366
CHAPTER 26
used, care has to be taken that the trocar is inserted well above the pubis in the midline
and, in particular, that the bladder is maximally distended and the patient lies in head
down position. These precautions may diminish the risk of injury to the peritoneum, as
during bladder distension the peritoneum is raised, and thus an uncovered area of the
bladder is exposed through which the trocar can be pushed into the bladder. However, it
must be remembered that the peritoneum down to the pubis forms a pouch in front of
the distended bladder which may even contain small gut (MacAlpine, 1948). In such cases,
the danger of causing peritonitis with any closed method is great, especially if the distended
paralysed bladder is already infected whether spontaneously or by previous urethral
catheterization, and extravasation of urine occurs. Moreover, the catheter, although
firmly fixed to the trocar, may break lose either on entering the abdominal fascia or, in
particular, before entering the bladder, by the resistance of the muscular bladder wall.
This may result in peritonitis, as happened to one of my own patients during the war,
which induced me to give up suprapubic catheterization by any closed technique.
Furthermore, once the catheter is inserted and suprapubic drainage is established, great
care has to be taken by the nursing staff not to pull out the catheter after this procedure
on turning the paralysed patient, especially if a small catheter has been used, for it may be
difficult or even impossible to insert a new catheter through the very small opening.
Actually, if the small catheter is pulled out during the night and this is not realized
immediately and rectified by the nursing staff or by the patient, the small fistula may
close within hours.
Because of the potential hazards of infection, encrustations and stone formation
following urethral catheterization, Smith, Cook & Robertson (1969) revived suprapubic
catheterization by using a 6 in. or 8 in. plastic canula with a hollow bevelled trocar
which, after insertion through a mid-line stab over the upper part of the anterior wall of
the distended bladder may remain in position for several weeks. The authors themselves
frankly admit the disadvantage of this method which they discovered in their 12 male
patients treated with that technique. Although 6 of the 18 cannulae inserted kinked
within as early as 2 days, each cannula lasted at an average of 13 days (o to 45). Moreover,
7 of the 12 patients eventually had a urethral catheter because a member of staff was
uncertain of the technique for re-insertion of the cannula after it had blocked due to a
kink. Deposits within the cannula were not avoided although the authors did not consider
them as significant.
In a paper on problems in the early management of bladder paralysis, Cook & Smith
(1970) reported about a modification of their technique by using an infant peritoneal
dialysis catheter in 4 patients, but again it was not possible to control infection satis
factorily (2 patients had an indwelling catheter before suprapubic catheterization).
From all the data given so far by these authors, it cannot be said that their technique
and its modification (1970) represent an improvement on any other form of suprapubic
catheterization including Riches' method. On the contrary, the not infrequent kinking
of their cannula (6 out of 18), the lasting of each cannula at an average of only 13 days and,
in particular, the fact that 7 out of their 12 patients eventually had an urethral catheter
because a member of staff was uncertain of the technique for re-insertion of the cannula
after it had blocked due to a kink, are additional risks to the other hazard of suprapubic
