Catheter Removal Sequence After Percutaneous Nephrolithotomy
Remove the urethral Foley catheter first, followed by the nephrostomy tube. This sequence minimizes urinary tract infection risk and allows assessment of antegrade urine flow through the ureter before removing the nephrostomy drainage.
Rationale for Foley Catheter Removal First
Infection Prevention Priority
The urethral Foley catheter should be removed within 24-48 hours after any urological procedure to minimize catheter-associated urinary tract infection (CAUTI) risk, which represents the fourth leading cause of hospital-acquired infections. 1, 2
Each additional day of urethral catheterization exponentially increases infection risk, with CAUTIs being a leading cause of nosocomial bacteremia and sepsis. 1
The nephrostomy tube, being externalized and draining into a closed system, poses lower infection risk than an indwelling urethral catheter. 3
Functional Assessment Advantage
Removing the Foley catheter first while maintaining nephrostomy drainage allows you to assess whether the patient can void spontaneously and whether urine flows antegrade through the ureter without obstruction. 3
If the patient develops urinary retention or inadequate drainage after Foley removal, the nephrostomy tube remains in place as a safety backup for urinary diversion. 3
This staged approach prevents the scenario where both drainage systems are removed simultaneously and the patient subsequently develops acute urinary retention or ureteral obstruction requiring emergent intervention. 3
Specific Timing Protocol
Foley Catheter Removal
Remove the urethral Foley catheter on postoperative day 1-2 after uncomplicated PCNL. 3, 1
Earlier removal (within 24 hours) is preferred unless there are specific contraindications such as significant hematuria requiring bladder irrigation or concern for bladder neck injury. 1
Nephrostomy Tube Management
Maintain the nephrostomy tube for at least 5 days postoperatively, removing it only when drainage output remains less than 50 cc daily for 3 consecutive days. 3
If there was collecting system repair during PCNL, the nephrostomy tube should remain until imaging confirms no urinoma formation or persistent leak. 3
A ureteral stent (if placed) and nephrostomy tube can be removed together once adequate healing is confirmed, typically after the Foley has already been removed. 3
Common Pitfalls to Avoid
Do Not Remove Both Simultaneously
- Removing both catheters at the same time eliminates all urinary drainage options if complications develop, potentially requiring emergent cystoscopy or percutaneous nephrostomy placement. 3
Do Not Prioritize Convenience Over Safety
- The temptation to remove the nephrostomy tube first (because it is more uncomfortable for patients) must be resisted, as this reverses the appropriate safety sequence. 1
Monitor for Complications Before Nephrostomy Removal
Before removing the nephrostomy tube, confirm the patient is voiding adequately without retention (post-void residual <100 mL), has no fever, and nephrostomy output has decreased appropriately. 3, 1
If nephrostomy output suddenly increases or becomes purulent after Foley removal, this suggests ureteral obstruction or infection requiring continued drainage. 3
Special Circumstances Requiring Modified Approach
Significant Collecting System Repair
- If extensive pelvicaliceal repair was performed during PCNL, maintain both the nephrostomy tube and ureteral stent longer (typically 7-14 days), but still remove the Foley catheter first within 48 hours. 3
Persistent Hematuria
- If gross hematuria persists beyond 48 hours, the Foley catheter may need to remain for continuous bladder irrigation, but this should not delay nephrostomy tube removal once output criteria are met. 4
Urinoma Formation
- If follow-up imaging demonstrates an enlarging urinoma, maintain the nephrostomy tube and consider adding a ureteral stent, but the Foley catheter can still be removed if bladder drainage is adequate. 3