The optimal catheter duration in hypospadias repair: A systematic review

Abstract

Hypospadias is the most prevalent congenital anomaly of the penis, with surgical intervention being its only treatment option. There remains ongoing debate regarding the necessity, the type, and duration of urine diversion following hypospadias repair. Early catheter removal may alleviate discomfort for both the patient and their family, facilitating earlier discharge. Nonetheless, premature removal raises concerns about the potential development of complications. A systematic review was conducted to assess the impact of catheter removal timing on the occurrence of complications. Six observational studies, including 1188 cases, were included. The duration before catheter removal varied among the study groups from less than 24 h up to more than 6 weeks. Prolonged catheterization can potentially lead to better urinary flow rate and better cosmetic results, but without a significant difference in most complications. There is an existing knowledge gap regarding the best urinary diversion and the optimal duration of catheterization in hypospadias repair. The available literature warrants further high-quality research. This includes conducting larger multicenter randomized trials to advance our understanding, aiming at improving the outcomes of hypospadias repair surgery.

Graphical abstract

Keywords

catheter duration / drainage / hypospadias / outcomes / pediatric

1 INTRODUCTION

Hypospadias occurs in approximately one out of every 300 live-born male infants, making it the most prevalent congenital anomaly of the penis. Its etiology is largely multifactorial and remains poorly understood[1]. This condition is characterized by three distinct anomalies of the phallus: the urethral meatus is abnormally located along the ventral surface of the penis, ranging from the glans to the perineum; the penis exhibits ventral curvature, commonly referred to as chordee; and the foreskin is ventrally deficient, accompanied by a dorsal accumulation of foreskin, creating a characteristic “hood” appearance[2].

Surgical intervention remains the sole treatment option for hypospadias. Various surgical techniques have been developed. Historically, meatal advancement and glanuloplasty (MAGPI), along with the perimeatal-based flap repair (Mathieu), represented the primary techniques for addressing distal hypospadias[3,4]. These techniques yielded low complication rates and satisfactory, albeit not optimal, cosmetic results. The tubularized incised plate (TIP) repair, first introduced by Snodgrass[5] as an adaptation of the Thiersch-Duplay ventral tube repair[6], has since gained widespread adoption in numerous centers. This transition is attributed to the TIP repair's superior cosmetic outcomes and comparably low complication rates.

To date, there remains ongoing debate regarding the necessity of urine diversion following hypospadias repair[7]. While many pediatric urologists advocate for urinary diversion, the type and duration of urinary diversion following hypospadias repair have remained a subject of ongoing debate. The alternatives include: no diversion[7], suprapubic diversion[8], a urethral stent placed below the external bladder sphincter[9], or a transurethral bladder catheter[10].

Many surgeons employ urinary diversion post-operatively, typically using a urethral stent or bladder catheter for a duration of 2–14 days, depending on the severity of the case. The European Association of Urology (EAU) and the European Society of Pediatric Urology (ESPU) do not offer specific guidelines regarding catheter removal post-surgery, citing the low level of evidence available[11].

Early catheter removal may alleviate discomfort for both the patient and their family, facilitating earlier discharge. Nonetheless, premature removal raises concerns about the potential development of urethrocutaneous fistulas and wound dehiscence, as urine flow may disrupt the healing suture line. On the other hand, prolonged catheter use can increase the risks of wound infection, meatal stenosis, and urethral stricture[9].

This systematic review aims to assess the impact of catheter removal timing following hypospadias surgery on the occurrence of complications such as urethrocutaneous fistula, foreskin dehiscence, meatal stenosis, urethral stricture, and urethral diverticulum, as well as on other complications and surgical success. The goal is to determine the optimal timing for catheter removal to avoid unnecessary delays while minimizing the risk of post-operative complications.

2 METHODS

This review was done according to the recommended items for the Preferred Reporting Items for Systematic Reviews (PRISMA) statement guidelines[12]. Our protocol was registered at PROSPERO: CRD420251048561.

2.1 Search strategy

A comprehensive literature search was conducted on: PubMed, Scopus, Web of Science, and Cochrane Library up to December 2024 to retrieve the eligible studies to be included in our systematic review. The following keywords were used: (“Catheter” OR “Catheterization” OR “Stent” OR “JJ” OR “DJ” OR “Urinary Drainage”) AND (“duration” OR “time” OR “period” OR “continuation” OR “extent” OR “span”) AND (“Hypospadias”)).

