CATHETER REMOVAL AFTER ANTERIOR ANASTOMOTIC (3 DAYS) AND VENTRAL BUCCAL
MUCOSAL ONLAY (7 DAYS) URETHROPLASTY
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HOSAM S. AL-QUDAH,
ANDRE G. CAVALCANTI, RICHARD A. SANTUCCI
of Urology (HSAQ, RAS), Wayne State University School of Medicine, Detroit,
Michigan, USA, and Section of Urology (AGC), Souza Aguiar Municipal Hospital,
Rio de Janeiro, Brazil
Physicians who perform urethroplasty have varying opinions about when
the urinary catheter should be removed post-operatively, but research
on this subject has not yet appeared in the literature. We performed voiding
cystourethrogram (VCUG) on our anterior urethroplasty patients on days
3 (anastomotic) and 7 (buccal) in an effort to determine the earliest
day for removal of the urethral catheter.
Materials and Methods: Retrospective chart
review of 29 urethroplasty patients from October 2002 - August 2004 was
performed at two reconstructive urology centers. 17 patients had early
catheter removal (12 anastomotic and 5 ventral buccal onlay urethroplasty)
and were compared to 12 who had late removal (7 anastomotic and 5 buccal).
Results: Of those with early catheter removal,
2/12 (17%) of anastomotic urethroplasty patients had extravasation, which
resolved by the following week and 0/5 (0%) of the buccal mucosal urethroplasty
patients had extravasation. Patients with late catheter removal underwent
VCUG 6-14 days (mean 8 days) after anastomotic urethroplasty and 9-14
days (mean 12 days) after buccal mucosal urethroplasty. 0% of the anastomotic
urethroplasty had leakage after the late VCUG and 1/5 (20%) of the buccal
patients had extravasation after the VCUG. Recurrences were low in all
Conclusion: Catheter removal after anastomotic
and buccal mucosal urethroplasty can be safely attempted on the 3rd and
7th post-operative days respectively, with a low rate of extravasation
on VCUG. Eliminating the catheter as soon as possible should improve patient
comfort without harming results and decrease the overall negative impact
of surgery on the patient.
words: urethra; urethral stricture; surgery; catheter; device
Int Braz J Urol. 2005; 31: 459-64
is a common procedure performed in many centers around the world. While
physicians agree on many details of the procedure, some controversy still
exists about other specific details of urethroplasty patient care. The
earliest feasible time to remove the catheter after surgery is a point
of significant discordance in the literature. The shortest time to remove
the catheter after anterior anastomotic urethroplasty seen in the literature
is 7 days, and can range as high as 14 days (Table-1). The earliest time
to remove the catheter reported after buccal mucosal urethroplasty is
7 days (but with concurrent suprapubic drainage for 14 days) and ranges
as high as 28 days (Table-2). To our knowledge, there are no reports that
specifically study this parameter, and time of catheter removal remains
largely a matter of physician opinion. In order to determine the earliest
feasible time to remove the urethral catheter, we performed voiding cystourethrogram
(VCUG) in our anterior urethroplasty patients on the third postoperative
day (POD) (the 4th day if this fell on a weekend) after anastomotic urethroplasty
and on the 7th POD after ventral buccal mucosal onlay urethroplasty.
There are several reasons why early catheter
removal is desirable in urethroplasty patients. First, studies of patients
with urethral catheters after prostate surgery have established that removal
of the catheter improves both patient comfort and mobility (1). Second,
there is some theoretical harm from the catheter on the just-completed
delicate repair. All catheters result in some inflammatory reaction (2),
with silicone catheters causing the least (but still measurable) amount
in experimental studies (3). Third, in general, removing the urethral
catheter earlier following surgery will decrease the total discomfort
of the patient after urethroplasty. Decreasing the total impact of surgery
makes urethroplasty a more palatable option for patients and more comparable
to lesser impact surgery, such as direct visual internal urethrotomy (DVIU).
