Features of the installation of a suprapubic cystostomy for laparoscopic treatment of patients with intraperitoneal bladder rupture

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INTRODUCTION

With a closed intra-abdominal injury, intraperitoneal bladder ruptures account for 2% of cases [1]. They can be either combined or isolated. Combined injuries of the bladder caused by road traffic accidents, falls from a height, and home injuries are most often observed. Isolated injuries of the bladder are less common, mainly represented by spontaneous ruptures. The mechanism of spontaneous rupture is presented by a sharp increase in the intravesical pressure in the overfull bladder at the time of injury, which results in a hydrodynamic effect in the place of least resistance in the apex of the bladder, leading to intraperitoneal rupture [2–5].

In all cases, intraperitoneal bladder injuries require surgical intervention. Laparotomy is traditionally performed [2, 6, 7]. In recent decades, the laparoscopic method of treatment has been increasingly used as an alternative to laparotomy for isolated intraperitoneal ruptures of the bladder [1, 3, 4, 7–9]. During laparoscopic surgery, the ruptured bladder is sutured hermetically with absorbable sutures [7, 10]. The bladder cavity in most cases is drained using a urethral catheter [2, 3, 8]. However, patients who had lower urinary tract diseases before the injury require prolonged drainage of the bladder. For such patients, the optimal method of drainage is the installation of a suprapubic trocar cystostomy [7, 10].

Despite the urgency of this problem, the literature presents insufficiently the issues of installing a suprapubic cystostomy during laparoscopic treatment of patients with bladder injury.

This study aimed to determine the optimal method for inserting a trocar cystostomy during laparoscopic treatment of patients with intraperitoneal bladder rupture.

MATERIALS AND METHODS

Over the period from 2012 to 2019, at the St. Petersburg I.I. Janelidze Research Institute of Emergency Medicine, suprapubic trocar cystostomy for laparoscopic treatment of isolated bladder injuries was performed in eight patients. All patients were middle-aged and elderly men. As regards the mechanism of trauma, 4 (50%) patients were injuried in a state of alcoholic intoxication. One patient fell out of bed. In 3 (37.5%) patients, bladder ruptures were associated with domestic conflicts. The duration of admission to hospital from the moment of injury ranged from 8 to 27 hours.

All patients indicated that they had urinary disorders even before the injury. Five of them had lower urinary tract diseases and were previously monitored by a urologist. Preoperative examination revealed prostatic hyperplasia in 7 (87.5%) patients, and stricture of the suspending part of the urethra in one patient.

After receiving the results of the examination, the patients were informed about the course of the upcoming surgery and the need to install a suprapubic trocar cystostomy. All eight patients underwent laparoscopic intervention. During surgery, the ruptured bladder was sutured endoscopically with absorbable sutures.

During laparoscopy, three methods of installation of a trocar cystostomy were employed. Method 1 consisted of traditional catheterization of the bladder with a urethral catheter through the urethra. The ruptured bladder was sutured hermetically with endoscopic sutures. Then, through the urethral catheter, the bladder was filled with 300 ml of saline solution. A trocar cystostomy was inserted into the filled bladder through the suprapubic region. At the same time, a laparoscope was used for the visual control of the extraperitoneal installation of a trocar cystostomy from the abdominal cavity (Fig. 1).

 

Fig. 1. Trocar cystostomy after suturing the intraperitoneal rupture. The bladder is filled with saline

Рис. 1. Троакарная цистостомия, после ушивания внутрибрюшинного разрыва. Мочевой пузырь заполнен физиологическим раствором

 

Method 2 involved installation of a suprapubic trocar cystostomy even before suturing the intraperitoneal bladder rupture. During the laparoscopic surgery, visual control of the extraperitoneal passage of the trocar was also performed (Fig. 2).

 

Fig. 2. Conducting a trocar cystostomy in case of non-sutured intraperitoneal rupture of an urinary bladder

Рис. 2. Проведение троакарной цистостомы при неушитом внутрибрюшинном разрыве мочевого пузыря

 

We proposed method 3 of suprapubic installation of a trocar cystostomy (Patent No. 2592023). For this method, a Foley-type catheter was inserted into the abdominal cavity through the laparoscopic port, with a balloon capacity of at least 200 ml when filled. The distal end of the Foley catheter with a balloon was antegradely passed through the intraperitoneal rupture into the bladder cavity (Fig. 3).

 

Fig. 3. Stages of suprapubic trocar cystostomy: a – antegrade placement of a Foley catheter into a urinary bladder through an intraperitoneal rupture; b – puncture of an anterior abdominal wall, urinary bladder and inflated balloon with a trocar; c – installation of a suprapubic cystostomy, intraperitoneal rupture of the bladder is hermetically sutured

Рис. 3. Этапы надлобковой троакарной цистостомии: а — антеградное заведение катетера Фолея в мочевой пузырь через внутрибрюшинный разрыв; b — прокол троакаром передней брюшной стенки, мочевого пузыря и раздутого баллона; c — установка надлобковой цистостомы, внутрибрюшинный разрыв мочевого пузыря герметично ушит

 

Inside the bladder, the balloon was tightly filled with saline solution. The filled balloon stretched the bladder walls from inside, displacing the transitional fold of the peritoneum cranially. A trocar puncture was made through the anterior abdominal wall in the suprapubic region above the extraperitoneal part of the bladder. The trocar was used to puncture in layers the anterior abdominal wall, bladder, and inflated balloon of a Foley catheter and was inserted in the bladder cavity. Another catheter was inserted through the hollow trocar tube into the bladder. The catheter with the ruptured Foley-type balloon was then removed from the bladder and the abdominal cavity through the laparoscopic port. Intraperitoneal bladder rupture was sutured hermetically with endoscopic sutures.