2.2 Eligibility criteria

Our inclusion criteria included: any primary research articles, either observational studies or clinical trials, about catheter duration in hypospadias repair. Our main outcomes were the fistula incidence rate, meatal stenosis, foreskin dehiscence, urethral stricture, and urethral diverticulum. On the other hand, we excluded in vitro studies, case reports, papers with unavailable full texts, studies with overlapping data sets, non-English studies, and non-original articles (i.e., reviews, commentaries, guidelines, editorials, correspondence, letters to editors, protocols, etc.).

2.3 Screening and study selection

All the retrieved results were screened blindly using Rayyan software[13] to avoid any selection bias. The screening process was conducted in two phases: title and abstract screening and full text screening. Each phase was done by two independent researchers, findings were compared, and conflicts were solved by group discussion. The Newcastle-Ottawa Scale was used for risk of bias assessment of included studies[14].

2.4 Data extraction

We extracted the following date: study design, year of publication, recruitment period, type of hypospadias, chordee and follow up.

2.5 Outcomes

Our main outcomes of interest were fistula incidence rate, meatal stenosis, foreskin dehiscence, urethral stricture, urethral diverticulum and other complications.

3 RESULTS

3.1 Search results

Six hundred and thirty-nine studies were identified through our literature search using the relevant keywords on different databases. After comprehensive screening of the retrieved results, we screened 458 studies after removing duplicates. Eventually, six studies were included in our systematic review (Figure 1). Table 1 shows summary of the included studies and baseline characteristics. The results of risk of bias assessment are shown in Table 2.

3.2 Studies summaries and patients' characteristics

We included six observational studies (four prospective cohorts and two retrospective cohorts), including 1188 cases with a mean age ranging from 1.23 ± 1.17 to 5.42 ± 2.53 years. The types of hypospadias in the included population varied between mild/proximal penile and distal hypospadias. Around 438 cases were distal hypospadias cases, representing 36.9% of the included population, while 750 cases were mild/proximal penile cases, representing 63.1% of the total population. The duration before catheter removal varied among the study groups from less than 24 h up to more than 6 weeks (Table 1). Two studies had exclusively distal hypospadias patients[15,16]. One study included proximal hypospadias patients[17] while three studies had mixed patients (distal, proximal, and midpenile)[18–20].

3.3 Efficacy

In Zhou et al. study, maximum urinary flow was evaluated across three groups with different durations of urinary catheter placement. The maximum urinary flow was found to be the highest at the 6-week group at 2 weeks and 4 weeks after stent removal with rates of 9.7 ± 2.9 mL/sec and 9.3 ± 3.3 mL/sec, respectively[17] (Figure 2). Regarding the cosmetic results, Daher et al. study reported that 84 out of 95 patients in the late catheter removal group rated the results as “very good” while in the early removal group 60 out of 94 cases had the same evaluation. Only four cases reported the results as “acceptable” in the late catheter removal group, while 26 cases reported the same evaluation in the early removal group. The rest of the cases were “good” with the cosmetic results[19]. In the study by Ritch et al. 48 out of 49 patients left with the urinary catheter overnight rated the cosmetic results as “very good”[20].

3.4 Fistula

A very common complication reported among the studies is urethral fistulas (Figure 3). In Aslan et al.'s study comparing between two groups of patients (Group 1 for less than 24 h, Group 2 for more than 24 h), the incidence rate of fistula was seven cases out of 99 cases in Group 1, while there were only two incidents in Group 2[15]. In Daher et al.'s study, two groups were compared for late complication of urinary catheter removal. The first group removed the catheter after 1 week, while the second group removed it after 3 weeks. The early group (catheter removed after 1 week) experienced 17 fistula cases, while the late group (removed after 3 weeks) had only five[19]. In Kumar et al. study, two groups were compared regarding the catheter removal complications before and after the fifth day of the catheter placement. The incidence of urethral fistulas was similar in the two groups, as there were two events of urethrocutaneous fistulas in each group[18]. In Zhou et al.'s study, patients' group who lift the catheter for 2 weeks complained of 45 events of fistula out of the 237 cases in this group, while there were 43 cases in the group with 4-week catheterization out of 206 patients. The last group with the 6-week of urinary catheter placement experienced 41 events of fistulas out of 222 cases[17].

3.5 Meatal stenosis

In Aslan et al.'s study, only three cases experienced meatal stenosis in the group with catheter placement for less than 24 h[15]. In Kumar et al.'s study, three cases were reported in the group with catheter removal before Day 5, while only two cases occurred in the later removal group[18]. In Daher et al. study, the early removal group reported four cases while only two cases were reported in the late removal group[19] (Figure 4A).

