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1. Overview 1.1 Background Cystostomy is the general term for the surgical creation of an opening into the bladder; it may be a planned component of urologic surgery or an iatrogenic occurrence. Often, however, the term is used more narrowly to refer to suprapubic cystostomy or suprapubic catheterization. In a setting where an individual is unable to empty his or her bladder appropriately and urethral catheterization is either undesirable or impossible, suprapubic cystostomy offers an effective alternative. Cystostomy for the purpose of suprapubic catheterization may be performed in 2 ways, as follows: Via an open approach, in which a small infraumbilical incision is made above the pubic symphysis Via a percutaneous approach, in which the catheter is inserted directly through the abdominal wall, above the pubic symphysis, with or without ultrasound guidance or visualization through flexible cystoscopy This article focuses on the percutaneous approach because this method can potentially be performed in outpatient, bedside, or urgent care settings. 1.2 Anatomy The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the retropubic space (of Retzius). The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to neighboring structures by reflections of the pelvic fascia and by true ligaments of the pelvis. The body of the bladder receives support from the external urethral sphincter muscle and the perineal membrane inferiorly and the obturator internus muscles laterally (see the image below).

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Page 1: Cyst Ostomy

1. Overview

1.1 Background

Cystostomy is the general term for the surgical creation of an opening into the bladder; it may be a planned

component of urologic surgery or an iatrogenic occurrence. Often, however, the term is used more narrowly to

refer to suprapubic cystostomy or suprapubic catheterization. In a setting where an individual is unable to empty

his or her bladder appropriately and urethral catheterization is either undesirable or impossible, suprapubic

cystostomy offers an effective alternative.

Cystostomy for the purpose of suprapubic catheterization may be performed in 2 ways, as follows:

Via an open approach, in which a small infraumbilical incision is made above the pubic symphysis

Via a percutaneous approach, in which the catheter is inserted directly through the abdominal wall, above the

pubic symphysis, with or without ultrasound guidance or visualization through flexible cystoscopy

This article focuses on the percutaneous approach because this method can potentially be performed in

outpatient, bedside, or urgent care settings.

1.2 Anatomy

The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue.

It is separated from the pubic symphysis by an anterior prevesical space known as the retropubic space (of

Retzius). The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to neighboring

structures by reflections of the pelvic fascia and by true ligaments of the pelvis.

The body of the bladder receives support from the external urethral sphincter muscle and the perineal membrane

inferiorly and the obturator internus muscles laterally (see the image below).

1.3 Indications

At least 4 situations exist in which suprapubic cystostomy is considered:

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Acute urinary retention in which a urethral catheter cannot be passed (eg, because of prostatic enlargement

secondary to benign prostatic hyperplasia or prostatitis, urethral strictures or false passages, or bladder neck

contractures secondary to previous surgery)

Urethral trauma

Management of a complicated lower genitourinary tract infection

Requirement for long-term urinary diversion (eg, because of neurogenic bladder)

Acute urinary retention without urethral catheterization

For a patient who is difficult to catheterize transurethrally, various steps are suggested before suprapubic

cystostomy is performed (see the image below).[1]

Failure to pass a urethral catheter may result from a false passage created by multiple attempts at urethral

catheterization or from urethral stricture disease. After a reasonable attempt at catheterization has been made,

including use of a coudé catheter, and if a urologist is not available to perform a flexible cystoscopy with

potential catheter placement over a wire, a suprapubic cystostomy is reasonable.

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Urethral trauma

In the setting of urethral trauma, functional bypass of the urethra may be required because of the possibility of

urethral disruption. Urethral disruption is usually associated with pelvic fractures or saddle-type injuries and

should be suspected when the triad of (1) blood at the urethral meatus, (2) inability to urinate, and (3) a palpably

distended bladder is observed. The urethral injury should be addressed by a urologist; however, a suprapubic

cystostomy may be a valuable measure for emergency drainage of the bladder.

Complicated lower genitourinary infection

In a complicated infection of the lower genitourinary tract with associated urinary retention (eg, acute bacterial

prostatitis), bladder drainage with suprapubic cystostomy should be considered.

Another indication for suprapubic catheter placement is Fournier's gangrene, which often necessitates multiple

genitourinary debridement procedures and, potentially, skin grafting. If a urethral catheter impedes wound care

and surgical management of this complicated, dangerous disease, consider a suprapubic cystostomy to divert

urine from these surgical sites.

