Azhar Khan and Paul Abrams Bristol Urological Institute, Southmead Hospital, Bristol, UK

. JOURNAL COMPILATION 2008 BJU INTERNATIONAL Lower Urinary Tract BJUI BJU INTERNATIONAL Suprapubic catheter insertion is an outpatient procedure: cost savings resultant on closing an audit loop Azhar Khan and Paul Abrams Bristol Urological Institute, Southmead Hospital, Bristol, UK Accepted for publication 10 July 2008 Study Type Economic (case series) Level of Evidence 4 OBJECTIVE To explore, by an audit, the regional practice of inserting a suprapubic catheter (SPC), and to prospectively determine the proportion of patients that can be successfully managed on an outpatient basis in one department. METHODS Both local and regional practice were determined by a retrospective analysis of the hospital database for all cases of SPC insertion between April 2005 and March 2006. In addition, a questionnaire was e- mailed to each of 11 urology departments. Locally, from August 2006 onwards, all patients scheduled for SPC insertion were referred to a new clinic, where the SPC was inserted using a new SPC kit and the Seldinger technique. RESULTS Locally, 66 patients (mean age 70 years, range 26 93) had a SPC inserted between April 2005 and March 2006; 49 had an elective procedure while 17 were emergency admissions. The median (range) hospital stay was 3.5 (1 85) days. Within the region, 480 SPCs were inserted in theatre during the same period, of which 52% (249) were inserted as elective inpatients, 11% (52) were inserted as a day case, and 37% (179) had SPCs as emergency admissions. A nurse-led outpatient service was available in two hospitals, where 89% of patients seen in the clinic had successful insertion under local anaesthesia, and only 11% were referred for insertion under general anasthesia. Between August 2006 and July 2007, 50 of 54 patients had a SPC inserted successfully in the new SPC clinic. There were no major complications. The cost benefits of adopting an outpatient management strategy were significant, at GB 100 000/year in our hospital, 790 000/year in the region and 9 500 000/year for the UK. CONCLUSION An outpatient procedure for a SPC is safe and feasible in most patients, and its widespread use would produce considerable cost savings. KEYWORDS suprapubic catheterization, Seldinger technique, outpatient, audit, cost savings INTRODUCTION Placing a suprapubic catheter (SPC) is a minor surgical procedure traditionally done in the operating theatre, either under general (GA) or local anaesthesia (LA), using blind or ultrasonography (US)-guided percutaneous trocar puncture. In recent years, SPCs have become more prevalent than indwelling urethral catheters for those requiring longterm catheterization, e.g. in patients with neurological disorders, intractable incontinence or BOO and who are unfit for TURP, most of whom are elderly, with complex medical conditions and anaesthetic risks that must be considered account when selecting patients for theatre. The SPC avoids the complications of long-term urethral catheterization, e.g. traumatic hypospadias due to ventral erosion, and ischaemic stricture formation. In cases of urethral stricture, urethral catheterization might not be possible and a SPC might have to be inserted to manage urinary retention. To safely place a SPC the bladder must be adequately distended; such distention of the bladder can be very difficult in patients with neuropathic bladder disorders, due to a hypertrophied bladder wall [1], and blind percutaneous insertion of conventional widebore trocars can result in bowel perforation [2 4]. A new SPC-introducing kit (Fig. 1), based on the Seldinger technique, has been developed, which allows controlled entry of the trocar into the bladder over a guidewire, and is designed to reduce the potential hazards of the blind technique. The aims of the present audit were to explore the practice of SPC insertion in the Southwest region, with reference to the method, type of anaesthesia, and to determine the factors and evidence base behind this practice. This report also describes our experience with the new SPC kit in patients who had an SPC inserted under LA in a new clinic, between August 2006 and July 2007. We also determined the cost-effectiveness of the outpatient SPC practice in the region and in the UK. METHODS Local practice was determined by a retrospective analysis of hospital database for all cases of SPC insertion between April 2005 and March 2006. Regional practice was explored by contacting the information departments in the regional hospitals to ascertain the number of SPCs placed during the same period. In addition, a questionnaire 640 JOURNAL COMPILATION 2008 BJU INTERNATIONAL 103, 640 644 doi:10.1111/j.1464-410x.2008.08125.x

