When should a catheter be removed after urethroplasty?

Catheter Removal After Urethroplasty

For uncomplicated urethroplasty, the urethral catheter can be safely removed at 8-10 days postoperatively, with earlier removal possible for anastomotic repairs (3 days) and slightly longer for buccal mucosal grafts (7 days). 1, 2, 3

Timing Based on Urethroplasty Type

Anastomotic Urethroplasty

• Remove catheter at 3 days postoperatively for tension-free anastomotic repairs 2
• Studies show only 17% extravasation rate at day 3, which resolves spontaneously by the following week 2
• Suprapubic catheter (if placed) can be removed at 2 weeks, with urethral catheter removal at 4-5 weeks in more complex cases 4

Buccal Mucosal Graft Urethroplasty

• Remove catheter at 7 days postoperatively for dorsal onlay buccal mucosal grafts 2, 5
• Zero extravasation observed at day 7 in one series 2
• Early removal at 7 days shows no significant difference in urinary flow compared to conventional 3-week removal (p=0.089) 5
• Periurethral leakage occurs in approximately 12% with early removal versus 8% with conventional timing, but this difference is not clinically significant 5

General Urethroplasty (All Types)

• For uncomplicated cases, remove catheter at 8-10 days 3
• Median duration of 8 days results in only 3.5% requiring additional catheterization 3
• Longer catheterization (>10 days) does not improve outcomes and may be associated with higher extravasation rates (8.3%) 3

Role of Voiding Cystourethrogram (VCUG)

When VCUG is Recommended

• Perform VCUG at 2-3 weeks post-urethroplasty to assess urethral healing before catheter removal in complex cases 1
• VCUG is particularly useful for pelvic fracture urethral injuries and complex reconstructions 1

When VCUG Can Be Omitted

• VCUG is not mandatory for routine tension-free anastomotic urethroplasty 4
• Trial without catheter (TWOC) can be performed at 4-5 weeks without pericatheter urethrogram 4
• Instead, use uroflowmetry at 1 week, 1 month, 3 months, and 12 months post-removal 4
• Consider VCUG only for difficult cases with tension anastomoses or redo procedures 4

Clinical Outcomes and Prognostic Factors

Extravasation Rates

• Overall extravasation on VCUG occurs in approximately 6% of urethroplasties 3
• 71% of patients with extravasation have clinical signs of impaired wound healing 3
• Extravasation is a prognostic factor for stricture recurrence and need for reoperation 3

Benefits of Early Catheter Removal

• Improved patient comfort and mobility 5
• Reduced catheter-related complications including urinary tract infections 5
• Shorter postoperative hospital stay (statistically significant, p<0.001) 5
• No increase in fistula, meatal stenosis, or stricture rates 2, 6

Algorithm for Catheter Removal Decision

Step 1: Identify urethroplasty type

• Anastomotic (excision and primary anastomosis) → Remove at 3 days 2
• Buccal mucosal graft (dorsal onlay) → Remove at 7 days 2, 5
• Other uncomplicated repairs → Remove at 8-10 days 3

Step 2: Assess for complicating factors

• Longer strictures (>4 cm) → Consider extending to 10-14 days 3
• Redo/revision urethroplasty → Consider VCUG at 2-3 weeks before removal 1, 4
• Tension anastomosis → Consider VCUG before removal 4
• Clinical signs of impaired healing → Extend catheterization and perform VCUG 3

Step 3: Post-removal monitoring

• Perform uroflowmetry at 1 week post-removal 4
• Qmax <15 mL/s indicates possible recurrence 4
• If flow is poor, obtain ascending urethrogram at 6 weeks post-procedure 4

Important Caveats

Avoid prolonged catheterization without indication - there is no evidence that leaving catheters longer than 72 hours after simple endoscopic procedures (dilation/DVIU) improves outcomes 7, and for urethroplasty, durations beyond 10 days in uncomplicated cases do not reduce complications 3

Watch for clinical signs of healing problems - if there are concerns about wound healing, tissue quality, or anastomotic tension during surgery, extend catheterization and consider VCUG before removal 3

Recurrence rates remain low with early removal - studies consistently show that early catheter removal does not compromise surgical success rates 2, 5, 6