Urological procedures: catheters, TURP and nephrectomy

• An indwelling urinary catheter is a drainage tube left in the bladder until it is no longer needed; the safest catheter is the one that is truly indicated, inserted aseptically, maintained in a closed system and removed at the first opportunity.
• Transurethral resection of the prostate (TURP) removes tissue from the transition zone to relieve bladder outflow obstruction caused by benign prostatic enlargement; monopolar TURP was for decades the reference operation, while bipolar (saline) TURP achieves similar symptom relief with lower bleeding and no TURP syndrome.
• Cystoscopy is the direct visual inspection of the urethra and bladder and is one of the commonest procedures performed by urologists; it is usually safe, and serious complications are rare.
• A ureteric (double-J) stent keeps the ureter open when there is obstruction, stone passage or a risk of stricture, but it commonly causes pain, urinary frequency and sometimes infection.
• Nephrectomy ranges from partial, kidney-preserving surgery for small renal cancers to radical removal of kidney and surrounding tissue for larger tumours; the kidney with cancer is preserved wherever oncological safety allows. ^[2]
• Radical cystectomy with pelvic lymph node clearance is the standard operation for muscle-invasive bladder cancer (T2 to T4a, N0M0 disease) and is accompanied by urinary diversion, usually an ileal conduit. ^[3]

By the end of this page you should be able to:

1. List the main types of urinary catheter, state their indications, and choose appropriate size and material.
2. Explain when a catheter should be avoided, how it should be inserted and maintained safely, and when it should be removed.
3. Describe the indication, technique, and main complications of suprapubic catheterisation.
4. Outline the indications, expected outcomes, and principal risks of monopolar and bipolar TURP, including the cause and management of TURP syndrome.
5. Describe cystoscopy and state its common indications and complications.
6. Summarise the indications, materials and complications of ureteric stenting.
7. Explain the indications for partial versus radical nephrectomy and the oncological and functional reasons that drive the choice.
8. Outline cystectomy and the forms of urinary diversion, including the trade-offs of ileal conduit, orthotopic neobladder and continent diversion.

These procedures share a common principle: they solve an obstruction or remove a tumour while disturbing as little healthy anatomy as possible. The urinary tract is continuous from kidney to urethral meatus, so a decision about one part affects the rest: a long-term catheter alters infection risk in the bladder, outflow surgery can affect continence, and major renal surgery is judged on whether the cancer is cured without precipitating kidney failure.

This page is written for the clinical years. It covers disease management, not individual operative detail, and follows current EAU, EAUN, NICE and CDC recommendations where they are open to review. NICE and EAU differences are stated plainly when they matter.

A urinary catheter is a tube that sits in the bladder and drains urine to the outside. The EAU-associated nurse guideline lists the contexts in which indwelling catheters are met in ordinary practice: urinary retention or bladder outlet obstruction, accurate fluid monitoring in critically ill patients, selected perioperative care, some situations of prolonged immobilisation, wound care in incontinence, and comfort at the end of life. The CDC list of appropriate indications is similar and also includes structural genitourinary surgery and anticipated prolonged operating times.^[4][7]

Catheterisation should be used only after considering alternatives, and the need should be reviewed and the catheter removed as soon as it is no longer needed.^[6] There is a strong association between the length of time a catheter stays in place and the risk of infection. Catheters are also sometimes inserted inappropriately, or removed late.^[4][6]

• Intermittent (short-term) catheter: passed into the bladder, drains it, and is removed straight away. Preferred over an indwelling catheter when the problem is incomplete emptying rather than a need for continuous drainage.^[7]
• Indwelling urethral catheter (Foley type): a catheter held in the bladder with a small balloon, connected to a drainage bag. NICE quality standard QS61 defines short-term use as 28 days or less and long-term use as more than 28 days; other infection-control sources define short-term use as less than 30 days in situ and long-term use as 30 days or more.^[6][12]
• Suprapubic catheter: a catheter inserted through the lower abdominal wall directly into the bladder, used when the urethra is damaged or blocked, or when intermittent catheterisation cannot be used.^[9]
• External (condom) catheter: a sheath worn over the penis for cooperative men without urinary retention or bladder outlet obstruction; it avoids urethral instrumentation but is not suitable when the bladder needs to be emptied.^[7]
• Three-way (irrigating) catheter: has an inflow channel for sterile irrigation; used mainly after transurethral surgery when bleeding and clot retention are expected.

