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| ORIGINAL ARTICLE |
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| Year : 2019 | Volume
: 30
| Issue : 4 | Page : 184-190 |
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Sonography-assisted seldinger wire technique: A safe way of a suprapubic catheterization training program for rotating staff
Chao-An Chen1, Yu-Jun Chang2, Man-Lok Lio3, Heng-Chieh Chiang1, Bai-Fu Wang1, Pao-Hwa Chen1
1 Department of Surgery, Devision of Urology, Changhua Christian Hospital, Changhua, Taiwan
2 Epidemiology and Biostatics Center, Changhua Christian Hospital, Changhua, Taiwan
3 Department of Medical Education, Changhua Christian Hospital, Changhua, Taiwan
| Date of Submission | 31-Mar-2019 |
| Date of Decision | 23-May-2019 |
| Date of Acceptance | 05-Jun-2019 |
| Date of Web Publication | 29-Jul-2019 |
Correspondence Address:
Pao-Hwa Chen
Department of Surgery, Changhua Christian Hospital, Changhua
Taiwan
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_19_19
Context: In Changhua Christian Hospital (CCH), the urology division is a branch of the surgical department. The urology residents in this division are, on average, off duty for 10 days/month; surgical residents from other divisions usually lack training to practice urology. Therefore, attending urology doctors or visiting urology staff members in CCH branches must be on call during off-duty periods in case a patient is indicated for suprapubic cystostomy. Aims:This study aims to promote a safe and efficient approach to train rotating residents to perform suprapubic catheterization. Subjects and Methods: On the basis of ultrasound-guided central venous catheter insertion, we designed training sessions for suprapubic cystostomy for rotating surgical residents during their urology course. Participants and Methods: From 2016 to 2018, senior residents or attending doctors of urology evaluated the clinical skills of rotating residents by using the direct observation of procedural skills tool before and after the training course. Statistical Analysis Used: Mann–Whitney U-test, Wilcoxon signed rank test, and multiple linear regression analysis. Results: The trainees were separated into different groups according to their sex, year of residency, and previous urology training in the postgraduate year (PGY). All groups had significant gain scores. Our multiple linear regression analysis revealed a relationship between previous urology training in the PGY and gain scores and between overall pretest score and gain scores. Conclusions: Real-time ultrasound-guided catheterization with a Seldinger wire is a safe and efficient approach to train rotating residents to perform suprapubic catheterization.
Keywords: Cystostomy, Seldinger technique, suprapubic catheterization
How to cite this article:
Chen CA, Chang YJ, Lio ML, Chiang HC, Wang BF, Chen PH. Sonography-assisted seldinger wire technique: A safe way of a suprapubic catheterization training program for rotating staff. Urol Sci 2019;30:184-90 |
How to cite this URL:
Chen CA, Chang YJ, Lio ML, Chiang HC, Wang BF, Chen PH. Sonography-assisted seldinger wire technique: A safe way of a suprapubic catheterization training program for rotating staff. Urol Sci [serial online] 2019 [cited 2019 Dec 15];30:184-90. Available from: http://www.e-urol-sci.com/text.asp?2019/30/4/184/263648 |
| Introduction | |  |
Suprapubic catheterization is indicated for acute urinary retention in situations in which a urethral catheter cannot be passed, urethral trauma is observed, management of a complicated lower genitourinary tract infection is required, and long-term urinary diversion is required.[1] Although this procedure is common practice in urology, it might engender complications such as hematuria and bowel injury.[2]
Changhua Christian Hospital (CCH) is a 1600-bed medical center located in central Taiwan. It is one of the country's premier academic medical centers and a major referral center for the mid-south area and beyond. CCH includes a urology division, which is a branch of the surgical department. In this hospital, urology residents share the same on-duty hours with other surgical residents in a work month and are distributed in different wards. The urology residents in this division are, on average, off duty for 10 days permonth, and surgical residents from other divisions usually lack training to perform urology. Accordingly, attending urology doctors or visiting urology staff members in CCH branch hospitals must be on call during their off-duty periods in case a patient is indicated for suprapubic cystostomy. This study reviewed a relatively safe and efficient approach for training surgical residents from other divisions to perform suprapubic catheterization.
