk for viscerl injury is not excluded from the study. Ahluwli et l. reported 10% intropertive compliction rte, 2.4% risk of owel injury, 19% 30-dy compliction rte following lind technique, nd 1.8% mortlity rte in 219 urology ptients who underwent percutneous suprpuic insertion with cystoscopic guidnce. [3] Despite the possiility of procedurl complictions, suprpuic ctheteriztion is preferred y 89% of ptients over urethrl ctheteriztion mostly sed on comfort nd ese of use, while providing decresed risk of infection. [3] One prospective review of men ctheterized either trnsurethrlly or suprpuiclly for prosttic enlrgement reported 3-yer incidence of urinry trct infection of 40% in the trnsurethrl group nd 18% in the suprpuic group. [8] There re numer of complictions tht my rise from SPC. Spontneous intrvesicl ctheter knotting hs een reported lthough descried risk fctor for this compliction is smller ctheter dimeter. [9,10] Migrtion of n 18F SPC into ureter resulting in ostruction nd pyelonephritis hs een descried; however, this compliction might e voided with lrger ctheters. [11] Incisionl herni following SPC insertion is descried lthough this compliction is rre. [12] Lekge round n SPC is lso possile compliction, however, not unique to SPC. Prctice guidelines pulished y the British Assocition of Urologicl Surgeons (BAUS) recommend considering SPC in ll ptients with chronic urinry retention, neurologicl disese, urinry incontinence, post-opertive cre needs, trumtic injury, nd those with pllitive needs. [13] Ultrsound hs een recommended y the BAUS s n djunct to SPC insertion to ensure tht no interposing owel loops re present. However, the society wrns tht only individuls who hve received specific trining nd re experienced with this tsk should utilize this technology. Although interventionl rdiologists re specilly trined in ultrsound- nd fluoroscopic-guided ctheter plcement, very few pulished studies descrie the role the interventionlist plys regrding SPC. This retrospective cse series presents the sfe plcement of lrgeore ctheters, rnging from 18 to 28F, y smll communitysed IR deprtment in 51 ptients. Lrge-ore suprpuic ctheter plcement under comined ultrsound nd fluoroscopic guidnce hs proven to e sfe nd efficient. There were no serious intropertive complictions, no complictions oserved during the sme hospitl dmission, nd two-step procedure ws rrely necessry (2 out of 51). Using direct rel-time imging, interposed owel cn e voided, nd percutneous plcement cn e chieved, oth in oese ptients nd those with complex post-opertive dominl/pelvic wlls or otherwise norml ntomy. Two cses we performed recently reinforce the importnce of imging guidnce. These ptients were not included in Americn Journl of Interventionl Rdiology (10) 4 the ove series ecuse the first ws plnned two-step procedure nd the second ws performed more recently, outside of the dt collection window. 1. An 83-yer-old mle with neurogenic ldder hd preprocedurl pelvic CT demonstrting owel loop trversing the spce of Retzius (Figure 3), nd it ws decided n initil 14F SPC would e plced under CT guidnce. The ptient ws susequently rought to the IR suite for exchnge of the 14F pigtil for 26F Foley. Given the previously mentioned 2.4% chnce of owel injury in trditionl SPC insertion, ny effort to void intervening owel is criticl. This cse demonstrtes how interventionl rdiologists, fmilir with performing procedures under imging guidnce, my e le to sfely plce n SPC even when there is nrrow percutneous window, or when the ldder cnnot e idelly opposed to the ventrl dominl wll (e.g. dhesions nd prior surgery). 