Long-term urinary diversion

Suprapubic catheterization may also be considered as an option in patients who require long-term urinary

diversion. The British Association of Urological Surgeons issued practice guidelines suggesting that clinicians

should consider whether a suprapubic catheter would be preferable to an urethral catheter for patients who

require a long-term indwelling catheter.[2]

A suprapubic catheter may be considered in patients with neurogenic bladder secondary to spinal cord

injuries, stroke, multiple sclerosis, neuropathy, or detrusor sphincter dyssynergia who are unable to void and

who are unable or unwilling to perform clean intermittent catheterization.[3, 2]

Patients who undergo phallic reconstruction or fistula repair[1] may also require longer-term urinary diversion. In

a retrospective study that included more than 10 years of follow-up data from 179 predominantly male patients

with spinal cord injuries, similar rates of urinary tract infections, bladder and renal calculi, and renal function

preservation were reported for those managed with urethral catheters and those managed with suprapubic

catheters.[4]

In this study,[4] urethral strictures, urethral fistulas, and scrotal abscesses were found only in the urethral catheter

group; 3 patients with urethral strictures and 3 patients with urethral-cutaneous fistulas switched to suprapubic

catheters as a result of these complications. Catheter-specific complications included erosion associated with

urethral catheters and leakage around the suprapubic catheter site and from the urethra.

1.4 Contraindications

Percutaneous suprapubic cystostomy is absolutely contraindicated in the following circumstances:

The bladder is not distended, is not easily palpable, or cannot be localized with ultrasonographic assistance

The patient has a history of bladder cancer

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Relative contraindications include the following:

Coagulopathy

Previous lower abdominal or pelvic surgery (because of the possibility of adhesions between the bowel and

the bladder)

Pelvic cancer, with or without a history of irradiation (because of the possibility of adhesions)

Placement of orthopedic hardware for pelvic fracture repair – Although some reports suggest that suprapubic

tubes leading to infection of hardware is a relatively rare complication, [5] consult with the orthopedist before

performing suprapubic catheterization in patients with hardware

If percutaneous placement is contraindicated and an open surgical approach to suprapubic cystostomy is

necessary to provide appropriate dissection through adhesions, avoid bowel injury, and achieve effective

hemostasis, this would probably have to be done by a general surgeon or urologist in an operative setting.[3]

1.5 Technical Considerations

Procedural planning

There are 2 key issues that must be kept in mind when placement of a suprapubic cystostomy is being

considered. The first issue is whether the patient’s bladder can be sufficiently well drained with a urethral

catheter. If this is the case, urethral catheterization may be a more appropriate choice because it is often easier

and is associated with less short-term morbidity, especially in women and men who develop acute urinary

retention and may regain the ability to void with straightforward medical management (eg, alpha-blocker

therapy).

On the other hand, suprapubic cystostomy may be preferable to urethral catheterization when the catheter is

needed for long-term bladder management, as in patients with neurogenic bladders. For instance, male patients

with suprapubic cystostomies have a decreased incidence of traumatic hypospadias and a reduced risk of urinary

tract infection, prostatitis, urethritis, and epididymitis. Male patients also retain sexual function. Female patients

have a decreased incidence of urinary tract infection and can avoid development of a patulous urethra.

If the procedure can be planned in advance, referring the patient to a urologist for an informed discussion of

elective procedures might be best. In those emergent situations where the patient is unable to empty his or her

bladder and a urethral catheter cannot be placed, suprapubic cystostomy is a viable option.

The second issue is selecting the method that will be used to place the suprapubic cystostomy. As noted (see

Background), either an open approach or a percutaneous approach to suprapubic catheterization may be taken.

Most individuals with training in general surgery or urology find the open procedure straightforward. Most other

physicians prefer a percutaneously placed suprapubic cystostomy, which can be performed by means of 5

different methods (see Technique). Unfortunately, the percutaneous option is not always a safe possibility.

1.6 Complication Prevention

Regardless of how a suprapubic cystostomy is placed, it is always advisable to distend the bladder during

localization of the surgical site. This affords the physician the best opportunity to find the bladder quickly and

avoid bowel injury.

