Abstract
Background: The inability to remove an indwelling urethral catheter in a postrobot-assisted laparoscopic radical prostatectomy (RALP) patient constitutes a serious problem to the urologist. If the proper deflation of the catheter balloon is not observed, forcible extraction can lead to devastating consequences such as urethral disruption and subsequent stricture formation.
Case Presentation: A 60-year-old male patient developed lower urinary-tract symptoms 20 months after robotic prostatectomy for early prostate cancer. Cystourethroscopy revealed a migrated Hemo-lok clip that was extracted near the anastomotic site, followed by insertion of an indwelling Foley catheter. Two weeks later, the patient accidentally pulled the catheter into the urethra. Several attempts were done to deflate the catheter, which failed. Subsequently, a transrectal ultrasound (TRUS)-guided transperineal puncture was done to deflate the catheter balloon followed by effective catheter removal.
Conclusion: TRUS-guided transperineal puncture (under local anesthesia) of an indwelling catheter balloon is a viable alternative for patients who have a history of RALP.
Keywords: transperineal, indwelling catheter, complications
Background and Introduction
Urethral catheterization is one of the most common operations in clinical practice, and the ureter can be easily removed in most cases. However, it can be difficult to remove the ureter when there is a calculus formed in the urethra or when the balloon can hardly be pulled out. Noticeably, improper operation will cause serious consequences.1 In recent years, the robot-assisted laparoscopic radical prostatectomy (RALP) technique has been under rapid development, and it has now emerged as the gold standard among the developed countries. After RALP, urethrovesical anastomosis is performed over an indwelling catheter, which is maintained for about a week to facilitate healing and to avoid the development of a urethral stricture.2
Case Presentation
The patient was a 65-year-old man found with prostate cancer who underwent RALP 20 months ago, with a postoperative pathology stage of pT3aN0, a Gleason score of 3 + 4, and an upper positive surgical margin. Two weeks ago, the patient presented with dysuria and bifurcation of urination. Cystoscopy revealed a hem-o-lock clip embedded in the posterior urethra at the anastomotic site. Thus, the patient received removal of the urethral foreign body under cystoscope at our hospital, with an indwelling catheter. At 14 days postoperatively, the patient pulled the catheter by mistake, and the balloon was unable to deflate by syringe suction. We failed in our attempt to cut the inlet port of the catheter, and to pierce the balloon using a guidewire.
The transrectal ultrasound (TRUS) view clearly displayed the catheter balloon in the urethra (Fig. 1)
FIG. 1.
Catheter balloon in the internal orifice of urethra and punctured by a needle.
Later, the patient received a TRUS-guided transperineal needle aspiration to remove water from the catheter balloon (Fig. 2). Then, the balloon was loosened completely without any fragment left, and the catheter was removed eventually (Fig. 3).
FIG. 2.
TRUS-guided transperineal needle aspiration for water from catheter balloon. TRUS, transrectal ultrasound.
FIG. 3.
The catheter was removed completely.
Discussion
To the best of our knowledge, this is the first published report regarding transperineal puncture for the difficult removal of an indwelling urethral catheter. In this particular case, the water within the balloon was hardly removed in the patient receiving urethral reconstruction after RALP. We hypothesized that the balloon was stuck in the rectal lacuna when the patient pulled the catheter by mistake. Otherwise, it would be difficult to remove the catheter through a transurethral operation caused by urethral reconstruction after radical prostatectomy, which might affect the recovery of urinary control function. According to previous studies, there are usually ways to remove the nondeflatable catheters. A special guidewire can be utilized to dredge the inflatable passage and to puncture the balloon from inside or outside. Typically, the hyperinflation rupture technique and chemical deflation technique, with or without radiologic or ultrasound guidance, are adopted as the puncture techniques. Also, the endoscopic technique can be applied, but it should be carried out under general anesthesia.3 Each of the mentioned techniques has adopted balloon puncture, which may possibly lead to retained fragments and require subsequent cystoscopy.4
In our transperineal balloon puncture for removing the indwelling urethral catheter under lidocaine infiltration anesthesia, satisfactory anesthesia was attained in the patient, with no pain or discomfort. In addition, such technique also avoids the risk of infection, which is more common in rectal puncture, and there are less complications such as postoperative hematuria.
Nowadays, the ultrasound machines are readily available in most operating rooms, and the application of such transperineal puncture operation is associated with the minimal additional cost. However, cystoscopy is linked with the greatest drawback of the need for an additional assistant. All these have placed certain restrictions on the operators.
All in all, according to findings in this study, TRUS-guided transperineal puncture (under local anesthesia) of an indwelling catheter balloon is a viable alternative for patients who have a history of RALP.
Abbreviations Used
- RALP
robot-assisted laparoscopic radical prostatectomy
- TRUS
transrectal ultrasound
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received.
Cite this article as: Dong Z, He B, Gao X, Xu C, Sun Y, Wang H (2020) Transrectal ultrasound-guided transperineal puncture: a viable alternative for difficult removal of an indwelling catheter in a postrobot-assisted laparoscopic radical prostatectomy patient, Journal of Endourology Case Reports 6:4, 516–518, DOI: 10.1089/cren.2019.0147.
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