DVIU has been shown not to be effective against recurrent strictures (4,5),
but it remains extremely popular, likely because it is so easy to perform
and easy on the patient. As innovations in urethroplasty continue to decrease
the impact of surgery, perhaps inappropriate persistence with DVIU, especially
in those with little chance of lasting cures, will decrease.
performed a retrospective chart review of 32 patients with anterior urethra
stricture who underwent anastomotic urethroplasty (19 patients) and ventral
buccal mucosal onlay urethroplasty (10 patients) in the period from October
2002 to August 2004 at 2 referral centers for urologic reconstruction.
One patient with previous local radiotherapy and 2 patients with end stage
renal disease on dialysis were excluded from the study because of expectations
for poor healing. Urethroplasty was performed by 2 surgeons (RAS, AGC).
Patients were divided into 2 groups. In the early catheter removal group,
we performed a VCUG on POD 3 (day 4 if it fell on a weekend) on anterior
anastomotic urethroplasty patients (n = 12) and on POD 7 on ventral buccal
mucosal graft urethroplasty patients (n = 5). In the late catheter removal
group, we performed VCUG on average 8 days after surgery for anastomotic
urethroplasty, and on average 12 days after surgery for buccal mucosal
urethroplasty. We compared the 2 groups by the rate of leakage seen on
VCUG and the recurrence rate. Patients who had extravasation in the first
VCUG had replacement of the Foley catheter and a second VCUG in 7 days.
Patients were followed closely after surgery for recurrence, as has been
previously described (6). Review of urinary symptoms, urinary flow rates
and postvoid residuals were measured 3,6,9,12 and 24 months after surgery
(7). Patients are considered to have undergone retrograde urethrogram
(RUG) if obstructive voiding signs or symptoms recur after urethroplasty.
average patient age was 43 years (range 19-75 years) and stricture length
measured by preoperative RUG was 1.2 cm (range 0.5-3 cm) for anastomotic
and 3.6 cm (range 2.5-5 cm) for buccal urethroplasty. Cause of stricture
was inflammatory in 8 patients, trauma in 6, iatrogenic in 3, and unknown
in 12 patients. Patient follow-up averaged 14 months (range 3-30 months).
In the early group (12 patients), 2 (17%)
of the anastomotic urethroplasty patients had extravasation in the first
VCUG. The other 10 patients (83%) had a normal VCUG and the Foley removed
at the same time (Figure-1). Patients with extravasation had their Foley
replaced and the VCUG repeated after one week, which was normal in both
cases. In the late group (7 patients), 100% of the VCUGs were normal and
the patients had their Foley removed (Figure-2). There were 2 recurrences:
1 (8%) in the early group and 1 (14%) in the late group.
Buccal Mucosal Graft Onlay Urethroplasty
In the early group (5 patients), 100% had
a normal VCUG and all had their Foley removed on the 7th POD. In the late
group (5 patients), one patient (20%) had extravasation and the other
4 patients were normal and had their Foley removed (Figures-1 and 2).
The second VCUG was normal and Foley removed. The recurrence rate was
0% in both groups.
best interval period for catheterization after urethroplasty is unknown,
and most published recommendations represent expert opinion only. For
anastomotic urethroplasty, suggested catheterization periods range from
7 to 21 days, but only 2 reports mention the rate of extravasation when
this timing is followed: 1% in 1 series and 10% in another, however this
second series mixed anterior and posterior urethroplasty patients (Table-1).
In our anastomotic urethroplasty patients with early catheter removal,
on POD 3 there was a 17% rate of extravasation. All of these patients
subsequently had catheters removed on POD 10. The stricture recurrence
rate was equivalent in these 2 groups.
While this rate of leakage is higher than
previously reported after longer catheterization times, it shows that
over 80% of patients can have their Foley removed after anastomotic urethroplasty
within 3 days time. In addition to increasing patient comfort, this approach
provides some logistical benefits to the patient. In those centers that
routinely admit the patient for 3-4 days postoperatively, removing the
Foley catheter on POD 3 will allow the patient to be discharged without
a catheter. This will improve patient comfort, eliminate troublesome catheter
care at home and also allow out-of-town patients to return home without
needing further acute follow-up.
