Panagiotis Mourmouris1*
Nikolaos Kostakopoulos2
Omer Burak Argun3
Ioannis Georgopoulos1Vasillios Klapsis1Nikolaos Pisiotis1Ioannis Salmas1
Tunkut Doganca4Sotirios Charamoglis1
- 1Urology Department, Metropolitan Hospital, Piraeus, Greece
- 2Urology Department, Metropolitan General Hospital, Athens, Greece
- 3Health Services of Vocational School, Medical Laboratory Techniques, Istanbul Kent University, Istanbul, Türkiye
- 4Department of Urology, Acibadem Taksim Hospital, Istanbul, Türkiye
Background: Robotic Radical Prostatectomy has become the dominant surgical approach for localized prostate cancer, offering offers many advantages in postoperative recovery and quality of life. Despite these advances, the standard duration of urethral catheterization- typically 7 days- has remained largely unchanged.
Objective: To systematically evaluate the feasibility and safety of early urethral catheter removal after robotic radical prostatectomy and to identify the optimal timing for catheter removal.
Methods: A systematic review was conducted according to PRISMA guidelines. PubMed, Web of Science, Cochrane Library, Google Scholar and Scopus databases were searched from inception to August 2025. Case reports, non robotic studies and non English publications were excluded Study quality was assessed using the Newcastle-Ottawa Scale for non randomized studies and the Jadad scale for randomized controlled trials.
Results: Thirteen studies involving 4.055 patients met inclusion criteria, including three randomized controlled trials. Early catheter removal was variably defined, most commonly between 1 and 4 post operative days. Across studies early removal was not associated with increased rates of anastomotic leakage, urethral stricture or bladder neck contracture. Continence recovery seams to be occur earlier with early removal although higher short term urinary retention rates were reported. Overall complications and readmission rates were low. Study quality was acceptable despite the limited evidence from high quality randomized studies.
Conclusions: Early catheter removal after robotic radical prostatectomy appears both safe and feasible in appropriate selected patients and may accelerate continence recovery without compromising long-term outcomes. Catheter removal on postoperative days 3-4 appears to offer the most favora.
Introduction
Prostate cancer (PCa) is currently the second most prevalent cancer in men with approximately 1.5 million new cases worldwide in 2020 (1). Its management has been revolutionized by the use of the robotic platform which had rapidly increased to a stunning 85% in 2012 in the USA (2). Robotic radical prostatectomy (RRP) offers several advantages over open prostatectomy due to its minimally invasive nature including reduced pain and discomfort, faster recovery and improved quality of life -benefits that may be further enhanced by early removal of the indwelling folley catheter (3). Reports indicate that in nearly 50% of patients undergoing radical prostatectomy, catheter may cause more pain and discomfort than the incision itself (4).
Despite the potential benefits that early catheter removal provides, the standard of care of 7 days doesn't seem to change even in high volume centers (3). However, some surgeons have questioned this standard of care, removed the catheter earlier and published their results. The basic concerns of anastomosis leakage and urethral stenosis have been addressed in these studies. This is the first systematic review to evaluate the feasibility and safety of early catheter removal with primary goal of determining the optimal timing of the catheter removal after robotic radical prostatectomy.
Material and methods
Design and inclusion criteria
Our systematic review was performed according to PRISMA guidelines (5). For this study Institutional Review Board approval was not required. We included in our systematic review: original prospective or retrospective studies, randomized or non-randomized, published in peer reviewed journal, having at least an abstract, in English language, from inception until 2025 whereas we excluded, case reports and case series, comments as well as studies not reporting robotic cases.
Search strategy
A systematic search of available literature was conducted in August 2025, in PubMed, Web of Science, Cochrane library, Google scholar and Scopus databases. The research question structured according to PICO criteria, focused on men with localized prostate cancer (P), who underwent robotic radical prostatectomy (I), with comparison of different indwelling catheter removal times (C), to evaluate functional outcomes for patients (O).
A combination of related keywords waw used for the search: (Robotic prostatectomy) AND ((Catheter removal time) OR (indwelling catheter) OR (optimal catheter) OR (optimal catheter removal time)). Title screening was independently performed by two authors manually (NK & PM) and consensus among all the authors resolved any discrepancies. After duplicates were removed and non-English studies were excluded, relevant studies were assessed for eligibility, by being subjected to a full-text review, before being included in the systematic review.