Catheter size is given in French gauge. As a guide, the smallest bore consistent with good drainage should be chosen to minimise urethral trauma. ^[7] Adult indwelling catheters are usually changed at least every three months, but should be changed on clinical indications such as infection, obstruction or a broken closed system, rather than at a fixed routine interval.^[7][9]

Material matters for long-term catheters. Silicone may be preferable to other materials to reduce encrustation in patients who have frequent blockage. Hydrophilic intermittent catheters may be preferable to standard catheters for patients who require chronic intermittent drainage. Antimicrobial- or antiseptic-impregnated catheters are reserved for situations where a comprehensive prevention bundle has failed to bring the infection rate down.^{[7] [5] [4]}

Safe catheterisation is a bundle, not a single ritual. Appropriate points from the NICE quality statement and the CDC guideline are:

1. Assess whether catheterisation is truly needed, review the need regularly, and document insertion, changes, care and removal.^[6]
2. Perform hand hygiene immediately before and after insertion or any manipulation of the catheter or drainage system; wear gloves.^[6][7]
3. Insert using aseptic technique with sterile equipment in acute care.^[7]
4. Clean the meatus before insertion according to local policy, using sterile saline or an antiseptic solution.^[6][7]
5. Use an appropriate lubricant from a single-use container to minimise urethral trauma and infection.^[6]
6. Secure the catheter properly to prevent movement and urethral traction.^[7]
7. Keep the drainage bag below the level of the bladder, off the floor, and empty it with a separate clean container for each person; avoid contact between the drainage tap and the container.^[6]
8. Obtain urine samples from the sampling port using an aseptic technique.^[6]
9. Wash the meatus daily with soap and water as part of normal hygiene; antiseptic meatal cleaning is not recommended once the catheter is in place.^[6][7]
10. Keep the closed drainage system unbroken unless there is a clinical reason. Routine irrigation with antimicrobials or instillation of antiseptic solutions is not recommended; clamping before removal is unnecessary.^[7]

For operative patients who have an appropriate indication, remove the catheter as soon as possible after surgery, preferably within 24 hours, unless there are good reasons to continue.^[7]

Catheter-associated urinary tract infection is one of the most common healthcare-associated infections, and 70 to 80% of these infections are attributable to the use of indwelling urethral catheters.^[4] In European surveys 17.5% of patients in 66 hospitals had a urinary catheter; in a United States survey 23.6% of patients in 183 hospitals had one.^[4] Infection risk rises with duration of catheterisation, but it is not the only hazard. Urethral trauma (false passage, urethritis, meatal injury) is usually caused by forcing the catheter or inflating the balloon in the urethra; encrustation can block the catheter and cause bypassing; and bladder spasms, latex sensitivity and inadvertent balloon injury are recognised. Good technique (lubrication, no force, securing the tube, appropriate sizing) prevents most of these.

In a cooperative male patient without retention or outflow obstruction, an external catheter avoids urethral instrumentation altogether. In spinal or neurogenic bladder emptying disorders, intermittent catheterisation is preferred to any indwelling catheter. Suprapubic and external catheters are alternatives, but their relative risks are not fully resolved by trials.^[7]

A suprapubic catheter is inserted through the lower abdominal wall a few centimetres above the pubic symphysis directly into the bladder, usually under local, regional or general anaesthesia. It is used when the urethra is damaged or blocked, or when a patient cannot use an intermittent catheter.^[9] It still enters the bladder, so it is a catheter rather than a diversion: it drains urine, it does not treat the underlying cause.

Considerations:

• The tract takes weeks to become epithelialised and stable; a newly placed catheter should not be changed early without care, and a suprapubic catheter that comes out must be replaced urgently before the tract closes.^[9]
• When the bladder is difficult to locate, image guidance is used to make sure there is no loop of bowel between the bladder and the abdominal wall.^[9]
• A catheter of appropriate size with a small balloon is commonly used for replacement; sterile water inflates the balloon.
• Compared with urethral catheters, suprapubic catheters are generally more comfortable for long-term drainage, avoid interference with sexual function, are easier to change, and may be associated with fewer catheter-associated infections, but good evidence for superiority is still lacking and insertion carries its own risk (bleeding, bowel injury, infection).^[7]
• Patients still get bladder spasms and bypassing, and the catheter blocks and encrusts just like a urethral one.
• For patients in whom the urethra is traumatised or structurally unsuitable, a suprapubic tube may need to stay in long term, with the same surveillance as any indwelling catheter.

