Although various techniques have been used for cuff shaving, the most standard seems to be as follows: Local anesthesia is injection into the skin around the exit site. Elliptical incision is made in the skin around exit site. Cautery is used to excise skin and soft tissue to expose the distal cuff (Fig. 13.2). Soft tissue is debrided off the distal cuff. The fibers of the cuff with a layer of silicone are then shaved off in strips using a scalpel or even a common razor [89] (Fig. 13.3). Using magnification may help the accuracy of the shaving. It should be noted that most catheters have thicker layer of silicone at the cuff to allow safe removal of all the fibers and a layer of silicone (Fig. 13.4). After all fibers are removed, the wound is packed and allowed to granulate around the catheter (Fig. 13.5).

Cuff shaving was described by Nolph and Nichols in 1983 [84] and Helfrich and Winchester were able to salvage 8 out of 12 catheters with exit site infections using this technique [85]. Piraino showed poor results from cuff shaving in 22 patients. The median catheter survival was only 1.5 months and there was high rate of dialysate leak and recurrent infection after the procedure producing a paultry 27% success rate [86]. However, in the largest series to date, Scalamogna reported a 50% 1 year survival after cuff shaving for staph aureus and staph epidermidis. Unfortunately, shortly after the procedure, 20 catheters (49%) were removed for either persistent tunnel infection or development of peritonitis [88]. In addition, Tan reported a 77% catheter survival after an average follow-up of 8.3 months using cuff shaving with a common razor [89]. Cuff shaving has also been described in children with good results. Yoshino compared 32 cuff shaving procedures with 29 catheter replacements in patients 1–20 years old. The primary outcome was time to post surgical tunnel infection and there was no significant difference between the groups. The incidence of recurrence of infection was 12.5% after the cuff shaving procedure with a 9.4% incidence of peritonitis. They concluded that compared to replacing the catheter, cuff shaving was less expensive, shortened hospital stay, and reduced the frequency of catheter replacement [92]. Another pediatric study reviewed 13 patients who underwent cuff shaving and formation of a new subcutaneous tunnel with exit site in the opposite side of the abdomen. After a mean follow-up of 31 months there were no recurrent exit site or tunnel infections. However five members of the group stopped PD due to receiving a transplant [93].

Based on the known literature, careful cuff shaving is a viable option to salvage a functioning PD catheter with superficial cuff extrusion or exit site infection. It may be performed under local anesthesia with minimal risk. However, if the tubing is damaged or cut during the procedure of if there is dialysate leak or persistent infection the catheter will need to be removed and a new one placed, usually on the opposite side of the abdomen.

Peritoneal dialysis is made possible by inflow and outflow through an intraperitoneal catheter which has intraabdominal, abdominal wall and external components. Mechanical complications may occur to the external component such as cracks or leaks in the tubing which prevent adequate dialysis and predispose the patient to peritonitis. Catheter damage is an infrequent but aggravating problem that occurs most commonly from accidental damage from clamps or scissors [94, 95]. However, it can also simply weaken over time, or be damaged by disinfectants such as alcohol or iodine and even some antibiotics [96]. Mupirocin which has been used for exit site infections has been shown to cause structural damage to polyurethane catheters. Furthermore, some catheters contain barium sulfate which over time can make the catheter brittle [97]. A final reason for catheter damage may be faulty production or a “bad batch” of catheters.

If the distal end is damaged, the catheter is simply cut and the cap is replaced. If the catheter damage is less than 2–3 cm from the exit site, there is a higher risk of infection and peritonitis. In addition there is not enough length to adequately use a repair kit. Therefore, it will most likely need to be replaced [94]. However, if there is catheter damage greater than 3 cm from the exit site, it is amenable to salvage using the Argyle™ Peri-Patch peritoneal dialysis catheter repair kit (Medtronic, Inc. Mansfield, MA). This kit includes a catheter extension with double-barbed connector, glue mold, locking ring, Beta-cap and Beta-cap clamp and medical-grade adhesive silicone to “glue” the pieces together, forming an air tight, water tight, bacteria resistant connection (Fig. 13.6).

Pain on instillation of PD fluid or draining (drain pain) is a known complication in patients undergoing PD occurring in 13 to 25% of patients [99–101]. It is thought to be due to shearing forces against the peritoneum or “jet” effect of dialysate emerging from the distal end of the catheter at relatively high velocity. It can also be related to the pH of the dialysate. If the pain is on outflow, it may be due to suction effect and is often positional. It is many times clinically significant, impacting the patient’s quality of life. The phenomenon occurs more frequently with cycler PD where hydraulic suction rather than gravity is used to drain the dialysate. Drain pain is more likely to occur when the catheter tip is implanted too low in the pelvis, wedging it between the rectum and uterus or rectum and bladder and leaving it susceptible to early termination of dialysate outflow and abrupt contact of the catheter tip with the peritoneum. A common cause of the catheter being implanted too deep in the pelvis is when the operator uses a single catheter type for all patients, inserting it at a fixed site relative to the umbilicus without consideration of catheter dimensions or patient body habitus [102]. This is why ISPD guidelines state that the umbilicus should not be used as a reference mark for catheter insertion [103].

Treatment includes altering the pH of the fluid, slowing down the infusion, converting to non-cycler PD using gravity-only drainage or not completely draining the peritoneum at the end of dialysis (tidal dialysis) [100, 101]. The pain may resolve with time; however if it is debilitating, catheter repositioning or removal may be necessary [104, 105].

There is no satisfactory surgical salvage procedure short of replacement for a catheter implanted too deep in the pelvis. Prevention of the problem can be achieved by employing methodology during preoperative planning to select the most appropriate catheter type and using the catheter itself to determine the insertion site that produces optimal pelvic position of the catheter tip [106]. In addition, long extraperitoneal tunneling for placement of the catheter body (straight portion of the catheter) may avoid movement of the catheter which may prevent the tip of the catheter hitting the peritoneum periodically during CAPD [107].