FIG. 1. The SPC introducing set (Mediplus Ltd). FIG. 2. The questionnaire distributed to regional departments. 1- Date 2- Name of hospital Regional SPC Audit 3- What is the preferred method of SPC insertion in your hospital? Total number of cases per year: Method Inpatient (Main theatre) Day case (Day theatre) Outpatient Inpatient (ward) 4- What type of anaesthesia is used? Anaesthesia LA GA Regional 5- If the procedure is carried out in theatre under GA, please answer the following questions. 6a- Is it a part of your practice to attempt SPC insertion in the ward or outpatient before adding the patient to waiting list (theatre)? Yes No was e-mailed to each of the 11 urology departments. The questionnaire (Fig. 2) aimed to determine the departmental practice of SPC insertion with regard to method, type of anaesthesia, preferred method of filling the bladder and whether US guidance was used to visualize the bladder during the procedure. The participants were also asked about the factors influencing their decision to place the SPC in the operating theatre, and whether outpatient-based SPC insertion was attempted before adding the patient to the theatre list. 18 g Hypodermic Needle Three-stage Guide Wire Ditator and Peelable Sheath Low Profile Silicone Foley Catheter Set includes 2 10 ml syringe and a scalpel 6b- What factors influence this decision? Factor Yes No Consultant s choice Patient s choice Previous history of abdominal surgery Suspected small capacity bladder e.g. neurological disease No other appropriate facilities (Please specify) 7-What method do you use to fill the bladder for this procedure? Method Flexible cystoscopy Rigid cystoscopy Urethral catheter 8-Do you use ultrasound guidance to visualize bladder before SPC insertion? Ultrasound Yes No 9- comments? Thank you for your time. As a result of the audit, a change was implemented by setting up a new SPC clinic as part of the BioMed catheter clinic in Southmead Hospital (one session per week at the end of the flexible cystoscopy list), and all the urological consultants and registrars in the local department were notified of its availability. All the patients from the authors firms were directed to the new clinic and submitted to this procedure. As the clinic showed more success, patients were referred from other firms. In all, 54 patients were referred to the clinic between August 2006 and July 2007. Their initial evaluation consisted of basic demographics, a detailed history and clinical examination. Informed verbal consent was obtained from all patients. All SPCs were inserted under LA (1% lignocaine); aspirin was stopped 10 days before the procedure, while warfarin was stopped 5 days before (the International Normalised Ration was checked 1 day before the procedure, with a target of <1.2). The bladder was filled with a target volume of >350 ml sterile water, either using the flexible cystoscope or a urethral catheter. Prophylactic antibiotic cover was provided with ciprofloxacin 500 mg 30 min before the procedure and continued for 3 5 days afterwards. All the procedures were done by one trainee urologist using the new SPC introduction set (Mediplus Ltd, High Wycombe, Bucks, UK; Fig. 1). The new kit uses the Seldinger technique for the safe insertion of the SPC, and is briefly outlined. With the patient supine and the suprapubic area thoroughly cleaned, LA was infiltrated 2 cm above the pubic symphysis in the midline. A small incision of 1 cm long was made in the skin to allow easier insertion of the trocar later. The bladder was then punctured using an 18 G needle. After confirming the position of needle in the bladder by aspiration or flexible cystoscopy, the floppy end of a 0.9 mm guidewire was introduced through the needle. The needle was then removed, leaving the guidewire in the bladder. The