Data extraction and quality assessment
Data extraction was performed using a standardized form shared by both reviewers. Baseline preoperative characteristics of the patients were recorded and also the relevant intra and post operative information were extracted. Complications were graded according to the Clavien-Dindo system (6). The quality of the non-randomized studies was assessed with the NewCastle-Ottawa Quality Assessment Tool(NOS) (7), with a total score 5 or less to be considered as low quality, a score of 6–7 intermediate and a score of 8 and above was considered as high quality. For randomized controlled trials we the Jadad Scale (8) was used.
Results
Our search yielded 724 papers, of which 699 were excluded after reviewing titles and abstracts. Of the remaining 33 articles 6 duplicates and 2 non-English studies were excluded, leaving 25 articles for full-text analysis. 13 studies met the inclusion criteria and were finally included in our study. The flowchart of our search is presented in Figure 1.
Figure 1. PRISMA flowchart.
Among the studies included, there were three randomized control trials (RCTs), five nonrandomized prospective trials and the remaining 6 were retrospective. A total of 4,055 patients were enrolled in these trials. The nonrandomized studies scored more than 7 in the NOS score whereas the two RCT scored 1 and 2 in the Jadad scale, finding suggesting that the overall quality of included studies was acceptable. Quality assessment of the studies that were included in our analysis is shown in Table 1.
Table 1. Patients basic characteristics and quality assessment of included studies.
Discussion
Indwelling catheter removal is considered one of the most important steps of the robotic radical prostatectomy that may significantly influence both functional outcomes and complications rates. Surgeons main concerns include anastomotic leakage with potentially devastating results, ureteral stricture, urinary retention requiring readmission or reoperation and of course the duration and severity of postoperative urinary incontinence. Although several studies support early catheter removal, many surgeons remain hesitant to adopt this practice and alter their standard post operative plan.
Definition of early catheter removal
It does not seem to be a consensus about the definition of early removal. There are studies that report removal of the catheter as early as post operative day (POD) 1 (9, 10), others POD 2 (11–14) and others on POD 3–4 (15–18). The list of the available studies is completed with few surgeons that point the early removal on POD 7 or later (19, 20). Most studies compare early vs. late removal, while some report outcomes of early removal without any direct comparison with group of late removal. Based on the published data, catheter removal on POD 3–4 appears to be the safest and most representative timing for early removal.
Preoperative patient's characteristics
Across all studies, groups were matched for key preoperative factors that may influence the final outcomes (BMI, PSA, Gleason Score, stage, prostate volume) with no statistically significant differences (10, 14, 18). Most patients were relatively young (57–65 years old), had a BMI of 25–27 kg/m2 and small to moderate prostate size (40–50 mL) (9–12, 14–20). The majority of included patients were operated for local or locally advanced cancer (T2 to T3a) with ISUP 1–3 and with no important lower urinary tract symptoms (IPSS 4–8) (11, 13–15).
The patients that were selected for inclusion in these studies represent the typical patient prostate cancer population that is commonly undergo robotic radical prostatectomy; therefore, and the reported outcomes are applicable to most urologic practices. We recommend that surgeons adopting early catheter removal begin with patients who have smaller prostate glands with low volume and organ confined disease. Baseline characteristics of patients are presented in Table 1.
Perioperative and postoperative outcomes
Most studies did not emphasize perioperative outcomes focusing instead on complications and long-term outcomes after the early removal of catheter. Available data indicate no difference in estimated blood loss (EBL) (9, 11, 13, 15, 18) or operating time (12, 15, 17) between groups suggesting comparable surgical quality. However, the randomized control study (RCT) by Lista et al, reported a significantly shorter hospital stay for early removal (4 days vs. 6 days p < 0.001) (18). Importantly, the rate of anastomotic leakage (after catheter removal) was very low (0.9%–2%) (12, 14) and it does not seem to differ between early and standard of prolonged removal (9, 17, 18, 21). In our opinion this is one of the main outcomes (along with rates of continence, ureteral stricture or bladder neck contracture, retention and readmission) that can help to turn the tide towards early removal, and it seems to be in favor of early catheter removal. Despite the fact that the only data we have for readmission of patients comes from one study, the rate of readmission seems to be as low as 4.3% another factor that implies that early removal of the catheter is safe and efficient (12). The outcomes are shown in Table 2.