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In urgent circumstances, when the urethra cannot be cannulated and the bladder must be decompressed, the

bladder is probably already distended with urine. This can be observed on physical examination. Otherwise, if

the urethra can be cannulated with a Foley catheter or a flexible cystoscope, the bladder can be distended with

normal saline.To prevent gram-negative bacteremia, an appropriate preprocedural intravenous gram-negative

antibiotic should be administered before instrumentation of the genitourinary tract.[3]

2. Periprocedural Care

2.1 Patient Education and Consent

Obtain informed consent from the patient or guardian. The patient should be informed in advance that the

procedure involves placing a tube and draining the bladder through the abdominal wall.

Patients should be instructed on how to care for the catheter and empty and change drainage bags (eg, from a leg

bag during daytime use to a larger drainage bag for overnight use). The suprapubic catheter exit site should be

washed daily with soap and water and may be covered with gauze. If not otherwise contraindicated, patients

should be instructed to drink plenty of fluids.

Patients should be instructed to seek immediate medical attention for catheter replacement if the catheter

becomes dislodged. The tract can close very quickly, requiring suprapubic cystostomy to be performed again, if

the suprapubic tube is not urgently replaced.

2.2 Equipment

A number of percutaneous suprapubic cystostomy kits are on the market. All are based on the same principle. It

should be kept in mind that if a suprapubic catheter kit is not available during an emergency situation that calls

for urgent bladder drainage, any device suitable for central venous access can be placed suprapubically by using

the Seldinger technique.[3]

Materials used for suprapubic cystostomy include the following (other materials, if equivalent, can be easily

substituted):

Sterile gloves

Face mask with protective shield

Clippers/shaver (to remove hair at the suprapubic site)

Sterile towels (4) or drapes

Antiseptic solution/applicators (eg, 3 ChloraPreps; CareFusion, Leawood, KS)

Marking pen

1% lidocaine (5 mL) and 0.25% bupivacaine (5 mL) in a Luer-Lok syringe

22-gauge, 7.75-cm spinal needle tip (some use 18- and 25-gauge needles)

Scalpel with a No. 11 blade

10 mL of sterile water in a Luer-Lok syringe (to inflate the catheter balloon)

Skin tape or 3-0 nylon suture on a curved needle (to secure the catheter loosely to the skin)

Adson tissue forceps, 1 × 2 teeth, 4.7 in.

Baumgartner needle holder, 5.5 in.

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4×4 inch drain gauze (2) or drain sponges

Tube-securing device (eg, Statlock, Bard Medical Division, Covington, GA; or Cath-Secure, M.C. Johnson,

Fort Myers, FL)

Catheter drainage bag

Suprapubic catheter kit – Many choices exist, all of which have their own slight variations; examples include

the Rutner percutaneous suprapubic balloon catheter set, the Cook Peel-Away Sheath Introducer, and the

Stamey Percutaneous Malecot suprapubic catheter set (see the image below), all made by Cook Medical

(Bloomington, IN)

2.3 Patient Preparation

Anesthesia

Some physicians desire patients undergoing suprapubic cystostomy placement to receive parenteral analgesia,

with or without sedation. To ensure patient and practitioner safety during this invasive procedure, procedural

sedation and analgesia may be considered in all patients who are uncooperative or agitated.

Local anesthesia should be used for a percutaneous suprapubic cystostomy. Light sedation may also be

beneficial for patient comfort. An example of an appropriate preparation would be a 1:1 formulation of lidocaine

1% 5 mL and bupivacaine 0.25% 5 mL, for a total of 10 mL. Many other formulations compositions would

serve equally well as a local anesthetic. With a 22-gauge needle tip, infiltrate the superficial and subcutaneous

tissue down to the fascia, approximately 2 fingerbreadths above the pubic symphysis.

Positioning

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During percutaneous suprapubic cystostomy placement under cystoscopic guidance, the patient could be either

supine, if a flexible cystoscope is being used, or in the dorsal lithotomy position, if a rigid cystoscope is being

used. If the urethra can be cannulated, the cystoscope allows observation of the dome of the bladder during the

procedure, enabling visual confirmation of percutaneous entry into the bladder.