trocar and sheath were introduced over the guidewire through the incision until safely in position in the bladder (Fig. 3). The guidewire and trocar were then removed from the outer sheath and a 14 F silicon catheter, which is part of the kit, was inserted into the bladder through the peel-away sheath. US was used to ensure that no intervening bowel loops were present in patients whose bladders could not be adequately distended. Patients remained under observation for 1 2 h after the procedure. The first catheter change was arranged in a nurse-led clinic after 4 weeks, following which the patients were discharged into primary care. Locally, with the help of the finance department, mean costs were calculated for an outpatient, an inpatient and a day-case procedure. The cost differential to the Trust of adopting outpatient SPC insertion was JOURNAL COMPILATION 2008 BJU INTERNATIONAL 641

estimated and this cost differential was extrapolated to the region and to the UK. RESULTS In the local department, 66 patients (mean age 70 years, range 26 93) had a SPC inserted between April 2005 and March 2006; 49 had an elective procedure, 17 were emergency admissions and only seven of 49 elective procedures were day cases. GA was used in 43 patients (only two as day cases), compared with LA in 23. The median (range) hospital stay was 3.5 (1 85) days and the mean hospital stay for elective cases was 4.1 days. In the region, 480 SPCs were inserted in operating theatres between April 2005 and March 2006, with the number in each hospital shown in Table 1; 52% (249) were elective inpatients, whereas 11% (52) were day cases, with 37% (179) SPCs inserted as emergency admissions. In Weston General Hospital, only four patients had their SPC inserted in theatre, mainly because of a nurse-led outpatient SPC service, where 39 had successful insertion under LA during the same period. A nurse-led outpatient service was also available in Musgrove Park Hospital, Taunton. In both these trusts, 89% of patients seen in the outpatient clinic had successful insertion under LA, and only 11% were referred for GA insertion in theatre. In addition, responses to the questionnaires from all the hospitals across the region were analysed. According to the respondents, 56% of SPCs were inserted under LA and 42% were inserted under GA; in 2% of cases, regional anaesthesia was used. In most patients rigid cystoscopy (42%) or flexible cystoscopy (37%) was used to fill the bladder, whereas in 20% a urethral catheter was used. Previous abdominal surgery (100%), small-capacity neurogenic bladder (100%), consultant s choice (87%), patient s choice (75%) and lack of other appropriate facilities (50%) were the main factors influencing where and how the SPC was inserted. In a re-audit of the SPC clinic, in all, 31 men and 23 women (mean age 67 years, range 30 91) had an SPC inserted using the new set in the newly established clinic. Fifty-two patients had primary insertion, whereas two had closed percutaneous tracks after their catheters had become displaced while in the community. Eighteen (33%) patients had Hospital Inpatient Day case Emergency Derriford 31 3 36 Southmead 42 7 17 Musgrove Park 19 5 35 Cheltenham 24 7 7 Exeter 44 12 37 Bristol Royal Infirmary 6 9 15 Gloucestershire 13 1 16 Weston-s-Mare 4 0 0 Swindon 52 4 3 Barnstaple 14 4 13 multiple sclerosis (MS) and either had intractable incontinence or incomplete bladder emptying. Sixteen (30%) patients had mechanical BOO and were unfit for TURP. Nine (17%) patients had intractable incontinence and needed a catheter to keep them dry. Other less common diagnoses included detrusor failure, head injury, Down s syndrome and cerebral palsy. Most had problematic long-term urethral catheters and were referred for SPC insertion to improve their care, and to decrease the discomfort and trauma associated with their urethral catheters. Outpatient SPC insertion was successful in 50 patients and failed in four; in three of the failures the SPC could not be inserted because of difficulty in filling the bladder, either because of severe pain or urine leakage (all three had small-capacity bladders due to MS). In the fourth patient the procedure had to be abandoned due to a panic attack (tachycardia and anxiety). Of the 50 successful