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© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Long-Term Outcomes Following  
Surgical Management of Urethral  
Catheter Injuries in Men With  
Spinal Cord Injury 

Kirtishri Mishra,1,2 Rodrigo A. Campos,3 Laura Bukavina,1,2 Reynaldo G. Gómez 3

1 Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, United States 2 Case Western Reserve University School of Medicine, Cleveland, 
United States 3 Urology Service, Hospital del Trabajador, Santiago, Chile

Abstract

Introduction To evaluate the outcomes of surgical management of men with spina cord injury (SCI) with 
subsequent catheter damage to the urethra that prevents clean intermittent catheterization (CIC).

Materials and Methods We performed a retrospective analysis of male SCI individuals on CIC with catheter-
induced urethral injuries who had undergone an operative intervention in the last 30 years at our institution. The 
offered surgical managements were direct vision internal urethrotomy (DVIU) or urethroplasty (UP). Continent 
diversion (CDIV) was indicated when reconstruction was not possible.

Results A total of 43 male SCI patients were identified. Median age was 50 years (IQR 41 to 57), and follow-up was 
69 months (IQR 34 to 125). Inability to perform CIC was due to urethral stricture (25), false passages (11), fistula 
(4), diverticulum (2), and urethral erosion (1). Primary intervention techniques were DVIU, UP, and CDIV. Overall 
primary success, defined by the ability to return to continent CIC, was 25/43 (58%); secondary surgery (10 CDIV,  
3 UP, 1 DVIU) rescued 14/18 failures for a final 91% success rate. 

Conclusion Urethral injuries in men with SCI are complex, but individualized continued surgical management can 
be successful in up to 90% of patients. Therefore, reconstruction should be considered in this population to restore 
continent intermittent catheterization.

Introduction

Urologic care in individuals with a history of spinal cord injury (SCI) continues to pose a medical challenge for 
urologists[1–5].There are advantages and disadvantages to each approach the provision of urologic care for a patient 
with a neurogenic bladder. Since its introduction in the early 1970s by Lapides and Diokno, clean intermittent 
catheterization (CIC) has become the mainstay for the management of neurogenic bladder in the SCI population[6,7]. 
Before the routine use of CIC, the leading cause of death in these patients was renal failure and urinary sepsis[2,8,9]. 
Those patients with an open sphincter/external sphincterotomy were managed with a condom catheter, and those 
with a closed sphincter were subjected to a chronic indwelling catheter, with urinary diversion being the most invasive 
option[1]. 

Key Words Competing Interests Article Information

Catheter urethral injury, urethral 
reconstruction, urethroplasty, intermittent 
catheterization, neurogenic bladder, spinal 
cord injury, reconstructive urology

None declared. Received on January 11, 2021 
Accepted on April 3, 2021

Soc Int Urol J.2021;2(3):144–150

DOI 10.48083//AGBN5610

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While condom catheters, indwelling catheters, and 
CIC are all efficacious in appropriately selected patients, 
they each have their own shortcomings[10]. A condom 
catheter can lead to a diverticulum, stricture, or erosion, 
a chronic indwelling catheter may lead to erosion and 
recurrent urinary tract infections, and CIC can lead to 
a false passage, stricture, or a fistula. In fact, numerous 
studies indicate that with a long enough course of 
chronic instrumentation and repeated trauma, most 
of these patients suffer some degree of catheter related 
complication[10–12]. 

In our practice at a large volume SCI rehabilitation 
referral center, we strongly advocate for maintaining 
urinary continence by means of CIC, instead of 
incontinent condom catheter or chronic indwelling 
catheters. However, as may be expected, over time the 
urethra is at risk for damage and complications[12]. 
Within the reconstructive field, there is continued debate 
about the utility of reconstruction in these patients, with 
some providers arguing that there is a high likelihood of 
failure[13,14]. Therefore, incontinent urinary diversions, 
such as an ileal conduit or an indwelling catheter, are 
used instead of reconstructive options. However, we 
believe that there is a benefit in restoring continent CIC, 
minimizing the use of indwelling catheters or external 
appliances, particularly for individuals with SCI who are 
already self-conscious about their appearance.

