Trapped cystofix: Laparoscopic modality to untie

Abstract

Suprapubic catheterization (SPC) is a temporary measure to relieve acute urinary retention (AUR). Despite being effective, it can lead to complications such as colon perforation, haematuria, and bladder wall spasm. We present a 52-year-old lady with cystofix for underlying urethral stricture presented with AUR. A new SPC was inserted to drain the urine. However, the SPC had looped and entangled with her cystofix, and laparoscopic removal of cystofix and insertion of a new SPC was done. In conclusion, trapped cystofix to the SPC tube is a potential complication during SPC insertion that can be avoided with appropriate care.

Introduction

Suprapubic urinary diversion is a temporary measure commonly used to drain urine among patients with acute urinary retention (AUR). There are two commonly used techniques namely Bard® large-bore and BBraun® small-bore cystofix suprapubic catheterization (SPC). It is not uncommon for urinary catheters to spontaneously knot and entrap inside the bladder. The risk is higher with using catheters less than 10 Fr in size, insertion during an overdistended bladder, and a residual catheter of more than 10 cm length inside the bladder.¹ There are various techniques for percutaneous insertion of SPCs. These include direct puncture using SPC trocar, Seldinger technique, ultrasound-guided, and also via cystoscopy-guided.² However, certain occasions require SPC to be inserted laparoscopically or open technique. Here, we report a case of a trapped cystofix with SPC tube which successfully removed and a new SPC reinserted laparoscopically.

Case report

A 52-year-old lady with urethral stricture on BBraun® cystofix catheterization presented to the emergency department with suprapubic pain and no urine output for 5 days duration. She was not in urosepsis upon assessment. A Bard® large-bore suprapubic catheterization (SPC) was inserted at the casualty for urinary drainage and pain relief. However, an attempt to remove the previously inserted cystofix had come to a total failure. Computed tomography (CT) scan of the abdomen showed an SPC catheter forming an acute angulation upon entry and travelled superiorly and looped back inferiorly into the pelvis penetrating the left side of the anterior urinary bladder wall (Fig. 1). Inferior to the SPC puncture site, there is a tubular structure seen with its tip just within the abdominal cavity likely the retained cystofix.

Fig. 1.

(A) CT at sagittal view shows 2 entry points for both cystofix and Foley's catheter (arrow in white). Both cystofix and Foley's catheter are inside the urinary bladder (arrow in black). (B) CT at sagittal view shows Foley's catheter loops back inferiorly into the pelvis (arrow in black) after forming angulation from its puncture site at suprapubic region. (C) CT at coronal view shows Foley's catheter after angulate and travels superiorly then loops back inferiorly penetrates the left side (arrow in black) of anterior urinary bladder.

A cystoscopy was performed but was unable to advance due to a complete stricture of the urethra. Hence, laparoscopic procedure was performed (Fig. 2). Intraoperative findings revealed SPC and cystofix catheter entering the dome of the bladder via the intraperitoneal route (Fig. 3A). Upon removal of SPC, we noted the cystofix had entangled with the SPC and it had to be cut to release the SPC (Fig. 3B–D). The bladder defect was sutured intracorporeally in 2 layers to achieve a watertight effect. It was confirmed by over distending the bladder with methylene blue water. A new SPC was inserted under direct laparoscopic guidance for temporary urine drainage. The patient had a full recovery in the ward and was planned for a definitive urethroplasty later.

Fig. 2.

Intraoperative view of laparoscopic camera and working ports application.

Fig. 3.

(A) The cystofix had looped intraperitoneally before entering the bladder. (B) The cystofix had knotted with the SPC tube. (C) The manipulation of the knotted tube before it was cut. (D) The cystofix after being cut laparoscopically.

Discussion

Bard® large-bore Foley's catheter and BBraun® small-bore cystofix are the two usual methods of SPC. AUR despite catheterization is not a rare phenomenon. This may happen as a result of the catheter being kinked, twisted, or knotted, and also due to blockage by blood clots.¹ Rarely, plugging of the bladder mucosa into the side holes of the catheter may also happen which eventually causes AUR. In such cases, immediate removal of the catheter is not necessary. Instead, patients may be benefited by cystoscopic examination to identify the cause of SPC malfunction.³

Infection, bleeding and bowel perforation are among the common complications of SPC insertion. Besides, rare complications such as small bowel obstruction also may occur especially if the SPC travels superiorly and loops back inferiorly to the pelvis. Few cases were reported before in which the SPC is penetrating the bowel mesentery before entering the urinary bladder which subsequently causes small bowel obstruction.⁴ In our case similarly, the catheter travelled superiorly and looped back to the pelvis, fortunately, did not cause any injuries to the bowel. However, it was entangled with the previously inserted cystofix causing it to fail to be retrieved. Hence, both SPC and cystofix were trapped inside the abdominal cavity.

Most reported cases of trapped SPC occur during insertion after urologic procedures in paediatric, which happened due to knotting at the tip of SPC making it difficult for removal. It was postulated that the knot formation is related to the size of SPC inserted, intravesical length of catheter advancement, and the volume of the urinary bladder.⁵ In this case, our patient is a woman with an underlying urethral stricture who developed AUR despite being on cystofix. New SPC was inserted to divert the urine. Unfortunately, the SPC is entangled with the cystofix.

CT scan prior to SPC insertion is reserved for more complicated scenarios to delineate the catheter placement in detail. Patient with underlying bowel adhesion or colostomy created before who requires SPC may need a CT scan to delineate the anatomy as it may be altered by previous surgery.⁴ Similarly, in our case that had trapped cystofix, a CT scan gives clearer images on the location and the condition of the catheter. This will facilitate much in managing this patient. We are unable to proceed with cystoscopy to look for the catheter as the patient has urethral stricture whereby the scope cannot be advanced up to the urinary bladder for images.

Knotted catheters can be retrieved by several methods, which include sustained traction under anesthesia, untwist by a guidewire, suprapubic cystostomy, and endoscopy retrieval. The role of cystoscopy is to assist diagnosis by direct visualization of catheter condition inside the urinary bladder. Besides, an endourologic attempt by using cystoscopy also may help to facilitate the retrieval of the catheter. It can be done by tightening the knot hence reducing its diameter followed by retrieval. Unfortunately, in our case, the patient is having urethral stricture where we are unable to advance the cystoscope into the urinary bladder. Hence on this rare occasion, we decide to retrieve the catheter and reinsert a new one laparoscopically. Altogether these works may need a more advanced technique to insert SPC, yet it is less invasive compared to laparotomy.

Conclusion

In conclusion, trapped cystofix to the suprapubic catheterization tube is a potential complication of suprapubic urinary diversion. Therefore, any percutaneous cystostomy may require imaging guidance before the insertion to avoid loop that causing an entrapment. Laparoscopic division of the tube is helpful to intervene in this issue without needing open surgery.