Clinicians can perform a suprapubic cystostomy through open and percutaneous approaches.[2] The open approach has several advantages: easy separation of adhering tissues, prevention of intestinal trauma, and prevention of wound bleeding. Nevertheless, this approach requires relatively high operator skill levels. The percutaneous approach entails sonography- and cystoscopy-guided techniques.[3],[4] The sonography-guided technique is easy to learn and perform at wards. This technique was thus used in this study.
| Subjects and Methods | | |
Real-time ultrasound-guided catheterization of the internal jugular vein
In CCH, every junior resident must participate in a training course for ultrasound-guided central venous catheter (CVC) insertion and must undergo recertification examinations every 3 years. Ultrasound equipment can be easily accessed in general wards and intensive care units.
Suprapubic cystostomy with Seldinger wire technique
On the basis of ultrasound-guided CVC insertion, we designed training sessions to train rotating surgical residents to perform suprapubic cystostomy during their urology course. The procedures involved in the training sessions are illustrated in [Figure 1].[5] | Figure 1: Suprapubic cystostomy with Seldinger wire technique. (a) Identify distended urinary bladder with ultrasound. (b) Real-time ultrasound-guided puncture of the urinary bladder, avoid bowel injury. Normal saline inflation with intravenous set after successful puncture if necessary. If not sure, single tapping and draw out urine with a syringe is acceptable. (c) Insert guide wire into the urinary bladder. (d) Serial dilation. (e) Insert catheter, from the 6fr central venous catheter to 16Fr pigtail drain may be considered
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Evaluation through direct observation of procedural skills
From 2016–2018, senior residents or attending doctors of urology evaluated the clinical skills of rotating residents by applying the direct observation of procedural skill (DOPS)[6] tool before and after the training course. The rating form of the DOPS tool was prepared after a review of relevant English examples available in the literature [Table 1]. A P < 0.05 was accepted as statistically significant in all statistical assessments.
| Results | | |
A total of 24 residents participated in our training course, 17 (71%) and 7 (29%) of whom were men and women, respectively. Of these residents, 14 (58%) were in their 1st year of residency and 10 (42%) were in their 2nd year of residency. Moreover, 6 (25%) residents had received previous urology training for 1 month in the postgraduate year (PGY).
The relationship between sex, years of residency, seniority, previous urology training in the PGY, and mean DOPS scores achieved were observed. In the pretest, female residents exhibited better performance than did male residents in all items, except for the items “positioning of the patient” and “communication with and consideration for patient.” In the posttest, female residents still outperformed male residents with respect to “checking and familiarity with equipment,” “procedure and situational awareness,” “communication with and consideration for the patient,” “professionalism” and “overall” scores. We observed no statistically significant difference between the scores (posttest score minus pretest score) for all items, except for the item “seeks help when necessary” [Table 2]a.
Second-year residents outperformed 1st-year residents with respect to the pretest and posttest scores for all items, but they exhibited lower performance with respect to the pretest scores for the items “positioning of the patient” and “postprocedure care including good notes.” The results revealed no statistically significant difference between the scores for all items, except for the items “checking and familiarity with equipment” and “communication and consideration for the patient” [Table 2]b.
Compared with residents who had not received previous urology training in the PGY, those who had received previous urology training in the PGY had more favorable pretest and posttest scores for all items, except for the pretest scores for the items “positioning of the patient” and “defining anatomy” and the posttest score for the item “explanation of indication, risk, and informed consent.” We observed no statistically significant differences between the scores [Table 2]c.
Both male and female groups showed statistically significant improvements in scores for all items, but the female group did not show statistically significant improvements in the scores for “aseptic technique” in the female group [Table 3]a. First-year and 2nd-year residents registered significant gain scores for all items, except for the “aseptic technique” item in 2nd-year residents [Table 3]b. We observed significant improvements in the scores for all items in residents with or without previous urology training in the PGY, except for the score for the item “aseptic technique” in residents without previous urology training in the PGY [Table 3]c.
Our multiregression analysis revealed a relationship between previous urology training in the PGY and gain scores. The analysis also showed a relationship between overall pretest score and gain scores [Table 4].
