The use of a catheter for urinary drainage post robotic assisted radical prostatectomy (RARP) is critical to allow urinary diversion and preservation of the vesicourethral anastomosis (VUA). Traditionally, this purpose is served by placement of an urethral catheter (UC), which can cause discomfort for patients. The use of suprapubic catheter (SPC) instead results in less discomfort with no compromise on bladder neck contracture (BNC) rates. In this video, we present the step-by-step method by which a SPC can be safely placed post RARP to minimize complications.

This is a prospective cohort study of patients undergoing RARP from February to October 2024 at two private hospitals Australia. We highlight key steps in the placement of SPC post RARP to ensure safety and minimize complications. Patients have both UC and SPC at the completion of RARP, with the UC being removed D1 post operation. They are discharged with SPC and undergo a trial of void (TOV) D7 post operation. At the time of TOV, patients were asked to fill in a questionnaire addressing pain associated with their catheter using the Visual Analogue Scale (VAS). BNC rates were assessed at 3 months.

So far, 30 patients have received SPC post RARP. All patients underwent a successful TOV. The mean VAS score was 2 (SD 2.1). There were no BNC at 3 months follow up. We report two complications which has guided changes in our practice. In the first case, the bladder was under-distended with only 120ml. The SPC was passed into the posterior bladder wall, resulting in an incomplete detrusor injury. This was recognized intra-operatively as there was no urine flowing from the sheath. The bowel was inspected for injury, and the posterior wall defect repaired. The patient recovered well without further complications. In the second case, the UC slipped out during insertion of the SPC, resulting in the SPC balloon partially inflating in the bulbar urethra. This was again recognized intraoperatively as the balloon was difficult to inflate and the SPC was not draining. The balloon was immediately deflated and SPC removed. An UC was left in situ following a flexible cystoscopy and the patient underwent a successful TOV 2 weeks later with no BNC at 3 months. Key steps to minimize complications during SPC insertion include ensuring adequate bladder distension at 300ml, and having the UC in situ to ensure the SPC remains in the bladder. It is also important to insert the SPC at the bladder dome to minimize tension and avoid traction on the anastomosis.

SPC can be safely placed post RARP by following the above steps and can result in improved patient tolerability without risk of BNC.