The goal of this study was to evaluate our experience 
of more t ha n 30 yea rs to determi ne whet her 
interventions to restore continent CIC in these patients 
provides a durable option for urinary management. 
We hy pot hesize t hat cat heter-induced uret hra l 
complications in SCI patients can be successfully 
managed with a selective surgical approach that can 
restore continent CIC and that should be routinely 
considered in this population.

Materials and Methods
With the approval of the Institutional Review Board 
(CEC/12/2020), we undertook a retrospective review 
of SCI patients with surgically managed with DVIU, 
UP, or CDIV and subsequent catheter urethral injuries 
from March 1988 to December 2019. Additional patient 

inclusion criteria were age >18 years and complete 
medical records and >10 months of follow-up. The 
procedures were performed by 6 different surgeons with 
half of the cases being performed by RGG.

Our institution is a high-volume tertiary referral 
center for trauma and rehabilitation, specializing in 
work-related injuries. After trauma stabilization, SCI 
patients are admitted to a comprehensive rehabilitation 
program that includes regular annual visits for life 
after discharge. Urological management is based on 
CIC, and able patients are quickly instructed in self-
catheterization. Baseline urodynamics and upper 
tract imaging are performed at the end of the spinal 
shock; afterwards, patients are followed with lifelong 
regular visits as required. Treatment is oriented to 
obtain a good capacity and low-pressure continent 
bladder. Anticholinergics, botulinum toxin, bladder 
augmentation, or sphincter reinforcing procedures are 
indicated as needed. Long-term periodic monitoring 
includes renal function test and urinary tract imaging.

Individuals presenting with catheter urethral injuries 
making CIC difficult or impossible were evaluated with 
endoscopy and urethrography. All patients considered 
as good surgical candidates were offered surgery. 
Surgical management was individualized according 
to the type of urethral pathology, including direct 
vision internal urethrotomy (DVIU), urethroplasty 
(UP), or continent diversion (CDIV). DVIU was used 
in patients with bulbar strictures up to 2 cm in length. 
Penile strictures, bulbar strictures > 2 cm, or any 
recurrence after DVIU were managed with a dorsal 
buccal mucosa graft (DBMG) urethroplasty. Posterior 
(membranous) urethral strictures were mostly related 
to neurogenic spasticity of the external sphincter and 
were managed with a DVIU plus simultaneous intra-
sphincter botulinum toxin injection. Diverticula were 
managed with tailoring and closure, with use of DBMG 
if a stricture was present. Penile urethral erosions were 
managed with primary closure with or without DBMG, 
depending on urethral plate. Fistulas were managed 
with resection and repair of concomitant stricture, 
diverticulum, or false passage, with use of DBMG as 
necessary. Continent diversion (CDIV) was indicated 
after failure of other options or when reconstruction was 
not possible. Our preference is for a continent cutaneous 
ileal cecocystoplasty as it avoids ureteral reimplantation, 
provides good bladder augmentation, and provides a 
reliable continent channel for catheterization. 

An indwelling urethral silicone catheter is left for 2 to 
3 days after DVIU and for 3 weeks after UP, before CIC 
is resumed. Pericatheter urethrography is performed 
before cat heter w it hdrawa l. A lt houg h reusable 
polyurethane catheters are the standard, hydrophilic 
coated catheters are prescribed after urethral surgery. 

Abbreviations 
CDIV continent diversion 
CIC clean intermittent catheterization 
DBMG dorsal buccal mucosa graft urethroplasty
DVIU direct vision internal urethrotomy
SCI spinal cord injury 
SPT suprapubic tube
UP urethroplasty

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CDIV patients are left with a catheter through the 
channel and a discharge suprapubic tube (SPT) 
cystostomy for 3 weeks, and CIC is started through the 
channel afterwards.

A continued surgical management protocol was 
followed; therefore, patients who failed primar y 
intervention were evaluated and offered individualized 
secondar y rescue surger y. Those who were not 
candidates for further surgery were managed with 
a definitive SPT. False passages managed by simple 
urethral catheter stenting and external sphincter 
spasticity receiving botulinum toxin without associated 
urethral stenosis were not included in this series.