Table 2. Perioperative and postoperative characteristics of included patients.
Functional outcomes
Key outcomes influenced by catheter removal timing include continence recovery, potency and of course the long-term ureteral stricture (or bladder neck contracture) formation. The data for continence are very revealing: continence recovery occurs sooner with early catheter removal, whereas prolonged catheterization may have a negative long-term impact (14, 20). Immediate continence rated after early removal seems to be as high as 86% and increases to 90% in 3rd postoperative month (9). These data are reinforced from the study of Hao et al, with a rate of 63% of immediate continence after POD 2 and only 46% for the standard POD 7 (19). Nevertheless these outcomes come with the cost of higher urinary retention rates which are reported at 11%–13% (12, 13) and with a clear disadvantage for the groups of early removal (1.5 vs. 9.5% p < 0.01) (17). In this point we must stress the fact that this complication does not have an impact on any long term outcomes, including urethral stricture or bladder neck contracture since all studies did not find any statistical significant difference between the analyzed patients (14, 16, 18, 20, 21).
Pain scores and quality of life
Pain and discomfort from indewelling catheterization remain major postoperative complaints and are often cited as reasons for early removal. The main goal of a minimal invasive procedure is to decrease pain and discomfort of the patient and enable him to return to his everyday life more rapidly.
Although available data are limited, one study reported no statistical significant differences in pain scores (urethral, perineal and abdominal VAS scores) between POD 2 and POD 7 (13). A very interesting finding, however, comes from the study of Prasad et al. who compared patients with early catheter removal but with the presence of suprapubic catheter (SPT). Even though there were no important differences in pain and discomfort scales, when patients were asked about how bothersome is the (indwelling)) catheter, in POD 0 only 21% of the patients answered greatly (with 21% in the SPC group) whereas in POD7 the rate was 41% (vs. 25% in the SPC group). This directly implies that the discomfort is increasing according to the days of catheterization.
Conclusions
Although current evidence remains limited, early urethral catheter removal after robotic radical prostatectomy appears to be both safe and feasible. Surgeons considering this approach should begin with patients with organ-confined disease, low to moderate prostate volume disease and counsel them regarding potential short-term disadvantages. With careful patient selection early removal can enhance the minimal invasive benefits of robotic prostatectomy.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author/s.
Author contributions
PM: Conceptualization, Formal analysis, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing. NK: Conceptualization, Formal analysis, Methodology, Validation, Writing – original draft, Writing – review & editing. OA: Data curation, Visualization, Writing – review & editing. IG: Supervision, Validation, Visualization, Writing – review & editing. VK: Resources, Software, Validation, Writing – review & editing. NP: Methodology, Supervision, Validation, Visualization, Writing – review & editing. IS: Software, Validation, Writing – review & editing. TD: Project administration, Visualization, Writing – review & editing. SC: Supervision, Visualization, Writing – review & editing.
Funding
The author(s) declared that financial support was not received for this work and/or its publication.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Keywords: catheter, complications, prostate cancer, robotic radical prostatectomy, surgery
Citation: Mourmouris P, Kostakopoulos N, Argun OB, Georgopoulos I, Klapsis V, Pisiotis N, Salmas I, Doganca T and Charamoglis S (2026) Optimal urethral catheter removal time after robotic radical prostatectomy: a systematic review of the current evidence. Front. Surg. 12:1731485. doi: 10.3389/fsurg.2025.1731485
Received: 24 October 2025; Revised: 16 December 2025;
Accepted: 18 December 2025;
Published: 15 January 2026.
Edited by:
Maria Angela Cerruto, Integrated University Hospital Verona, ItalyReviewed by:
Evangelos N. Symeonidis, European Interbalkan Medical Center, GreeceSebastian Lenart, St. John of God Hospital Vienna, Austria
Copyright: © 2026 Mourmouris, Kostakopoulos, Argun, Georgopoulos, Klapsis, Pisiotis, Salmas, Doganca and Charamoglis. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Panagiotis Mourmouris, dGhvZG9yb3MxM0B5YWhvby5jb20=