procedures, one patient was given prophylactic i.v. vancomycin over 100 min because of an infections with methicillin-resistant Staphylococcus aureus, as per microbiological advice. There were no serious complications during the procedure. FIG. 3. Dilatation of the suprapubic tract over the guidewire, using the Seldinger technique. TABLE 1 SPCs inserted in each hospital, analysed according to the method One patient was admitted with haematuria after insertion. In one patient, the SPC stopped draining after it had been changed due to a blockage within the first week of insertion and needed reinsertion under GA. In Southmead Hospital, the mean cost of a theatre-inserted SPC as an inpatient was 2400, compared with 462 for a day case theatre insertion. Costs included in this study were salaries, disposables, instruments and anaesthetics. In addition, the cost of an inpatient procedure included the mean time in hospital (4.1 days). In the cost for day case surgery, the costs for the proportion of patients eventually needing an overnight stay was factored in. The cost of outpatient SPC insertion was estimated to be 150, and included disposables, as well as salaries of a trainee doctor and one nurse. In addition, costs of added procedures, where outpatient SPC insertion failed, were added to determine average costs. The cost differential of adopting outpatient SPC insertion was calculated assuming that 90% of SPCs in the region could have been inserted as an outpatient procedure. Although the mean hospital stay for emergency admissions was 25 (2 85 days), we acknowledge that these prolonged stays could have been due to reasons other than the SPC. As the causes for 642 JOURNAL COMPILATION 2008 BJU INTERNATIONAL

the stays beyond 4 days are not clear, costs for emergency cases were based on the costs for elective inpatients and the prolonged hospital stays were ignored for the purpose of estimating the costs. We estimated that the cost benefits of adopting an outpatient management strategy was 100 000/year in our hospital, 790 000/year in the region, and 9 500 000 in the UK. DISCUSSION SPCs are reportedly better than urethral catheters with regard to UTIs when used in the short-term after major abdominal surgery and acute urinary retention [5 7]. In patients with spinal cord injury, the use of an SPC is associated with a significantly lower incidence of UTI than with indwelling urethral catheters, at 0.34 infections vs 2.73 for urethral catheterization per 100 patients daily [8]. In patients requiring long-term catheterization, there is a growing consensus that the SPC is associated with higher levels of satisfaction and comfort, and with easier care [9]. Theoretically, there are fewer microbes on the abdominal wall than on the perineum, creating less risk of infection, especially in patients with fecal incontinence. SPC changes are easier than changing urethral catheters, and some patients prefer a SPC to a urethral catheter for their sexual function [10]. Inserting a SPC is a relatively minor surgical procedure, traditionally done in the operating theatre via an incision 2 cm above the pubic symphysis. Most patients requiring SPCs are generally elderly and severely disabled due to neurological conditions, e.g. MS, Parkinson s disease, stroke or spinal injury, and might not be fit to have the procedure under GA. In addition, it is more costly to insert a SPC in theatre, with costs related to operating room, staff and anaesthesia. In addition, our data showed that the hospital stay after insertion can be prolonged in this high-risk group. In Southmead Hospital, the median hospital stay for inserting a SPC was 3.5 days, but with several patients being hospitalized for >2 months. Our survey showed that the predominant practice in the region was to insert the SPC in theatre. Although factors such as a smallcapacity neurogenic bladder and previous abdominal surgery were mentioned by the participants as reasons, the lack of an alternative service influenced the decision about half the time. In addition, a urethral catheter was used to fill the bladder in 20% of patients, primarily due to the practice in only two regional hospitals where an outpatient SPC service was available. The audit of the regional hospital database showed that most SPCs