10. PERI-OPERATIVE CARE OF URETHRAL SURGERY
10.1. Urethral rest
After any form of urethral manipulation (urethral catheter, ISD, dilatation, DVIU), a period of urethral rest is necessary in order to allow tissue recovery and stricture “maturation” before considering urethroplasty. This improves the ability to identify the true extent of the fibrotic segments during subsequent surgery. If the patient develops incapacitating obstructive symptoms or urinary retention, a suprapubic catheter should be inserted. Terlecki et al., propose diagnostic evaluation after two months and urethroplasty after three months of urethral rest. These timings are based on the general principles of wound healing . In their study, it has been shown that these periods allow for reliable stricture evaluation during urethrography which is, in turn, important to ensure selection of the most appropriate urethroplasty technique . Utilising this strategy, similar outcomes were obtained compared to patients with stable previously unmanipulated strictures . However, the optimal duration of urethral rest for all patients is not known and the degree of associated infection and inflammation should be taken into account as well, with longer periods of rest in those with greater degrees of infection and inflammation.
Summary of evidence
After any form of urethral manipulation, a minimum period of three months urethral rest is necessary to allow for tissue healing before performing urethroplasty.
Do not perform urethroplasty within three months of any form of urethral manipulation.
Post-operative wound infection and UTI are common post-operative complications and infection at the site of reconstruction may contribute to failure of urethroplasty. The vast majority of reconstructive urologists perform urine culture one to two weeks prior to surgery . Urine culture is superior to urine-analysis which can be omitted in the pre-operative evaluation . If infection or colonisation is present, a therapeutic course with antibiotics is recommended pre-operatively. Preoperative UTI, even when properly treated, could increase the risk of post-operative UTI . In case of an indwelling catheter general principles would suggest at least an attempt to suppress the colonisation with pre-operative antibiotics . These practices are in accordance with the strong recommendations of the EAU Guidelines on Urological Infections:
- “Screen for and treat asymptomatic bacteriuria prior to urological procedures breaching the mucosa.”
- “Treat catheter-associated asymptomatic bacteriuria prior to traumatic urinary tract interventions.”
An intra-operative prophylactic regimen with antibiotics (according to local antibiotic resistance profiles) is effective in reducing the rate of post-operative surgical site and UTIs . Although most urologists continue with post-operative antibiotics upon and even beyond catheter removal, there is no evidence that such a prolonged administration would reduce the infective complication rate . A retrospective study from Baas et al., revealed that extended postoperative antibiotic prophylaxis (three weeks until catheter removal versus 3 days around catheter removal) does not appear to affect UTI rates following urethroplasty . The EAU Guidelines on Urological Infections do not routinely recommend the use of antibiotic prophylaxis to prevent clinical UTI after urethral catheter removal. There is no evidence that this recommendation would not apply to catheter removal after urethral surgery.
Summary of evidence
An intra-operative prophylactic regimen with antibiotics is effective in reducing the rate of postoperative surgical site and urinary tract infections.
Administer an intra-operative prophylactic regimen with antibiotics at time of urethral surgery.
10.3. Catheter management
After uncomplicated DVIU, there is no advantage in maintaining the catheter for a prolonged period and it should be removed within 72 hours .
After one-stage urethroplasty and closure of the urethral plate after staged urethroplasty, urinary extravasation at the site of reconstruction must be avoided . For this purpose, urinary diversion by either transurethral catheter or suprapubic catheter with urethral stent can be used. With respect to the type of catheter material, a prospective randomised (but underpowered) trial comparing silicone vs. hydrogel coated latex transurethral catheters showed no significant difference in the time to stricture recurrence nor in the overall recurrence rate . The size of the urethral catheter utilised usually varies between 14 Fr and 20 Fr [547,548]. Systematic use of anticholinergic drugs has not shown a significant reduction in the rate of involuntary pericatheter voiding whilst catheterised .
After urethroplasty an indwelling catheter is commonly left in situ for two to three weeks [548,550]. After three weeks of urethral catheterisation, an extravasation rate of 2.2-11.5% at urethrography has been reported after different types of urethroplasty [550-553]. However, success with early catheter removal under three weeks has also been reported. A study after EPA for non-complicated anterior strictures demonstrated no significant difference in extravasation (6.8% vs. 4.5%) and recurrence rates (4.9% vs. 5.2%) between catheter removal at one or two weeks respectively . Poelaert et al., reported an extravasation rate of 3.5% vs. 8.3%, when the catheter was removed < 10 days or > 10 days respectively after all types of urethroplasty (n=219) (p=0.158) . Importantly, patients who had a duration of catheterisation of > 10 days had longer and more complex strictures . Beiske et al., revealed a higher incidence of UTI in patients with a three week catheterization after open urethroplasty, compared to two weeks .
Prior to catheter removal after urethroplasty, it is important to assess for urinary extravasation to avoid ensuing complications including peri-urethral inflammation, abscess formation and fistulation [550,552]. Importantly, some authors have identified urinary extravasation as a predictive factor for stricture recurrence [547,556]. Other series, however, could not confirm the prognostic significance of urinary extravasation but they included any form of extravasation (including minor leaks) [552,553]. Grossgold et al., found that high-grade leaks (defined as length > 1.03 cm and width > 0.32 cm) were significantly associated with higher restricture rates. This study also found length of extravasation > 1.03 cm alone to be an independent predictor of restricture . In cases of persistent and significant urinary extravasation, the catheter should be maintained or reinserted and the examination repeated after one week . However, low-grade (“wisp-like”) extravasation does not appear to affect long-term restricture rate and the catheter can be removed in these cases without subsequent urethrogram [552,556]. In case of any doubt about the significance of extravasation, it is safe to keep the catheter in for an additional week and ReDo the assessment.
The assessment of urinary extravasation is achieved by either pericatheter retrograde urethrography (pcRUG), classic RUG or VCUG . A prospective study (n=80) comparing pcRUG and VCUG in a within-patient fashion demonstrated a comparable sensitivity for contrast extravasation. Moreover, pcRUG averts the risk of having to reinsert the catheter, avoids the problem of patients being unable to void during VCUG and requires significantly less radiation (120 mGy/cm2 versus 241 mGy/cm2; p < 0.001) .
In cases of attempted VCUG where the patient is not able to void during fluoroscopy after catheter removal, RUG should be performed .
Although limited evidence for urethroplasty care in trans men exists, one study advised a three-week period of transurethral catheterisation with pcRUG upon catheter removal .
Summary of evidence
Prior to catheter removal after urethroplasty, it is important to assess for urinary extravasation with urethrography to avoid ensuing complications including peri-urethral inflammation, abscess formation and fistulation.
After uncomplicated DVIU, there is no advantage in maintaining the catheter for a prolonged period.
Early catheter removal may be appropriate for a subset of patients with short, uncomplicated, strictures.
Perform a form of validated urethrography after urethroplasty to assess for urinary extravasation prior to catheter removal.
Remove the catheter within 72 hours after uncomplicated direct vision internal urethrotomy or urethral dilatation.
Consider 1st urethrography seven to ten days after uncomplicated urethroplasty to assess whether catheter removal is possible, especially in patients with bother from their urethral catheter.