The goal of all procedures was to recover easy, 
non-traumatic, continent CIC. Failure was defined 
as inability to return to continent CIC requiring a 
secondary surgical procedure or definitive SPT. The 
Clavien-Dindo classification was used for surgical 
complications.

Results
There was a total of 43 patients, with a median age of 

50 years (IQR 41 to 57) and follow-up of 69 months (IQR 
34 to 125). All patients were compliant with their regular 
appointments and no patient was lost to follow-up. Five 
individuals died from unrelated causes 23 to 293 months 
after the initial surgery. 

Figure 1 summarizes the urethral pathology. Four 
patients with false passage and both patients with 
diverticulum also had a stricture; these patients are not 
counted doubly as strictures.

Table 1 describes the types of injuries and the 
primary surgical interventions with associated success 

rates. The primary success rate for the cohort as a whole 
was calculated at 25/43 (58%). 

Table 2 highlights the outcomes according to the 
type of surgical intervention. The primary success of 
DVIU, UP, or CDIV was fairly similar (53%, 64%, and 
58%, respectively); however, CDIV had the highest 
perioperative morbidity (41%), with 36% of the patients 
suffering Clavien-Dindo ≥ 3 complications. In contrast, 
DVIU and UP had 17% and 18% morbidity, with none 
of the patients in the DVIU group suffering a Clavien-
Dindo ≥ 3 complication. Complications are listed in 
Table 3. Complications were observed in 15/57 (26%) of 
procedures, and 10 of them (18%) were Clavien-Dindo 
≥ 3. The most common complication was chimney 
failure (5), which refers to anything that leads to channel 
kinking and difficult catheter passage needing revision.

TABLE 1.

The cohort categorized by the presenting pathology and 
the associated interventions. Success was defined as the 
ability to return to continent intermittent catheterization

Type of Injury
Primary procedure

(patients)
Success

n (%)

Stricture

DVIU (16) 9 (58)

UP (6) 5 (83)

CDIV (3) 2 (67)

Total 25 58 (64)

False passages

UP (4) 2 (50)

CDIV (6) 3 (50)

DVIU (1) 0 (0)

Total 11 5 (45)

Fistulas
UP (2) 0 (0)

CDIV (2) 2 (100)

Total 4 2 (50)

Catheter erosion UP (1) 0 (0)

Total 1 0 (0)

Diverticulum UP (2) 2 (100)

Total 2 2 (100)

Overall 43 25 (58)

Classi�cation of urethral 
injury inhibiting further CIC use

Mean follow-up (months) =
69 [IQR 34, 125]

43 males total

Type of urethral injury 

False 
passage

26%

Stricture 
58%

Fistula
9%

 

Catheter 
erosion

2%
 

Diverticulum
5%

 

FIGURE 1. 

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The continued management of primary failures is 
also shown in Table 2. Rescue surgery was offered to 14 
of 18 patients in whom primary failure occurred, while 
the remaining 4 patients were not considered surgical 
candidates and were left with a SPT. All secondary 
procedures were successful in re-establishing CIC. The 
final success of DVIU was 10/18 (56%), of UP 12/17 
(71%), and CDIV 17/22 (77%). Of the 10 patients in the 
DVIU and botulinum toxin group, 6 did not require 
any further procedure, while the remaining 4 patients 
required UP (2), CDIV (1), and SPT (1). Additionally, 
the re-do CDIV (Table 2) group refers to failure of the 
channel requiring a completely new channel. Isolated 
stomal stenosis was reconstructed at the stomal level 
only. Ultimately, after a total of 57 surgical procedures, 
the reconstruction goals were achieved in 39 of 43 
patients (a 91% overall success rate), and there was no 
surgical mortality.