The prostate is a gland wrapped around the prostatic urethra just below the bladder. In benign prostatic enlargement the transition zone grows and compresses the channel, producing lower urinary tract symptoms: hesitancy, weak stream, intermittency, frequency, urgency, nocturia and, eventually, acute retention. Transurethral surgery relieves this obstruction without an abdominal incision by resecting or enucleating tissue through the urethra using a resectoscope.

TURP should be considered when bothersome moderate-to-severe symptoms do not improve with conservative or medical treatment, or when complications such as recurrent urinary tract infection, haematuria, bladder stones or renal impairment from outflow obstruction occur. It is an endoscopic resection of the transition zone, and it produces a substantial improvement in urinary flow and symptom scores.

From the 2026 EAU guideline on male lower urinary tract symptoms:

• the procedure removes tissue from the transition zone in various degrees, resulting in a volume and prostate-specific antigen reduction of 25 to 58%.^[1]
• In a meta-analysis of 20 randomised trials with up to five years of follow-up, monopolar TURP produced a mean Qmax improvement of about 162%, with around 70% reduction in International Prostate Symptom Score, 69% improvement in quality of life and 77% reduction in post-void residual volume.^[1]
• Monopolar TURP delivers durable outcomes over 8 to 22 years, and retreatment with a further resection occurs at a fairly constant annual rate of 1 to 2%.^[1]

Monopolar TURP (M-TURP) uses electrical current passed through irrigating fluid (classically glycine) to a diathermy plate on the patient's skin. It is effective but demands time: as surgical duration rises complications increase, and it is safest when performed in under 90 minutes. Prostate size for M-TURP is usually 30 to 80 mL.^[1]

Bipolar TURP (B-TURP) completes the circuit locally and uses normal saline for irrigation, which removes the risk of TURP syndrome. Its medium-term efficacy is similar, and its perioperative safety profile is better:

• bleeding requiring transfusion, clot retention and hospital stay are all lower.^[1]
• The largest meta-analysis found TUR-syndrome and transfusion events lower by about 20 and 28 events per 1,000 patients compared with monopolar TURP.^[1]
• B-TURP can be offered to patients on antiplatelet therapy with acceptable bleeding, but the data for oral anticoagulation are less reassuring.^[1]

The choice between monopolar and bipolar TURP is usually driven by equipment availability, surgeon's experience and patient preference.^[1]

The EAU 2026 figures are worth knowing precisely, because exam questions often disguise them:

• perioperative mortality and morbidity of M-TURP remain considerable: about 0.1% perioperative mortality and about 11.1% morbidity.^[1]
• In an Austrian nationwide cohort of over 41,000 M-TURP procedures, 30-day mortality fell to 0.1% and 90-day mortality to 0.5%; retreatment rates (re-TURP, urethrotomy or bladder neck incision) were 0.9%, 3.7%, 9.5% and 12.7% at three months, one, five and eight years, and re-TURP itself occurred in 0.8%, 2.4%, 6.1% and 8.3% at those times.^[1]
• TUR syndrome is reported as under 1.1% of M-TURP cases in the EAU 2026 non-neurogenic male LUTS guideline and as about 2.4% (24 per 1,000) of monopolar TURP cases in the Cochrane review of 44 randomised trials, reflecting different study sets; bleeding requiring transfusion occurred in 2.9% of 10,654 procedures.^[1][11]
• Pooled short- to mid-term complications with M-TURP were: transfusion 2% (range 0 to 9%), TUR syndrome 0.8% (0 to 5%), acute urinary retention 4.5% (0 to 13.3%), clot retention 4.9% (0 to 39%) and urinary tract infection 4.1% (0 to 22%). The EAU 2026 pooled TUR syndrome estimate of 0.8% (0 to 5%) is lower than the about 2.4% baseline TUR syndrome rate reported by the Cochrane review of 44 randomised trials, and the two are not directly comparable because they pool different sets of studies.^[1][11]
• Long-term complications include urinary incontinence, urinary retention, urinary infection, bladder neck contracture, urethral stricture, retrograde ejaculation and erectile dysfunction.^[1]
• Retrograde ejaculation is common after TURP and patients should be told about it before consent.