For buccal mucosal graft ventral onlay urethroplasty,
recommended catheterization periods range from 14 to 28 days (Table-2).
In 2 series, the Foley is removed on POD 7 and POD 10, but urine is diverted
suprapubically for another 7-14 days. When we removed the Foley on POD
7 after buccal mucosal urethroplasty, no patient in our series had urinary
extravasation. One patient in the late Foley removal group had leakage,
and the Foley was removed 7 days later after a normal VCUG was obtained.
The stricture recurrence rate was equivalent whether or not the Foley
was removed early or late.
Prolonged catheterization is consistently
reported by our patients and those of other physicians (1,8) as the most
troublesome part of their surgery experience, and we believe that limiting
this unpleasant experience significantly decreases the negative “impact”
of surgery. As we learn to decrease the requirements for postoperative
stay, in some cases using same-day surgery (9), then an anastomotic urethroplasty
becomes more comparable to minimally invasive therapies like direct visual
internal urethrotomy (DVIU) with its attendant short catheter times (usually
3 days), and thus potentially more acceptable to both patient and surgeon.
removal after anastomotic and buccal mucosal urethroplasty can be safely
attempted on the 3rd and 7th postoperative days respectively, with a low
rate of extravasation on VCUG. Getting the Foley out earlier did not increase
recurrence rates on short-term follow-up. Eliminating the catheter as
soon as possible has beneficial effects on patient comfort and the overall
negative “impact” of surgery.
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Received: July 8, 2005
Accepted: August 15, 2005
Dr. Richard A. Santucci
Chief of Urology, Detroit Receiving Hospital
4160 John R. Suite 1017
Detroit, MI, 48201, USA
Fax: + 1 313-745-0464
spite of the great advances in urethral reconstructive surgery, there
are still many controversies. Considerable controversy is related to the
urinary drainage after urethroplasty. This generates many questions: using
of intra-urethral or suprapubic catheter, or both; how long and by whom;
which size (12-20 Ch) and type of the catheter? According to the different
authors, duration of urinary drainage ranges from 1-3 weeks. There is
also suprapubic drainage with small fenestrated or grooved stents, which
only pass the level of urethral repair. There is not unique approach,
regarding urinary drainage after urethroplasty - it depends on the type
of urethroplasty and surgeon’s preference. There is no comparable
study in the present literature.
In this present study, the authors evaluated
early removal of intraurethral catheter after anterior anastomotic and
ventral buccal mucosa onlay urethroplasty on the third and seventh days,
respectively. They had control group of patients with the same types of
urethroplasty with late removal of the catheter on eight and twelfth days,
respectively. Outcome was the same in both groups. Early versus late catheter
removal has several advantages: catheter in native urethra may cause significant
morbidity, such as irritative symptoms and discomfort, may interfere with
urethral secretion and ejaculation that may be the cause of infection.
However, the most important question is by whom early catheter removal
should be done. Only very experienced and skillful surgeons with referral
population and familiar with this demanding field of surgery can achieve
such a success, as in this study. These results could hardly be reproduced
by the surgeon who performs urethroplasty occasionally. Early catheter
removal after urethroplasty is intriguing, but limited on relatively small
number of the patients with short-term results. Long-term results are
awaited with great interest.
Sava V. Perovic
Professor of Urology/Surgery
School of Medicine, University of Belgrade
Belgrade, Serbia and Montenegro
some years ago, I used to remove the urethral catheter 3 to 5 days after
ventral urethroplasty and 7 to 10 days after ventral buccal onlay urethroplasty
with good results.
I began this technique after an intentionally
early removal of urethral catheter in 2 patients and results were very
Mostafa A. Al-Rifaei
Department of Urology
Faculty of Medicine, University of Alexandria