Discussion
The management of neurogenic bladder in patients with 
SCI continues to be an evolving issue[1–5]. Since the 
advent of CIC, most providers would agree that patients 
with good upper extremity function status should 
be afforded this modality of bladder management. 
Although recently reported patient outcomes suggest 
individuals with SCI may prefer indwelling catheters 
for convenience, there is support in the literature for the 

benefits of avoiding long-term indwelling catheters or 
external condom catheters, as well as for the benefits of 
avoiding major surgeries for urinary diversion[6,7,15,16]. 
Because of this, we believe every reasonable effort should 
be made to maintain CIC.

There is a lack of consensus on the optima l 
management strategy for patients who are unable to 
continue performing CIC because of catheter-induced 
urethral pathology, such as obstruction, false passage, 
diverticulum, or fistula, and very little has been 
published on this issue. In this study, we investigated 
the outcomes of our management of these described 
pathologies over the course of 30 years at our institution 
[13]. We hypothesized that surgical interventions aimed 
at restoring continent CIC would be successful in the 
majority of these patients.

Overa l l, we found t hat 91% of patients who 
underwent continued surgical intervention to restore 
CIC were successful through the course of our follow-
up. These interventions included DVIU, UP, and CDIV. 
The secondary procedure was determined on the basis 
of the status of the urethra. DVIU is considered as the 
first option, mainly for short and simple strictures; for 
longer, heavy fibrous or complex cases (like associated 
false passages) a more definitive reconstruction was 
necessary. Unreconstructible urethras were considered 
for diversion. Although DVIU showed the lowest success 

TABLE 2.

The cohort categorized by the type of surgical intervention performed. The overall final success rate was 91% 
and only 4 patients ultimately failed surgical interventions and required a definitive suprapubic tube

Primary 
procedure 
(patients)

Primary 
procedure 

failure
n (%)

Secondary 
procedure 
(patients)

Secondary 
procedure 
success 

(patients)

Final success*
(%)

Overall 
Morbidity*  

(%)

Clavien ≥3  
(%)

DVIU 17 8 (47)

UP 3 3

14/17 (82) 3/18 (17%) 0
DVIU 1 1

CDIV 1 1

SPT 3 –

UP 14 5 (36) CDIV 5 5 14/14 (100) 3/17 (18%) 2/17 (12)

CDIV 12 5 (42)
CDIV 4 4

11/12 (92) 9/22 (41) 8/22 (36)
SPT 1 –

Total 43 18 (42) 14 39 (91)

* Final success and overall morbidity were calculated combining primary and secondary surgeries.

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(56%), as mentioned above it is the best choice for 
short bulbar and membranous strictures because of its 
simplicity and low complication rate. In contrast, CDIV 
achieved the highest success (77%) but was linked to the 
highest morbidity. 

The UP subgroup had a 71% success rate, which 
contrasts with previous reports. Specifically, in 2003, 
Secrest et al. noted a 65% (11/17 patients) failure rate 
in urethral reconstruction in a similar cohort, so the 
authors concluded that these patients are best treated 
with urinary diversion from the beginning[13]. In our 
series, however, we found that 71% of the patients who 
underwent a UP were able to successfully return to 
CIC, avoiding a diversion and with a tolerable 18% 
complication rate. 

Our results also emphasize the value of continued 
surgical management: 14 of the 18 failures (and 33% of 
the whole series) were taken for selective individualized 
secondary surgery with 100% secondary success. 
Reconstruction was considered a failure in only 4 
patients (9%), who left with a chronic SPT. After 
these results, providers should strongly consider 
reconstruction for patients who are good candidates to 
restore continent CIC.

The field of reconstruction has evolved significantly 
in the last 15 years, so that instead of reported 65% 
failure rate, most studies now cite a 70% to 90% success 
rate after urethroplasty[17]. Urethral reconstruction 
is an evolving art, with more fellowship-trained 
reconstructive urologists practicing at the current 
time, with an improvement in graft techniques and 
postoperative care[18]. In 2004, Ronzoni et al. cited 
a 73% success rate in 48 neurological patients with 
urethral diverticulum[19]. Following this finding, Meeks 
et al. reported a 63% success rate after urethroplasty 
to restore CIC in 2008[20]. They cited the presence 
of a good urethral plate as an important prerequisite 
for successful repair. In a follow-up study by the same 
group, Casey et al. reported a 70% success rate in 23 
neurogenic patients after urethral reconstruction, with 
no patients requiring urinary diversion[21]. Of note, 
we favor a dorsal buccal mucosal graft urethroplasty as 
we believe it allows a smoother passage of the catheter 
for patients performing CIC; a ventral graft or flap may 
produce ventral irregularity, which may be a risk factor 
for a false passage.