Elderly patients (over 80 years) having TURP had more complications than those having holmium laser enucleation of the prostate in one retrospective study, including postoperative haematuria and transient retention; this is one reason the EAU 2026 document presents laser enucleation as an alternative, not just a fallback.^[1]

TURP syndrome is the systemic consequence of absorbing large volumes of non-physiological irrigating fluid through the prostatic venous sinuses. In monopolar TURP the irrigating medium was electrolyte-free (usually glycine 1.5%), so absorption caused dilutional hyponatraemia, fluid overload and, rarely, death. Bipolar (saline) and laser techniques largely avoid it because saline is not hypotonic.

Clinical picture:

• timing is from about 15 minutes after resection starts to 24 hours after operation.^[10]
• Headache, facial or hand burning, restlessness, anxiety, nausea and tachypnoea progress to bradycardia, hypertension then hypotension, visual disturbance, confusion, convulsions, pulmonary oedema and coma. Hyponatraemia and an increased osmolar gap from absorbed glycine are the measurable markers.^[10]
• Glycine itself can cause hyperglycaemia, hyperammonaemia and transient blindness.
• Hypothermia can occur because large volumes of fluid are absorbed.

Management principles (educational summary):

• tell the surgeon, stop irrigation, complete haemostasis, and stop or finish the procedure early.
• Assess volume status; a diuretic (furosemide) and fluid restriction are used when overload dominates, and hypertonic saline is reserved for severe or symptomatic hyponatraemia, with close sodium monitoring.
• Check electrolytes, glucose, ammonia, arterial oxygen and imaging for pulmonary oedema.
• Prevention is the real treatment: limit resection time, keep irrigation pressure low, use bipolar (saline) technique, monitor fluid balance, and consider ethanol in the irrigant or expired breath ethanol monitoring where that system is in use.^[1]

Cystoscopy is the direct visual examination of the urethra and bladder using a cystoscope. It is one of the most frequently performed procedures in urology and serves diagnosis, biopsy, stone removal, stent placement and surveillance. In most cases it needs no general anaesthesia.

Common indications include haematuria, recurrent or unexplained infection, surveillance of bladder cancer, outflow symptoms, suspected urethral stricture, incontinence assessment and the evaluation of structural bladder or ureteric problems.^[8]

The NHS describes complications as usually minor and rare: there is a small chance of a urinary tract infection, problems emptying the bladder because of swelling, and very rarely damage to the bladder. Patients who cannot pass urine, have heavy or persistent bleeding, fever or worsening pain need urgent review.^[8]

The EAU documents on muscle-invasive and non-muscle-invasive disease use cystoscopy both to diagnose and to follow up bladder cancer, including restaging after treatment and surveillance after transurethral resection. High-level disinfection of the instrument, sterile equipment and patient-level informed consent remain standard.^[3]

A ureteric stent (usually a double-J stent) is a hollow tube with coiled ends that sits between renal pelvis and bladder; it maintains ureteric patency when obstruction, stricturing or surgical trauma threatens urine flow. A useful review of the subject lists the reasons it is placed: to facilitate passage of stone fragments, to prevent ureteric obstruction or delayed stricture, to drain an obstructed infected kidney in an emergency, and to passively dilate the ureter before a later procedure.^[5]

Stents are commonly 12 to 30 cm in length and 4.5 to 18 French in diameter. Double-J stents have a J coil at either end to resist migration; other shapes exist (tail, pigtail-suture, metallic spiral, mesh, magnetic-tipped) for particular indications, and magnetic-tipped ends make removal easier.^[5]

Material selection balances durability and tolerance. Silicone has the lowest encrustation rate and is probably the best choice for stone disease after ureteroscopy; polyurethane drains well but encrusts more readily; metallic stents resist compression and can stay in place for one to three years, although their ideal replacement is nearer six months. Hydrophilic and drug-eluting coatings are options, but the evidence behind most coatings is mixed.^[5]

Complications and patient experience:

• encrustation, microbial colonisation and symptomatic urinary infection are the main problems.^[5]
• Stent-related symptoms (pain, frequency, urgency, haematuria) are common and depend on position and material; smaller-diameter stents may cause fewer symptoms.^[5]
• A retained stent can become heavily encrusted and be very difficult to remove; stents should be tracked and either removed or replaced on time.
• Ureteric stenting is less comfortable for most patients than a stone-free state, and fluid intake, analgesia and timely removal matter as much as the equipment.