For any of the other percutaneous techniques (except the Lowsley retractor technique), the patient should be

supine. Also, the patient should always be in the Trendelenburg position. This allows the bowels to fall

cranially, decreasing the likelihood of puncturing the gastrointestinal tract during catheter placement.[6]

2.4 Monitoring and Follow-up

If not already under the care of a urologist, all patients who undergo suprapubic tube placement should be

referred to a urologist for correction of the underlying disease, as well as routine cystostomy tube care.

The first catheter change should take place after approximately 4-6 weeks to allow time for a tract to form.

Subsequently, if the catheter is intended for long-term use, it can be changed monthly, with upsizing (eg, to a

lumen of 22 or 24 French) if desired. Any lumen smaller than 16 French in diameter is at high risk for

obstruction (with sediment or mucus) over time. Repeated catheter blockage should be investigated with

cystoscopy.[2]

Some patients may require additional procedures, such as revision of the suprapubic catheter site, surgical

closure of the bladder neck or urethra, procedures for treatment of calculi, or anticholinergic medication to stop

bladder spasms that might be associated with urethral leakage. Over an extended period, long-term indwelling

catheters are associated with chronic inflammation of the urothelium, with a small increased risk of bladder

malignancy over years.[7] Thus, annual screening cystoscopies should be considered in this patient population.

3. Technique

3.1 Approach

If percutaneous suprapubic cystostomy is an option, it can be performed by means of 5 different methods:

Percutaneous placement of a suprapubic cystostomy using Seldinger technique

Percutaneous placement of a suprapubic catheter over or through a sharp trocar

Percutaneous placement of a suprapubic cystostomy under direct cystoscopic visualization

Percutaneous placement of a suprapubic cystostomy under direct ultrasonographic visualization

Percutaneous placement of a suprapubic cystostomy with localization of the bladder using a Lowsley retractor

This article focuses primarily on the first 2 techniques (Seldinger technique and use of a sharp trocar). The third

and fourth techniques (cystoscopic and ultrasonographic visualization) are essentially modifications of the

second. Both require a certain skill level that must be attained before the procedure is attempted. If the

practitioner performing the procedure is familiar with this equipment, both cystoscopy and ultrasonography can

provide visual confirmation of appropriate placement of the instruments and catheter.

Page 8: Cyst Ostomy

The fifth technique involves the use of a Lowsley retractor. This surgical instrument is, for the most part, known

only to urologic surgeons and should not be used by personnel unfamiliar with it.[8]

Available suprapubic catheter kits, though based on the same general concept, vary considerably in their details.

The packet insert that comes with the kit should always be read carefully (see the video and images below).

In most instances, a sharp obturator (or trocar stylet) is used to obtain percutaneous access to the bladder. In

other instances, the Seldinger technique is employed. A spinal needle is used to gain percutaneous access to the

bladder, with urine aspirated out of the needle. A guide wire is then advanced through the needle, the needle is

removed, and a catheter is advanced over the wire and into the bladder.

The following discussion provides step-by-step instructions for placing both the Cook Peel-Away Sheath (One

Step Introducer) suprapubic catheter set (Cook Medical, Bloomington, IN) and the Rutner suprapubic catheter

set (Cook Medical, Bloomington, IN).

3.2 Percutaneous Suprapubic Cystostomy

Initial steps

The first steps in a percutaneous suprapubic cystostomy are the same for the Peel-Away Sheath catheter set as

for the Rutner catheter set.

Clean the abdominal wall. Shave the suprapubic operative field with clippers. Prepare the site with an antiseptic

(eg, 3 ChloraPreps). Create a surgical field with 4 sterile towels, ensuring that the pubic symphysis can be

visualized and palpated. Remove the introducer and catheter from the packaging, using aseptic technique, and

place in the sterile field.

Ensure that the patient has a full and palpable bladder to confirm urine return. Palpate the distended bladder, and

use a marking pen to note the site of percutaneous catheter placement, 2 fingerbreadths above the pubic

symphysis in the midline; avoid placing the catheter in natural skin creases.

Fill a 10-mL Luer-Lok syringe with 5 mL of 1% lidocaine and 5 mL of 0.25% bupivacaine. Attach the syringe

to a 22-gauge, 7.75-cm spinal needle. Raise a skin wheal at the marked site, and infiltrate the anesthetic into the

subcutaneous tissue and rectus abdominis muscle fascia, aiming the needle at a 10-20° angle toward the pelvis.