2. During SPC plcement in 74-yer-old mle with neurogenic ldder, the finl imge tken to confirm ctheter plcement demonstrted tht the contrst injected into the ldder collected in limited ring round the Foley lloon (Figure 4). Lterl fluoroscopic imging showed the contrst limited to the posterior pelvis, without inferior extension into the retropuic spce s would e expected (Figure 4). Intr procedurl re evlution of recent dominl CT confirmed the presence of posterior ldder diverticulum (Figure 4c). On defltion of the Foley lloon, the contrst flowed freely into the retropuic spce (Figure 4d). The Foley ws retrcted 5 cm nd the lloon ws reinflted. Without the ility to evlute the ptient s ntomy in rel time, the ptient would hve likely developed n outlet ostruction. One lrge retrospective review y Cronin et l. found 99.6% technicl success rte for primry SPC insertions plced y interventionl rdiologists in 549 ptients, lthough the ctheters plced rnged in size only up to 14 French. These smller ctheters, however, re prone to occlusion nd often require djustment. [14] Lee et l. descried series of 60 ptients who received n SPC under imging guidnce, similr to the technique descried here, however, the ctheters tht their tem plced were only French. [15] Similrly, Chiou et l. descried series of 56 ptients where similr percutneous method ws used to plce 18F ctheters. [16] 46 of the 51 ctheters plced in this series, however, were 26 French. In 2015, Flynn et l. descried n inside-out pproch, sfely performing trnsurethrl suprpuic endocystostomy (T-SPeC) with new medicl device (T-SPeC, Swn Vlley Medicl Inc., Denver, CO). They did not report ny mjor procedure-relted complictions; however, the T-SPeC procedure still required nesthesi nd cystoscopy, disdvntge over the imge-guided technique descried here. While their cses were mostly performed in conjunction

5 Figure 3: An 83-yer-old mle with neurogenic ldder ws plnned for suprpuic ctheteriztion. () Axil nd () sgittl preprocedurl dominopelvic computed tomogrphy demonstrtes loop of owel trversing the nterior ldder (white rrows), nrrowing the window cross which percutneous suprpuic urinry ldder ctheter my e inserted sfely. ctheters of this clier hs not een previously descried. The originl 1989 pper did not specify ctheter size (only 18 F) mong its 15 ptients, ut this series demonstrtes tht primry percutneous imge-guided insertion of lrge-ore SPC in the rnge of 26F is sfe ldder diversion lterntive nd does not require stged upsizing of prior trct. The ptients in this study were given lrge-ore ctheters t the urologist s request s necdotlly, they hve hd fewer complictions nd required fewer repet procedures. Nonetheless, it remins to e seen whether this lrger size truly provided clinicl enefit over smller ctheters. Not ll ptients require such lrge ctheter on initil insertion; however, lrger ctheters re sometimes preferred or even necessry for ptients who re prone to chronic hemturi/ clotting nd occlusion/sedimenttion. [18,19] In these ptients, the interventionl rdiologist my e n idel procedurlist for this tsk given the enefit of imge utiliztion s mens of prolem-solving s descried ove. c d Figure 4: A 74-yer-old mle with neurogenic ldder underwent suprpuic ctheteriztion. () AP fluoroscopic imge demonstrtes contrst limited to smll re (white rcket) round the ctheter lloon (white rrow) on finl imging. () Lterl fluoroscopy imge demonstrtes contrst limited to the posterior pelvis, without expected extrvstion inferiorly into the retropuic re. (c) Prior sgittl pelvic computed tomogrphic (CT) imge confirming the presence of posterior ldder diverticulum (red outline). (d) Lterl fluoroscopy imge following prtil defltion nd retrction of the Foley lloon demonstrtes contrst freely lyering in the ldder, reveling the neck of the diverticulum tht ws previously occluded y the inflted lloon (dotted line). with pelvic surgery, it remins to e seen if trnsurethrl pproch would e s successful under light sedtion. [17] The present study is limited y lck of control group, overll smll smple size, nd limited follow-up. Moreover, the technique descried here is similr to tht descried y Ppnicolou