What is the order of removal for a Suprapubic Catheter (SPC), Foley catheter, and Double J (DJ) stent after Vesicovaginal Fistula (VVF) repair?

Order of Catheter and Stent Removal After VVF Repair

Remove the DJ stent first (typically on postoperative day 10-14), followed by the Foley catheter on the same day or shortly after confirming bladder healing, and finally remove the suprapubic catheter last if bladder function is adequate.

Recommended Removal Sequence

1. DJ Stent Removal (First)

• Remove ureteral stents between postoperative days 10-14 1, 2
• The stents protect the ureterovesical junctions during the critical healing period when bladder edema is maximal 3
• Earlier removal risks ureteral obstruction from postoperative edema, particularly in complex repairs 3

2. Foley Catheter Removal (Second)

• Remove the Foley catheter on postoperative day 10-14 after confirming bladder healing with voiding cystourethrography 1, 4
• Studies consistently demonstrate Foley catheter duration of 10-25 days post-VVF repair, with mean duration of 15.75 days 2
• The catheter must remain in place for 2-3 weeks to allow adequate healing of the bladder repair 5
• Perform voiding cystourethrography before removal to confirm no leak at the repair site 1

3. Suprapubic Catheter Removal (Last)

• Remove the SPC after confirming adequate spontaneous voiding following Foley removal
• The SPC serves as a safety backup if urinary retention develops after Foley removal 5
• Keep the SPC clamped initially after Foley removal to assess voiding function
• Remove once the patient demonstrates consistent, complete bladder emptying with post-void residuals <100 mL 6

Clinical Rationale

Why This Sequence Matters

• Ureteral protection is paramount early: Removing DJ stents too late increases infection risk, but removing them before day 10 risks obstruction from surgical edema 3
• Bladder healing requires time: VVF repairs involve both bladder and vaginal closure with interposed tissue (typically omentum), requiring 2-3 weeks for secure healing 1, 2
• The SPC provides safety: Maintaining the SPC until last allows for backup drainage if urinary retention occurs, avoiding emergency catheterization that could disrupt the repair 5

Important Caveats

Extend Catheterization If:

• Significant hematuria persists beyond postoperative day 10, suggesting incomplete healing 5
• Complex or tenuous repair was performed, particularly with large fistulas (>2 cm) 2
• Cystography demonstrates persistent leak at the planned removal time 1
• Patient has concurrent neurological injury requiring prolonged bladder drainage 5

Simultaneous Removal Option

• In straightforward repairs with excellent healing on cystography, the DJ stent and Foley catheter may be removed simultaneously on day 10-14 1, 4
• The SPC should still be maintained until voiding function is confirmed 5

Avoid Common Pitfalls

• Never remove the SPC before the Foley: This eliminates your safety backup for bladder drainage 5
• Never remove catheters without imaging confirmation: Cystography is essential to document healing before Foley removal 1
• Do not rush removal in complex cases: Extended catheterization (up to 4 weeks) is acceptable for complicated repairs 5