Advance the needle in this direction, while aspirating the syringe; urine should be easily aspirated when the

bladder is entered.

After this point, placement techniques for the 2 catheter sets diverge (see below).

Cystostomy with Peel-Away Sheath suprapubic catheter set

Page 9: Cyst Ostomy

Once needle entry into the bladder has been confirmed by aspiration of urine, suprapubic cystostomy with the

Cook Peel-Away Sheath (One Step Introducer) suprapubic catheter set (see the image below) proceeds as

follows.

Remove the Luer-Lok syringe from the spinal needle, and advance a guide wire through the needle into the

bladder. While holding the wire securely (this is now the route of access to the bladder), carefully remove the

needle over the wire, leaving the wire in place.

Directly posterior to the wire, use a scalpel with a No. 11 blade to make a stab incision through the skin and

subcutaneous tissue. Pass the Peel-Away Sheath and the indwelling fascial dilator together over the wire and

into the bladder. Remove the guide wire and the fascial dilator, leaving only the Peel-Away Sheath inside the

bladder.

Pass a Foley catheter (of appropriate size) through the indwelling intravesical sheath and into the bladder.

Aspirate urine to confirm proper placement. Inflate the Foley balloon with 10 mL of sterile water, using a Luer-

Lok syringe.

Gently withdraw the Peel-Away Sheath from the bladder and anterior abdominal wall; using each side of the

Peel-Away Sheath, split the sheath into 2 parts, leaving the catheter in place. Connect the indwelling suprapubic

Foley catheter to a drainage bag.

Using a Baumgartner needle holder, an Adson tissue forceps, and 3-0 nylon sutureon a curved needle, secure the

catheter to the skin of the anterior abdominal wall. Place an air knot at the skin, adjacent to the cystostomy site,

and then proceed to use the 2 loose ends of suture (now affixed to the skin by an air knot), to place another knot

around the catheter itself.

Place 2 drain gauze pads (4 × 4 in) at the cystostomy site. The catheter may be secured to the patient with foam

tape or tube-securing devices (eg, Statlock or Cath-Secure). The aim is to ensure that the catheter is not

accidentally tugged or pulled by the patient as a consequence of not being properly secured.

Page 10: Cyst Ostomy

3.3 Cystostomy With Rutner Suprapubic Catheter Set

Once needle entry into the bladder has been confirmed by aspiration of urine, remove the spinal needle, and use

a scalpel with a No. 11 blade to make a stab incision at this site.

Ready the catheter by removing the protective sleeve from the balloon and discarding it. Place the needle

obturator inside the balloon catheter, and secure its position with the Luer-Lok.

Insert the balloon catheter, using one hand to push the catheter from behind the needle hub (using the palm) and

the other at skin level to guide the needle. Insert the catheter into the bladder at an 80° angle, aiming at the pubic

symphysis. Advance the catheter no more than 4-5 cm beyond where bladder fluid is first seen coming out of

the needle obturator. This ensures that the balloon is fully in the bladder (not the subcutaneous tissue) before

inflation. The balloon catheter midpoint (etch mark on the needle) is an approximation of the proper depth.

If bladder pressure is low and urine fails to flow spontaneously through the needle obturator, aspirate urine to

verify that the balloon catheter is within the bladder. When proper positioning of the catheter is confirmed,

inflate the balloon with 10 mL of sterile water. Release and remove the needle obturator. Connect the indwelling

suprapubic Foley catheter to a drainage bag.

Using a Baumgartner needle holder, an Adson tissue forceps, and 3-0 nylon suture on a curved needle, secure

the catheter to the skin of the anterior abdominal wall. Place an air knot at the skin, adjacent to the cystostomy

site, and then use the 2 loose ends of the suture (now affixed to the skin by an air knot) to place another knot

around the catheter itself.

Dress the site with 2 drain gauze pads (4 × 4 in).

3.4 Complications

Adverse events associated with suprapubic cystostomy may include inadvertent urethral catheterization,

intraperitoneal extravasation (without a history of previous surgery), altered body image, latex allergy,

overgranulation at the cystostomy entry site, extraperitoneal extravasation, obstruction of tubing (by blood,

mucous, or kinking), and loss of the cystotomy tract or access if the tubing comes out.