et l. in 1989 with minor differences (the peelwy sheth ws dvnced over the trnsmurl lloon insted of dvncement with n inner diltor). The 5-yer series reported here is nonetheless notle, s there ws high technicl success rte (96%), nd series of lrge-ore CONCLUSION lrge-ore suprpuic ctheter insertion hs the dvntge Vrious options re ville for ptients requiring chronic urinry ldder dringe. Suprpuic cystostomy offers mny dvntges including improved ptient comfort, low risk of compliction, nd lower risk of infection. Initil of precluding susequent upsizing procedures. Sfe percutneous insertion of lrge-ore SPC in the rnge of 26F y rdiologists trined in imging-guided procedures is demonstrted here. REFERENCES 1. Kidd EA, Stewrt F, Kssis NC, Hom E, Omr MI. Urethrl (indwelling or intermittent) or suprpuic routes for short-term ctheteristion in hospitlised dults. Cochrne Dtse Syst Rev 2015:CD Dunn TS, Figge J, Wolf D. A comprison of outcomes of trnsurethrl versus suprpuic ctheteriztion fter urch cystourethropexy. Int Urogynecol J Pelvic Floor Dysfunct 2005;16: Ahluwli RS, Johl N, Kouriefs C, Kooimn G, Montgomery BS, Plil RO, et l. The surgicl risk of suprpuic ctheter insertion nd long-term sequele. Ann R Coll Surg Engl 2006;88: Cho KH, Doo SW, Yng WJ, Song YS, Lee KH. Suprpuic cystostomy: Risk nlysis of possile owel interposition through the percutneous trct y computed tomogrphy. Koren J Urol 2010;51: Aguiler PA, Choi T, Durhm BA. Ultrsound-guided suprpuic cystostomy ctheter plcement in the emergency deprtment. J Emerg Med 2004;26: Ppnicolou N, Pfister RC, Nocks BN. Percutneous, Americn Journl of Interventionl Rdiology (10) 5

6 lrge-ore, suprpuic cystostomy: Technique nd results. AJR Am J Roentgenol 1989;152: Scks D, McClenny TE, Crdell JF, Lewis CA. Society of interventionl rdiology clinicl prctice guidelines. J Vsc Interv Rdiol 2003;14:S Horgn AF, Prsd B, Wldron DJ, O Sullivn DC. Acute urinry retention. Comprison of suprpuic nd urethrl ctheteristion. Br J Urol 1992;70: Frook SA, Kriholu U, Kousidis G, Powlis M. Not to knot ctheter. Cse report of the knotting of suprpuic ctheter. Scientific World Journl 2007;7: Srin YK. Spontneous intrvesicl knotting of urethrl ctheter. APSP J Cse Rep 2011;2: Shuiin W, Hiqi M, Qin F, Hifeng Y. An unusul compliction of suprpuic ctheter migrtion into the left ureter. Urol J 2018;15: Loel RW, Snd PK. Incisionl herni fter suprpuic ctheteriztion. Ostet Gynecol 1997;89: Hrrison SC, Lwrence WT, Morley R, Perce I, Tylor J. British ssocition of urologicl surgeons suprpuic ctheter prctice guidelines. BJU Int 2011;107: Cronin CG, Prksh P, Gervis DA, Hhn PF, Arellno R, Guimres A, et l. Imging-guided suprpuic ldder tue insertion: Experience in the cre of 549 ptients. AJR Am J Roentgenol 2011;196: Lee MJ, Ppnicolou N, Nocks BN, Vldez JA, Yoder IC. Fluoroscopiclly guided percutneous suprpuic cystostomy for long-term ldder dringe: An lterntive to surgicl cystostomy. Rdiology 1993;188: Chiou RK, Morton JJ, Engelsgjerd JS, Mys S. Plcement of lrge suprpuic tue using peel-wy introducer. J Urol 1995;153: Flynn BJ, Lrke RJ, Knoll PB, Anderson KM, Siomos VJ, Windsperger AP, et l. Prospective study of the trnsurethrl suprpuic endo-cystostomy (T-SPEC( )): An inside-out pproch to suprpuic ctheter insertion. Int Urol Nephrol 2015;47: Lee C, Gill BC, Vsvd SP, Rckley RR. Does size mtter? Mesured nd modeled effects of suprpuic ctheter size on urinry flow. Urology 2017;102:266. e1-266.e Willette PA, Coffield S. Current trends in the mngement of difficult urinry ctheteriztions. West J Emerg Med 2012;13: How to cite this rticle: Chen J, Lndu E, Ahmd N, Giordno C, Scheiner J, Ktlowitz N, Geller D. Imging-guided Percutneous Lrge-Bore Suprpuic Cystostomy, Sfe Bldder Diversion Alterntive. Am J Interv Rdiol 2018; 2(10) 1-6. Americn Journl of Interventionl Rdiology (10) 6

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