3.6 Foreskin dehiscence

In Honkisz et al.'s study, two groups were compared for foreskin dehiscence, and reported nine cases in the group removed the catheter the next day after placement, while there were only two cases that experienced this event in the group that left the catheter for more than 5 days[16]. In Zhou et al.'s study, the least group that experienced this event was the 6-week group with only two cases, while there were four cases in the 4-week group and three cases in the 2-week group[17] (Figure 4B).

3.7 Urethral stricture and urethral diverticulum

In Kumar et al.'s urethral stricture and urethral diverticulum were not common complications in both groups, with only two cases (one stricture and one diverticulum) in the group removed the catheter before the fifth day of placement[18]. In Zhou et al.'s study, there were 26 cases in the group of patients who were left for 2 weeks with the urinary catheter who experienced urethral stricture, while the 4-week group experienced only 12 cases, and only four cases in the 6-week group. Urethral diverticulum was noticed as a postoperative complication in five cases in the 2-week group, while there were four cases in the 4-week group and six cases in the 6-week group[17] (Figure 5).

3.8 Other complications

In Aslan et al.'s study, one case of tube dehiscence was noticed in the group of patients left the catheter for more than 24 h, and one buried penis in both groups[15]. In Kumar et al.'s study, early complications were also evaluated. Wound infection occurred in two cases in each group. Urinary tract infection was reported in one case in the early group and in three cases in the post–5-day removal group. Bladder spasm occurred in four cases exclusively in the late group. Four patients in the early group experienced urinary retention, and two cases of urinary extravasation were reported[18].

4 DISCUSSION

The type of urinary diversion after hypospadias repair, whether or not to perform diversion, and the duration of diversion will continue to be a source of debate. Catheterization can be a source of pain, bladder spasms, and infection, but it has many advantages, like preventing urinary retention and dysuria during voiding, in addition to tamponading any bleeding and acting as a splint for better healing. On the other hand, the catheter itself can induce inflammation and inhibit scarless healing in addition to being a source of discomfort[15]. Moreover, some reports state that unstented repair is even better option for better healing, and urine flow can be enough to keep healing edges separate, allowing healing[21]. No additional benefit in outcomes was found in addition to better postoperative care and comfort with omission of medications such as anticholinergics and antibiotics[22,23]. Furthermore, suprapubic diversion was used to provide diversion of urine, together with avoiding the problems with a urethral catheter. They found significantly lower fistula rate but with more meatal stenosis[8,9].

To better understand the healing process, many experimental and animal studies have been conducted. It was confirmed that reepithelization starts in 2 days and is almost complete by the fifth day after urethral plate incision[24]. When analyzing the healing process, it was found that it has a longer duration of each phase of healing. One reason for this prolonged healing process could be the urine extravasation, and hence the presence of a urethral catheter is mandatory, even if it does not completely prevent urine leak into the urine, but it will definitely decrease the amount of it[25]. In addition, Bleustein et al. found that even after 21 days postoperatively, there was still some healing and inflammatory response, which supports that prolonging catheter duration could potentially decrease the risk of complications[26].

The majority of urologists choose to leave a urethral catheter following hypospadias repair surgeries, but the ideal duration has not been determined yet. Some would think that a longer duration means a more inflammatory reaction and less healing[15]. Others advocate for a longer duration to allow optimal healing and prevent complications[27].

To our knowledge, this systematic review is the first of its kind to compare the efficacy and complications of early versus late catheter removal following surgical repair of mid, proximal, and distal hypospadias, with the aim of determining the optimal timing for catheter removal. One of the main findings of this study was the assessment of the procedure's efficacy, which was evaluated based on maximum urinary flow rate, cosmetic outcomes, and the rate of complications (early, late, and voiding-related) between groups that had the catheter removed at different points in time.

Regarding maximum urinary flow, only Zhou et al. evaluated this outcome and found that maximum urinary flow was inversely proportional to the timing of catheter removal, with those who had their catheter removed later showing better performance. They suggested that this could be due to the early development of urethral strictures. While the exact cause of these strictures is unclear, it could be related to a small diameter of the neourethra, persistent inflammation causing urine blockage when the catheter is removed too early, or the neourethral anastomosis not being fully healed. Premature removal of the catheter might lead to local urethral distortion or urine extravasation into surrounding tissues. They concluded that prolonged stenting reduces the risk of urethral strictures and subsequent decline in maximum urinary flow without increasing the risk of other postoperative complications.