RESULTS

After sanitation of the abdominal cavity, the bladder was examined in all patients. Ruptures in all cases were localized on the intraperitoneal part of the bladder. The bladder cavity was also examined during laparoscopy to rule out combined injuries (Fig. 4). The size of the rupture ranged from 2 to 8 cm. The sequence of suturing the bladder rupture and insertion of the suprapubic cystostomy was different in all three cases.

 

Fig. 4. Checkup of the bladder through the intraperitoneal rupture

Рис. 4. Осмотр мочевого пузыря через внутрибрюшинный разрыв

 

Installation of a suprapubic cystostomy by method 1, which involved suturing the bladder rupture and subsequent filling of its cavity with saline solution through a urethral catheter, was performed in 2 (25%) patients. Two main disadvantages of this method were identified during cystostomy. One of them was leakage of saline solution between the sutures into the abdominal cavity during the bladder filling. Therefore, it was technically difficult to create a sealed bladder vessel for safe extraperitoneal placement of a trocar cystostomy. Another disadvantage was the divergence of the sutured wound edges of the bladder with intravesical administration of saline solution. Therefore, depressurization and bladder wound dehiscence required additional imposition of endoscopic sutures. As a result, the surgery time increased.

Suprapubic drainage of the urinary bladder by method 2 was performed in 3 (37.5%) patients. The drawback of this method was the nearly complete absence of the extraperitoneal part of the anterior wall of the bladder for safe trocar cystostomy. Thus, in two patients, the trocar passed into the bladder through the abdominal cavity, causing a risk of intestinal damage. Both patients required repeated insertion of the trocar for suprapubic cystostomy. After suprapubic drainage, the bladder was hermetically sutured.

Drainage of the urinary bladder using method 3 with a Foley-type catheter inserted antegradely into the bladder cavity through the intraperitoneal rupture was also performed in 3 (37.5%) patients. With tight filling of the Foley-type catheter balloon, the capacity of the bladder increased. As a result, the inflated balloon of the Foley catheter inside the bladder provided cranial displacement of the transitional fold of the peritoneum. This surgical technique helped establish a trocar cystostomy for all three patients without unnecessary punctures and risk of intestinal damage. After removal of the Foley-type catheter with a ruptured balloon, the bladder was sutured (Fig. 5).

 

Fig. 5. Suturing of the bladder after trocar cystostomy

Рис. 5. Ушивание мочевого пузыря после троакарной цистостомии

 

During drainage of the urinary bladder by method 3, no intraoperative and postoperative complications were recorded. No additional surgery time was required.

DISCUSSION

Spontaneous intraperitoneal injury is recorded in patients with overfull bladders. These patients are often middle-aged and elderly men with pre-existing lower urinary tract symptoms. Some of them do not undergo timely treatment of prostate and urethral diseases, despite having persistent urinary disorders. If intraperitoneal rupture occurs in such patients, choosing a method for draining the bladder is always a concern. In most cases, studies have described a method of urine diversion from a sutured bladder using a urethral catheter [2, 3, 8]. However, no data are available on the condition of the lower urinary tract in patients with trauma. Several studies have described installation of a trocar cystostomy after suturing an intraperitoneal rupture of the bladder; however, indications for such a method of drainage are not provided [7, 10].

When selecting a method for draining the bladder in case of intraperitoneal injury, we approach each patient individually. Drainage of the bladder using a urethral catheter is undoubtedly a priority. This drainage method is applicable to most patients. However, men with lower urinary tract diseases and dysuria experiencing intraperitoneal rupture often require longer bladder drainage. Installing a urethral catheter for a long period of time is at risk of various complications [11]. Therefore, for patients with lower urinary tract symptoms, the temporary placement of a trocar cystostomy appears to be the only possible solution.

In our study, we employed three methods to determine the optimal one for inserting a trocar cystostomy in case of intraperitoneal rupture of the bladder. Methods 1 and 2 have certain disadvantages, as they require additional endo-videosurgical manipulations associated with depressurization, bladder wound dehiscence, or repeated installation of the trocar for cystostomy. With method 3, the only difficulty was the absence of common application of Foley catheters with a large balloon capacity.

CONCLUSIONS

In the laparoscopic treatment of patients with intraperitoneal rupture of the bladder, trocar cystostomy can be technically performed in several methods. The most optimal method was the insertion of a Foley-type catheter through the abdomen and the existing intraperitoneal rupture into the bladder cavity. Filling the Foley-type catheter balloon inside the bladder creates an airtight vessel necessary for the safe extraperitoneal placement of a trocar cystostomy.

ADDITIONAL INFORMATION

Conflict of interest. The authors declare no conflict of interest.

About the authors

Gocha S. Shanava

I.I. Dzhanelidze St. Petersburg Research Institute of Emergency Medicine; Almazov National Medical Research Centre

Author for correspondence.
Email: dr.shanavag@mail.ru

Cand. Sci. (Med.)

Russian Federation, Saint-Petersburg; Saint-Petersburg

Igor V. Soroka

I.I. Dzhanelidze St. Petersburg Research Institute of Emergency Medicine

Email: drsoroc@rambler.ru

Cand. Sci. (Med.)

Russian Federation, Saint-Petersburg

Michail S. Mosoyan

Almazov National Medical Research Centre; Academician I.P. Pavlov First Saint Petersburg State Medical University

Email: moso3@yandex.ru
SPIN-code: 5716-9089
Scopus Author ID: 57041359200

Dr. Sci. (Med.)

Russian Federation, Saint-Petersburg; Saint-Petersburg

References

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