What is the recommended duration for keeping a catheter in place after major surgeries?

Optimal Duration for Urinary Catheter Retention After Major Surgery

Urinary catheters should be removed within 24 hours after major surgery in most patients, even when epidural analgesia is in use, to reduce the risk of urinary tract infections and promote earlier mobilization. 1

Rationale for Early Catheter Removal

Early catheter removal is supported by high-quality evidence demonstrating significant benefits:

• A randomized trial of early (day 1) versus standard (day 4) catheter removal in major abdominal and thoracic surgery showed UTI rates of 2% versus 14% respectively 1
• Catheter-associated urinary tract infections (CAUTIs) are the most common hospital-acquired infection, accounting for almost 40% of all nosocomial infections 1
• Longer catheterization is directly associated with increased risk of UTIs 1
• Patients with catheters for longer than 2 days postoperatively are twice as likely to develop UTIs compared to those with shorter durations 2

Patient Risk Assessment for Catheter Removal

Assess for risk factors that may require longer catheterization:

• High risk for retention: Male sex, pre-existing prostatism, pelvic surgery, neoadjuvant therapy, large pelvic tumors, and abdominoperineal resection 1
• Need for fluid monitoring: Patients with ongoing sepsis or acute physiological derangement may require continued catheterization 1
• Mobility status: Immobile or sedated patients may need continued catheterization 1

Algorithm for Catheter Management

1. Day of surgery (Day 0): Maintain catheter for accurate fluid balance monitoring
2. Postoperative Day 1: Remove catheter in most patients, including those with epidural analgesia 1
3. For high-risk patients: Consider extending catheterization but reassess daily 1
4. After removal: Monitor for signs of retention (inability to void within 6-8 hours or post-void residual >100mL) 3

Special Considerations

• Epidural analgesia: Contrary to traditional belief, urinary catheters can be safely removed on postoperative day 1 even with ongoing epidural analgesia 1
• Pelvic surgery: In rectal/pelvic surgery with low risk of retention, catheter can still be removed on day 1 1, 4
• Colon surgery: In patients without preoperative urinary disorders, catheterization must not exceed 24 hours 4
• Rectal surgery: Consider removal on day 2 if no risk factors for retention are present 4

Management After Catheter Removal

• Implement bladder training with scheduled voiding every 2 hours during the day and 4 hours at night 3
• Monitor for signs of retention (inability to void, discomfort, distended bladder)
• If retention occurs, consider:
  • Single in-out catheterization before resorting to reinsertion of indwelling catheter 1
  • Alpha-blocker therapy prior to next catheter removal attempt in males 3

Complications of Prolonged Catheterization

Beyond UTIs, extended catheterization is associated with:

• Increased 30-day mortality 2
• Decreased likelihood of discharge to home 2
• Increased risk of delirium in older adults 1
• Delayed mobilization and recovery 1
• Increased length of hospital stay 1, 4

Conclusion

The evidence strongly supports removing urinary catheters within 24 hours after major surgery for most patients. This practice significantly reduces infection rates and promotes faster recovery without increasing the risk of urinary retention, even in patients with epidural analgesia. Daily assessment of catheter necessity should be performed, with removal as early as possible to minimize complications.