Early versus late urethral catheter removal after kidney transplantation

What is the issue?
The ureter is a pipe that drains urine from the kidney into the bladder, where it is stored until patients go to the bathroom to pass urine. During a kidney transplant operation, the new kidney is placed inside the patient, and the new ureter is attached to the patient's bladder. During this procedure, a catheter is inserted through the urethra into the bladder and left in place following the operation. A catheter is a narrow flexible tube that allows urine to drain from the bladder. The catheter continuously drains urine and prevents the bladder from stretching. It is thought that by keeping the bladder empty, the connection between the new ureter and the bladder is able to heal better. However, catheters can introduce bacteria into the bladder and cause urine infections. The longer the catheter stays in the bladder, the greater the risk of getting an infection. Urine infections can be very troublesome for transplant patients, as they need to take medicines that suppress their immune system. These immunosuppressive medications mean patients find it very difficult to fight off infections. Currently, no one knows when the best time is for the removal of the catheter. We want to find this out so that we can minimise the risk of urine infections because of catheters whilst still giving the connection between the bladder and the new ureter the best possible chance of healing.

What did we do?
This study was designed to review all the previously published research in this area to determine the answer to this question. Two studies, including 197 people who have received a kidney transplant, were identified.

What did we find?
It is uncertain whether the number of patients with bacteria in their urine was different in patients whose catheter was removed less than five days after the operation compared with patients whose catheter was removed more than five days after their operation. The studies identified for this review were generally of poor quality.

We need a well-designed and high-quality study to investigate the best time for catheter removal in patients following their kidney transplant operation.

Authors' conclusions: 

A high-quality, well-designed RCT is required to compare the effectiveness of early catheter removal versus late catheter removal in patients following a kidney transplant. At the present time, there is insufficient evidence to suggest any difference between early and late catheter removal post-transplant, and the studies investigating this were generally of poor quality.

Read the full abstract...

The optimal treatment for end-stage kidney disease is kidney transplantation. During the operation, a catheter is introduced into the bladder and remains in place postoperatively to allow the bladder to drain. This decreases tension from the cysto-ureteric anastomosis and promotes healing. Unfortunately, urinary catheters can pose an infection risk to patients as they allow bacteria into the bladder, potentially resulting in a urinary tract infection (UTI). The longer the catheter remains in place, the greater the risk of developing a UTI. There is no consensus approach to the time a catheter should remain in place post-transplant. Furthermore, the different timings of catheter removal are thought to be associated with different incidences of UTI and postoperative complications, such as anastomotic breakdown.


This review aimed to compare patients who had their catheter removed < 5 days post-transplant surgery to those patients who had their catheter removed ≥ 5 days following their kidney transplant. Primary outcome measures between the two groups included: the incidence of symptomatic UTIs, the incidence of asymptomatic bacteriuria and the incidence of major urological complications requiring intervention and treatment.

Search strategy: 

We searched the Cochrane Kidney and Transplant Register of Studies up to 13 April 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov.

Selection criteria: 

All randomised controlled trials (RCTs) and quasi‐RCTs comparing timing of catheter removal post-transplantation were eligible for inclusion. All donor types were included, and all recipients were included regardless of age, demographics or type of urinary catheter used.

Data collection and analysis: 

Results from the literature search were screened by two authors to identify if they met our inclusion criteria. We designated removal of a urinary catheter before five days (120 hours) as an 'early removal' and anything later than this as a 'late removal.' The studies were assessed for quality using the risk of bias tool. The primary outcome of interest was the incidence of asymptomatic bacteriuria. Statistical analyses were performed using the random effects model, and results were expressed as relative risk (RR) with 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Main results: 

Two studies (197 patients) were included in our analysis. One study comprised a full-text article, and the other was a conference abstract with very limited information. The risk of bias in the included studies was generally either high or unclear.

It is uncertain whether early versus late removal of the urinary catheter made any difference to the incidence of asymptomatic bacteriuria (RR 0.89, 95% Cl 0.17 to 4.57; participants = 197; I2 = 88%; very low certainty evidence). Data on other outcomes, such as the incidence of UTI and the incidence of major urological complications, were lacking. Furthermore, the follow-up of patients across the studies was short, with no patients being followed beyond one month.