In a distressed, infected, obstructed patient a stent (or nephrostomy) is an emergency decompression, not a definitive treatment.

For localised renal cell carcinoma, surgery is offered to achieve cure. For T1 tumours, partial nephrectomy is the preferred approach because it better preserves kidney function and may reduce long-term cardiovascular risk without compromising cancer control. For T2 tumours without the possibility of partial nephrectomy, laparoscopic or robotic radical nephrectomy is offered. Partial nephrectomy is extended to T2 tumours in a solitary kidney or chronic kidney disease when it is technically feasible.^[2]

In a solitary unit or a patient with chronic kidney disease, nephron-sparing surgery can be life-sustaining even for larger tumours; the decision weights renal function against oncological risk.^[2]

The EAU 2026 document argues that minimally invasive radical nephrectomy should not be performed for a T1 tumour where partial nephrectomy is feasible by any route, including open. Adrenalectomy should not be performed unless there is clinical evidence of adrenal invasion. Routine lymph node dissection in organ-confined disease has not been shown to improve survival. Embolisation is used palliatively for massive haematuria or flank pain in patients unfit for surgery.^[2]

• Laparoscopic radical nephrectomy has lower morbidity than open, with equivalent short-term oncological outcomes for T1 to T2a tumours.^[2]
• Robotic and laparoscopic partial nephrectomy are associated with shorter hospital stay and less blood loss than open surgery; approach should follow surgeon expertise.^[2]
• Postoperative drains: the evidence suggests that omitting a drain after standard partial or radical nephrectomy is not associated with increased complication rates and may shorten hospital stay, although the data are mostly observational.^[2]
• Once pathology shows a positive surgical margin, a microscopic margin does not necessarily need immediate completion nephrectomy or re-resection; follow-up is intensified instead, because only a minority of patients with positive margins develop recurrence.^[2] A positive surgical margin is found in about 2 to 8% of T1 partial nephrectomies, and even negative margins do not guarantee freedom from recurrence (up to about 1.5%).^[2]

Radical cystectomy is offered to patients with muscle-invasive bladder cancer (T2 to T4a, N0M0 disease) and, in selected cases, to people with very high-risk or treatment-refractory non-muscle-invasive disease. In men the operation removes bladder, prostate, seminal vesicles, distal ureters and regional lymph nodes.^[3]

The choice of urinary diversion shapes the rest of the patient's life:

• Ileal conduit (urostomy): a short loop of ileum brings urine to a stoma on the abdominal wall; a bag is worn. This is the commonest, most predictable option. Early complications (within 30 days) include urinary infection, pyelonephritis, ureteroileal leak and stenosis, reported in nearly half of patients in some series.^[3]
• Orthotopic neobladder: a bladder substitute built from ileum, connected to the urethra so that the patient voids through the natural route. Age above 80 is often taken as a relative cut-off, but there is no absolute age barrier. Continence, especially at night, and the ability to empty, require motivated, able patients and meticulous surgery; conversion or explantation is occasionally needed.^[3]
• Continent cutaneous diversion: a reservoir emptied by self-catheterisation, now used rarely because of stoma stenosis and incontinence; sigmoid diversion is rarely used because of high infection and stone rates.^[3]
• Ureterocutaneostomy: the ureters open straight on to the skin; it is technically the simplest operation and is preferred in very frail patients or those with a solitary kidney needing supravesical diversion, but stenosis and ascending infection are more common because of the small ureteric diameter.^[3]

The segments that can be used include ileum, colon and appendix, with ileum used in most cases. Randomised trials comparing conduit with neobladder or continent diversion have not been done, so the decision rests on comorbidity, cardiac and pulmonary function, cognitive ability, social support and patient preference rather than on hard evidence.^[3]

The operation is demanding: reported 90-day mortality is about 11% in patients aged 80 and over, compared with about 2% in younger patients, and early readmission is common. Centralisation (at least 10, and preferably more than 20, radical cystectomies per hospital per year) is strongly associated with lower mortality and fewer complications, and venous thromboembolism prophylaxis with low-molecular-weight heparin should begin on the first postoperative day for four weeks.^[3]

Neobladder and ileal conduit have similar oncological results. Most forms of continent diversion require the patient to be able to manage self-catheterisation and to accept the possibility of catheterisation in the long term.^[3]