Immediate complications of suprapubic catheter placement include gross hematuria, which is usually transient,

and the possibility of postobstructive diuresis, in which urine output may be greater than 200 mL/h. The latter is

usually a physiologic response to the volume expansion and solute accumulation that developed during the

obstruction, but a pathologic diuresis might ensue.

Patients should be monitored for postobstructive diuresis. Vital signs should be checked, along with serum

electrolyte, magnesium, blood urea nitrogen, and creatinine concentrations. The intensity of monitoring depends

on the patient’s mental status, renal function, and electrolyte status.

Serious complications of the procedure include bowel perforation and other intra-abdominal visceral organ

injuries and urosepsis, whose manifestations may be delayed.

Page 11: Cyst Ostomy

A mucous or mucopurulent discharge around the exit site may occur; if present, it can be managed with local

hygiene measures alone if there is no cellulitis and no evidence of systemic infection.

Possible complications from long-term catheter use include penile erosion (traumatic hypospadias, see the

image below), recurrent symptomatic urinary tract infection, leakage from the urethra, bladder and renal calculi

formation, deterioration of renal function, and increased risk of bladder cancer.

Squamous cell carcinoma of the bladder was a more common subtype in a population of chronically

catheterized patients with spinal cord injury who were treated for bladder cancer.   Thus, annual screening

cystoscopies should be considered in patients with long-term indwelling catheters in place over years.

Suprapubic catheter use may be additionally complicated by exit site infections or leakage. Bladder stones

developed in 22-45% of patients with long-term suprapubic catheter use.

CASE

A 93-year-old man with advanced prostatic cancer had a 1000 ml urinary retention (video on presentation),

hydronephrosis (video on presentation), and an increased plasma creatinine level. If a ultrasonography device is

available, check the position and volume of the bladder before the procedure. The puncture site is anaesthetized

with a long needle. Make sure that the needle is in the bladder by aspirating urine. The cystostomy catheter is

inserted into the needle up to the first position mark. Make a stab incision into the skin to facilitate the

penetration of the cystostomy needle. Insert the needle into the bladder with a brisk thrush - if inserted too

slowly, the point of the needle may push the bladder wall towards the back wall. About 2/3 of the catheter

lenght is inserted into the bladder, after which the needle is pulled back and cleaved. If the catheter has no

balloon, fix it to the skin with a firm stitch. If the catheter has an inflatable balloon, inflate it and push the

catheter back gently until the balloon prevents further pulling. If the urine becomes bloody, keep pulling for

about 5–10 min to compress the site of puncture in the bladder wall with the balloon. For catheter replacement

see video.

Page 12: Cyst Ostomy

References

1. Wein AJ, ed. Campbell-Walsh Urology. 10th ed. Philadelphia: Elsevier; 2011.

2. Harrison SC, Lawrence WT, Morley R, Pearce I, Taylor J. British Association of Urological Surgeons'

suprapubic catheter practice guidelines. BJU Int. Jan 2011;107(1):77-85. .

3. Roberts JR, Hedges JR. Roberts: Clinical Procedures in Emergency Medicine. 5th ed. 2009..

4. Katsumi HK, Kalisvaart JF, Ronningen LD, Hovey RM. Urethral versus suprapubic catheter: choosing

the best bladder management for male spinal cord injury patients with indwelling catheters.  Spinal

Cord. Apr 2010;48(4):325-9.

5. Patterson BM. Pelvic ring injury and associated urologic trauma: an orthopaedic perspective. Semin

Urol. Feb 1995;13(1):25-33.

6. Hinman F. Atlas of Urologic Surgery. 2nd ed. 1998.

7. Castillo CM, Ha CY, Gater DR, Grob BM, Klausner AP. Prophylactic Radical Cystectomy for the

Management of Keratinizing Squamous Metaplasia of the Bladder in a Man with Tetraplegia.  J Spinal

Cord Med. 2007;30(4):389-91.

8. Edokpolo LU, Foster HE Jr. Suprapubic cystostomy for neurogenic bladder using Lowsley retractor

method: a procedure revisited. Urology. Nov 2011;78(5):1196-8.

9. Robinson J. Insertion, care and management of suprapubic catheters. Nurs Stand. Oct 29-Nov 4

2008;23(8):49-56; quiz 58.