in the region were inserted in theatre (480). Only 66 SPCs were inserted in an outpatient setting, most of these in only two hospitals where urology clinical-nurse specialists had been trained to carry out the procedure in carefully selected patients. In both centres, although no flexible cystoscope or US was used, a strict protocol was followed, and only patients whose bladder distended to >300 ml, using a urethral catheter, had outpatient SPC insertion. In both hospitals, 89% of patients had successful insertion and only 11% needed to be referred for GA insertion. The practice in these hospitals showed that outpatient SPC insertion is safe in selected patients. The questions posed to us were whether this practice can be safely adopted by other hospitals, and what were the cost savings. Bowel perforation is a well recognized complication of suprapubic cystostomy [2,3], and the risk of bowel injury is higher in patients with a history of previous lower abdominal surgery, as the bowel frequently adheres to the scar. Abdominal wall adhesions can be found in up to 59% of patients with previous midline laparotomy scars [11]. Several aids can be used to make the procedure safer in an outpatient setting, including US. Our results from the SPC clinic were similar to those from Weston and Taunton, as 91% of patients had a successful insertion under LA, with only 9% being referred for insertion under GA. Most of the present patients were elderly and severely disabled, with the mean age of 67 years. In our experience, the procedure was relatively straightforward in patients with a history of retention, who were men and had age-related incontinence, and in patients who had had a urethral catheter for a relatively short duration. Distending the bladder in patients with neurogenic bladder disorders, especially MS, was quite challenging, primarily due to a small contracted bladder. Demyelination of the neural pathways between the pontine micturition centres and the sacral cord is the major cause of bladder dysfunction in patients with MS [12]. As during urodynamics, slow filling is recommended in patients with neurological abnormalities (<10 ml/min) because faster flow rates can produce marked detrusor overactivity [13]; in our experience we found slow filling for SPC insertion was associated with less discomfort. Although placing a percutaneous SPC using the Seldinger technique has been described [14 16], catheterization through a blind trocar remains the predominant technique used in the UK. Furthermore, these reports of the Seldinger technique include few patients and the authors used either a balloon dilatation catheter or the passage of multiple fascial dilators for track dilatation. We think that our technique is simpler, with a single trocar being used for dilating the tract. SPC insertion using a blind technique can be hazardous, especially in patients with a small contracted bladder, or when leakage occurs during attempted bladder filling. Some patients had troublesome urinary leakage around the catheter, or repeated catheter expulsion through the urethra in whom antimuscarinic drugs had been tried to no effect. We either used a urethral catheter or flexible cystoscope to fill the bladder. Leakage around the cystoscope or catheter was countered by using assistance in the form of digital pressure in the vagina or gentle traction on the catheter to ensure a tight seal. The procedure had to be abandoned in two patients with MS due to pain associated with filling. It is possible that patients might leak and lose the distended bladder during a blind trocar insertion. The Seldinger technique is less likely to cause bowel perforation than blind insertion, as it keeps the tract preserved even in the presence of minor leaks, and enables the trocar to be introduced safely over the guidewire. Using the flexible cystoscope for bladder filling allows the needle to be accurately sited in the bladder under direct vision. Lee et al. [17] reported the use of US and fluoroscopy to seek intervening bowel loops for the safer insertion of a SPC. Fluoroscopy is unlikely to be available in urology outpatients, but both US and flexible cystoscopy are available in most departments, due to the ever-growing services of one-stop haematuria and prostate clinics. Furthermore, US can help to precisely locate the bladder for needle puncture, particularly in patients with a small-capacity neurogenic bladder, previous abdominal surgery or marked obesity. JOURNAL COMPILATION 2008 BJU INTERNATIONAL 643