No short-term complication, including bowel injury, was reported.
| Discussion | | |
Suprapubic catheterization is common practice in urology. It is indicated for acute urinary retention in situations such as those in which a urethral catheter cannot be passed, urethral trauma is detected, management of a complicated lower genitourinary tract infection is necessary, drainage for complex pelvic surgery is required, and long-term urinary diversion is required. This procedure is contraindicated in patients with a history of bladder cancer, those with uncorrected coagulopathy, those whose urinary bladder cannot be localized with ultrasonographic assistance, and those who have been exposed to procedures that may engender bowel adhesion, including lower abdominal or pelvic surgery. Except for urology residents, other residents are relatively unfamiliar with suprapubic catheterization.
In CCH, personnel from certain subspecialties are not always available when needed. Therefore, residents from various subspecialties must learn cross-specialty procedures; for example, urology residents must learn other procedures such as tendon repair, k-pin fixation of distal extremity fractures, and simple flap reconstruction. Accordingly, training rotating surgical residents to perform suprapubic catheterization is reasonable. Because our hospital did not have commercialized kits during our study, we performed suprapubic catheterization with a pigtail drain instead.
According to a previous report, suprapubic catheterization can be performed through several techniques, including ultrasound-guided, fluoroscopically guided,[7] and cystoscopy-guided techniques. Other techniques can also be used to gain access, such as catheter-through-the-sheath, cutdown, and coaxial dilation techniques.[3] Sven Ivar Seldinger, a pioneering Swedish interventional radiologist, introduced the Seldinger technique. Before the introduction of this technique, sharp large-bore trocars were employed to gain arterial access, which resulted in a high rate of complications, thus limiting their application to larger arteries. While working at Karolinska University Hospital, Sven Ivar Seldinger introduced a novel method of gaining vascular access using a hollow needle, exchange wire, and catheter; this method enabled radiologists to perform angiography in a relatively risk-free manner, thus leading to the emergence of minimally invasive procedures.[8] Real-time ultrasound-guided catheterization with a Seldinger wire is a relatively safe approach through which beginners can learn to perform suprapubic catheterization.
We designed a training course on the basis of ultrasound-guided CVC insertion. All trainee groups showed statistically significant improvements in scores. Our multiregression analysis revealed a relationship between previous urology training in the PGY and gain scores; the analysis also showed a relationship between overall pretest score and gain scores. Similar to other clinical skills, practice improves performance of suprapubic catheterization. Trainee sex or year of residency is not related to performance with respect to this procedure.
However, under the Taiwan National Health Insurance program, physicians may be inclined to consult urologists rather than performing suprapubic catheterization. Some of our trainees reported success in performing suprapubic cystostomy during their daily work on social media. This procedure may become as prevalent as central venous catheterization or abdominal paracentesis.
| Conclusions | | |
Real-time ultrasound-guided catheterization with a Seldinger wire is a safe and efficient approach to train rotating residents to perform suprapubic catheterization.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Wein AJ. Campbell-Walsh Urology. 11 th ed. Elsevier: 3598; 2016.  |
| 2. | Dogra PN, Goel R. Complication of percutaneous suprapubic cystostomy. Int Urol Nephrol 2004;36:343-4. |
| 3. | Irby PB 3 rd, Stoller ML. Percutaneous suprapubic cystostomy. J Endourol 1993;7:125-30. |
| 4. | Aguilera PA, Choi T, Durham BA. Ultrasound-guided suprapubic cystostomy catheter placement in the emergency department. J Emerg Med 2004;26:319-21. |
| 5. | Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine: Expert Consult 7 th ed, Elsevier, 1581; 2019. |
| 6. | Kara CO, Mengi E, Tümkaya F, Topuz B, Ardıç FN. Direct observation of procedural skills in otorhinolaryngology training. Turk Arch Otorhinolaryngol 2018;56:7-14. |
| 7. | Lee MJ, Papanicolaou N, Nocks BN, Valdez JA, Yoder IC. Fluoroscopically guided percutaneous suprapubic cystostomy for long-term bladder drainage: An alternative to surgical cystostomy. Radiology 1993;188:787-9. |
| 8. | Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol 1953;39:368-76. |
[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4]
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