It is impor ta nt to ack nowledge t hat despite 
i mprovement i n tech niques a nd postoperat ive 
ma nagement, reconst r uct ion fa i lure rema ins a 
possibility, and the surgeon must have a secondary 
procedure in mind for these patients. Therefore, patients 
should be thoroughly evaluated before undergoing 
procedures, and should be provided comprehensive 
counseling to ensure they are aware that they have a 

higher failure rate than non-neurogenic patients. Factors 
that may lead to worse outcomes include but are not 
limited to poor tissue quality, poor nutrition, subpar 
hygiene, lack of social support, and persistent insults 
to the urethra. Strict postoperative care with delayed 
wheelchair usage and avoidance of perineal pressure 
may prevent wound breakdown and pressure ulcers. 
Furthermore, the outcome is also associated with the 
complexity of the case and team’s experience. If any 
of these issues are non-modifiable and appear to be a 
significant impediment to undertaking a reconstruction, 
then diversion should be considered.

Factors that may stratify a urethra as “unreconstruc-
tible” include persistent or recurrent fibrosis, large 
false passage with persistent infection, large fistula, 
severe panurethral stricture, poor vascularity of the 
urethral plate, poor quality of local tissues, and a small 
capacity bladder requiring bladder augmentation. 
In these patients, a continent or incontinent urinary 
diversion with or without bladder sparing should be 
considered. The authors of this study favor bladder-
sparing continent diversion if possible. The advantages 
of such diversion are that no ureteral reimplantation is 
needed and patients can continue to perform continent 
CIC via a catheterizable channel (continent cutaneous 
ileal cecocystoplasty, or channels like Mitrofanoff, 
Yang-Monti, or Casale). Bladder augmentation may be 
considered in these patients if appropriate. Patients with 
poor performance status or recurrent reconstruction 
failures are elected for a definitive suprapubic tube 
placement.

TABLE 3. 

List of observed complications 

Complication n

 Chimney failure 5

 Stomal stenosis 4

 Perineal phlegmon 1

 Peritonitis 1

 Wound infection and graft loss 1

 Clot retention 1

 Pressure ulcer 1

 Febrile UTI 1

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One of the weaknesses of this study is its retrospective 
nature. However, most of these patients were treated 
by a single provider (RGG), who operated on and 
managed the follow-up care of these patients for most 
of the 30-year follow-up. Furthermore, despite being a 
comparatively large series with SCI individuals who 
underwent reconstructive urethral surgery, this study 
still has a limited cohort. Overall, this shortcoming can 
be addressed with a prospective analysis, which may 
require a multi-institutional effort. 

Conclusion
We  pre s e nt  ou r  lon g-t e r m  re s u lt s  of  s u r g ic a l 
reconst r uc t ive ma nagement of c at heter-i nduced 
u re t h r a l  i nju r ie s  i n  t he  m a le  S C I  p at ie nt .  A 
selective surgical approach is described, depending 

on the t y pe of injur y and patient’s condition. Our 
findings suggest that surgery should be considered 
to restore cont i nent c at heter i z at ion. W h i le t he 
pr i ma r y succe s s r ate is lower t ha n i n non-SCI 
cases, properly selected secondar y rescue surger y 
may improve success up to 90%, so reconstruction 
is well worth the effort to restore continent CIC in 
these complex cases.

Author Contributions
Kirtishri Mishra: data analysis, manuscript writing 
and editing; Laura Bukavina: data analysis, figure, 
manuscript writing and editing; Reynaldo G. Gómez: 
protocol and project management, data analysis, 
manuscript writing and editing; Rodrigo A. Campos: 
data collection.

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