More recently the UK NHS has passed through many reforms, largely due to the pressure of cancer targets, financial constraints and increased workload. Urology is at the forefront of these changes, with outpatient services such as one-stop haematuria clinics and TRUS-guided prostate biopsy clinics already well established. Our experience indicates that outpatient SPC insertion using the Seldinger technique is simple and safe in most patients. It can help to avoid the potential hazards of the blind technique, especially in patients with neurological disorders. Depending on the workload, it can be done as part of the flexible cystoscopy clinic, to avoid under-use. The cost differential in the present study was based purely on the cost savings in the areas of salaries, anaesthetics and hospital stay. In addition, available theatre slots could be used for other surgical procedures and would help to cut the waiting lists in the NHS. Outpatient SPC insertion has the potential to be a new service model in NHS and can be safely adopted by other hospitals regionally and nationally. ACKNOWLEDGEMENTS We thank Mr Jack Chalker and Mr James Urie (Mediplus Ltd) for kindly providing permission to reproduce Figs 1 and 3. We especially thank all the staff nurses at Urology Outpatients, Southmead Hospital and Adele Long (Director BioMed) for helping with the study. CONFLICT OF INTEREST None declared. REFERENCES 1 Parks RW, Browna RJ. A novel technique for suprapubic catheterization. Br J Urol 1996; 78: 128 30 2 Noller KL, Pratt JH, Symmonds RE. Bowel perforation with suprapubic cystostomy. Report of two cases. Obstet Gynecol 1976; 48 (Suppl.): 675 95 3 Cundiff G, Bent AE. Suprapubic catheterization complicated by bowel perforation. Int Urogynecol J Pelvic Floor Dysfunct 1995; 6: 110 3 4 Ahmed SJ, Mehta A, Rimigton P. Delayed bowel perforation following suprapubic catheter insertion. BMC Urol 2004; 4: 16 5 Horgan AF, Prasad B, Waldron DJ, O Sullivan DC. Acute urinary retention. Comparison of suprapubic and urethral catheterization. Br J Urol 1995; 70: 1449 51 6 Sethia KK, Selkon JB, Berry AR, Turner CM, Kettlewell MG, Gough MH. Prospective randomized controlled trial of urethral versus suprapubic catheterization. Br J Surg 1987; 74: 624 5 7 O Kelly TJ, Mathew A, Ross S, Munro A. Optimal Method for urinary drainage in major abdominal surgery: a prospective randomized trial of suprapubic versus urethral catheterization. Br J Surg 1995; 82: 1367 8 8 Esclarin De Ruz A, Garcia Leoni E, Herruzo Cabrera R. Epidemiology and risk factors for urinary tract infection in patients with spinal cord injury. J Urol 2000; 164: 1285 9 9 Warren JW. Catheter-associated bacteriuria. Clin Geriatr Med 1992; 8: 805 19 10 Atkinson K. Incorporating sexual health into catheter care. Prof Nurse 1997; 13: 146 8 11 Levrant SG, Bieber EJ, Barnes RB. Anterior abdominal wall adhesions after laparotomy or laparoscopy. J Am Assoc Gynecol Laparosc 1997; 4: 353 6 12 Fowler CJ. Pathophysiology of micturition disturbances in multiple sclerosis. Sex Disabil 1996; 14: 7 12 13 Abrams P. Urodynamics, Chapter 3. London: Springer Verlag, 2006: 61 14 O Brien WM. Percutaneous placement of a suprapubic tube with peel away sheath introducer. J Urol 1991; 145: 1015 6 15 Chiou RK, Morton JJ, Engelsgjerd JS, Mays S. Placement of large suprapubic tube using peel-away introducer. J Urol 1995; 153: 1179 81 16 Papanicolaou N, Pfister RC, Nocks BN. Percutaneous, large-bore, suprapubic cystostomy: technique and results. Am J Roentgenol 1989; 152: 303 6 17 Lee MJ, Papanicolaou N, Nocks BN, Valdez JA, Yoder IC. Fluoroscopically guided percutaneous suprapubic cystostomy for long-term bladder drainage: an alternative to surgical cystostomy. Radiology 1993; 188: 787 9 Correspondence: Azhar A. Khan, BioMed Centre, Bristol Urological Institute, Southmead Hospital, Bristol, UK. e-mail: drizharr@hotmail.com Abbreviations: SPC, suprapubic catheter; GA, LA, general, local anaesthesia; US, ultrasonography; MS, multiple sclerosis. 644 JOURNAL COMPILATION 2008 BJU INTERNATIONAL