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What’s known on the subject? and What does the study add? The suprapubic catheter (SPC) is a useful and widely used tool in urological practice. However, complications can arise from its insertion or ongoing care. Currently there are no guidelines relating to SPC usage. This study has reviewed the available clinical evidence relating to SPC usage. Where this is lacking, expert opinion has been sought. Guidelines are suggested to help maximise safety and ensure best practice in relation to SPC usage. OBJECTIVE To report the British Association of Urological Surgeons’ guidelines on the indications for, safe insertion of, and subsequent care for suprapubic catheters. METHODS A comprehensive literature search was conducted to identify the evidence base. This was reviewed by a guideline development group (GDG), who then drew up the recommendations. Where there was no supporting evidence expert opinion of the GDG and a wider body of consultees was used. RESULTS Suprapubic catheterisation is widely used, and generally considered a safe procedure. There is however a small risk of serious complications. Whilst the evidence base is small, the GDG has produced a consensus statement on SPC use with the aim of minimising risks and establishing best practice (Table 1). It should be of relevance to all those involved in the insertion and care of suprapubic catheters. Given the paucity of evidence, areas for future research and development are also highlighted. This review has been commissioned and approved by BAUS and the Section of Female, Neurological and Urodynamic Urology. Table 1. Summary of recommendations for suprapubic catheters (SPCs) practice General considerations • Clinicians who are involved in the management of patients with long-term catheters should consider in each case whether an SPC would offer advantages to the patient over the use of a urethral catheter • Patients in whom an SPC is felt to be appropriate should have access to an efficient and expert service for SPC insertion • Patients who are undergoing SPC placement either as an isolated or as a combined procedure should undergo an appropriate consent procedure with best practice including the provision of both verbal and written information The suprapubic catheterization procedure • If appropriate expertise for SPC insertion is not available at a particular time, suprapubic aspiration of urine using a needle of up to 21 gauge can be used as a means of temporarily relieving the patient’s symptoms (LE3) • A general or regional anaesthetic should be used if the bladder cannot be comfortably filled with at least 300 mL of fluid and in spinal cord injury patients with an injury level of T6 or above (LE3) • The use of antibiotic prophylaxis is recommended for patients where the urine is likely to be colonized with bacteria despite there being a lack of published data addressing this issue (LE3) • The different catheter insertion techniques and kits have not been compared in adequate clinical trials; the choice of technique is therefore a matter of individual preference. All of the closed (abdominal puncture) techniques run the risk of injury to intra-abdominal organs and the operator must have received training that allows the level of risk to be appreciated (LE3) • Ultrasonographic examination of the abdomen may be used as an adjunct to SPC insertion. However, the practitioner involved must have appropriate training and experience. Ultrasonography should only be used to look for interposing bowel loops along the planned catheter track by individuals who have received specific training and are experienced in this task. (LE3) • In the patient with a readily palpable bladder and no history of lower abdominal surgery, it is considered reasonable to insert a SPC using a closed technique providing that urine can be easily aspirated from the bladder using a needle passed along the planned catheter track (LE3) • In the patient in whom there is no history of lower abdominal surgery but where the distended (over 300 mL) bladder cannot be palpated because of obesity, it is considered that blind insertion should not be undertaken. In such circumstances, ultrasonography may be used to identify the distended bladder or cystoscopy may be used to ensure that an aspirating needle on the planned catheter track is entering the bladder at an appropriate point on the anterior bladder wall (LE3) • In the patient with either a history of lower abdominal surgery or a bladder that cannot be adequately distended, the SPC should either be inserted using an open technique or with the adjunct of imaging that can reliably exclude the presence of bowel loops on the intended catheter track. An open procedure must be performed in a manner that will reliably identify the bladder and allow mobilization of any interposing intestine away from the catheter track. Imaging to support a closed procedure would include the use of ultrasonography in skilled hands (see above) or CT scanning (LE3) Postoperative complications • Patients, carers and clinical staff must be made aware that urgent medical attention is needed if there are symptoms present that might suggest the presence of a catheter insertion-related visceral injury. Symptoms would include the persistence or worsening of lower abdominal pain or pain that is spreading away from the catheter insertion site (LE3) • Written instructions covering contact details and indications for seeking medical assistance should be given to patients and carers immediately after catheter insertion (LE3) Long-term SPC management • The use of a catheter valve as an alternative to continuous free drainage should always be considered where the bladder is known to provide safe urinary storage • The patient should have prompt and easy access to catheter change services and be offered the option of either them or their immediate carers being taught to change the catheter • Immediate access to a urology unit should be provided in the event of a failed catheter change • Antibiotic administration is indicated where there is evidence of cellulitis in the catheter site area or where there is evidence of symptomatic urinary tract infection (LE3) • Systemic antibiotics should not be used to treat uncomplicated pericatheter discharge or asymptomatic bacteruria (LE3) • Regular catheter bypassing or blockage should prompt referral to the local urology department for further investigation and management • Cystoscopy should be undertaken if repeated catheter blockages are occurring CONCLUSIONS It is hoped that these guidelines will assist in minimising morbidity associated with SPC usage. |
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