Two studies evaluated the cosmetic outcomes of early versus late catheter removal. Ritch et al. reported “excellent” cosmetic results in all but one patient (98%), who required re-intervention for persistent chordee[20]. In the study by Daher et al., cosmetic results were categorized as “very good,” “good,” and “acceptable”. They found significant differences between the two groups in the “very good” and “acceptable” categories, both favoring prolonged stenting[19]. Neheman et al. published predictors of cosmetic outcomes, including the degree of chordee, glans width, and preoperative HOPE and GMS scores, but did not account for the duration of catheterization[28]. Therefore, it could be suggested that prolonged catheterization may serve as an additional predictor of better cosmetic outcomes. This is important because better cosmetic outcomes are linked to better sexual outcomes, as individuals with a history of hypospadias repair have a relatively high incidence of erectile dysfunction and premature ejaculation[29].

Early complications of hypospadias repair include wound infection, UTI, bladder spasms, AUR, and urinary extravasation. Wound infection was reported in two studies[18,19], both showing no significant difference between the groups with early versus late catheter removal. Regarding UTIs, three studies[18–20] found no significant difference between the two groups. These findings align with the literature, which classifies these events as rare, mainly due to the routine use of prophylactic antibiotics in the postoperative period[30]. Although urinary extravasation was higher in the early removal group in the study by Kumar et al., it did not reach statistical significance[18]. This is significant because urinary extravasation can eventually result in chronic urethritis, which in turn raises the risk of long-term complications like urethral fistula and stricture[31]. Bladder spasms and acute urinary retention (AUR) showed significant differences between the two groups in the Kumar et al. study[18]. The authors suggested that the early removal group experienced subjective improvement in comfort, did not require anticholinergics, and that most patients in the delayed removal group were irritable until the stent was removed.

Regarding the formation of postoperative fistulas, four studies compared the rates between the early and late catheter removal groups. We could not get a pooled analysis due to significant heterogeneity, especially the variability of catheter duration between studies. However, a significant difference was reported in only one study, published by Daher et al., where they found a higher rate of 18% in the early removal group compared to 5% in the late removal group. Even after subgrouping the included studies according to the type of hypospadias of the included patients, as shown in Figure 3, there was no significant difference among different studies except for Daher's study. These results align with the literature, where the reported incidence of urethrocutaneous fistula following hypospadias repair falls between 6.2% and 38.8%[19]. Daher et al. suggested that the higher rates of fistulization in the early removal group were due to urinary leakage and a disrupted healing process. They concluded that leaving the catheter in place for a longer duration reduces the likelihood of complications, particularly fistulas. This is important because, although risk factors for fistula formation, such as urethral defect length and previous urethral surgeries, have been described, the duration of catheterization has not been specifically addressed in the literature.

Regarding meatal stenosis, although studies reported higher stenosis rates in the early removal groups, none of these differences reached statistical significance. Aslan et al. argue that the development of stenosis after urethral surgery is not necessarily related to the duration of stenting[15]. Early catheter removal allows the tissue to heal through re-epithelialization rather than concentric fibrosis, suggesting that early removal may actually reduce the risk of strictures or stenosis. Again, results were not different whether the included population was distal hypospadias or mixed.

Two studies[16,17] evaluated foreskin dehiscence with one of them featured distal hypospadias patients and the other one included proximal hypospadias patients and found a difference in dehiscence rates, but this difference was not statistically significant. These findings align with the literature, which reports that this complication occurs in 9%–17% of patients with severe hypospadias[32]. In a study by Snodgrass et al., proximal meatal location and a history of previous surgeries were identified as independent risk factors for the development of dehiscence[33]. However, they did not consider the duration of catheterization as a potential factor.

Urethral strictures are one of the most common long-term complications following hypospadias repair in childhood. Zhou et al. suggest that this complication typically arises early in the healing process and that prolonged stenting may help prevent it. This study included only proximal hypospadias patients[17]. Given the decreasing prevalence of strictures and no increase in other complications, they concluded that prolonged catheterization could reduce early strictures without raising the risk of other complications. However, their findings were not consistent with previous studies by Aslan et al. and Ritch et al.[15,20]. They argued that the risk of strictures does not increase when the catheter is removed on postoperative day one, as partial re-epithelialization can occur as early as 5 days, with full maturation and normal urothelium covering the defect by the 2-week mark.

Our aim was to conduct a meta-analysis of the included studies in order to provide accurate evidence and conclusion, but we found a significant heterogeneity and variability across methods, patient selection, type of hypospadias repair and duration of catheters in addition to follow-up duration. That's why we choose to only do a systematic review aiming at gathering the current evidence from the literature to guide future research. There is a need for a multicenter randomized controlled trial with standardized criteria to reach a solid conclusion.

5 CONCLUSION

There is an existing knowledge gap regarding the best urinary diversion and the optimal duration of catheterization in hypospadias repair. The available literature warrants further high-quality research. This includes conducting larger multicenter randomized trials to advance our understanding, aiming at improving the outcomes of hypospadias repair surgery.

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