Abstract
Background/Objectives: The optimal timing for definitive repair of urethral injuries, early versus delayed, remains a subject of ongoing debate. While delayed repair has traditionally been favored to allow resolution of local tissue trauma, emerging evidence suggests that early intervention may offer comparable or superior outcomes without increased risk of complications. This systematic review compares outcomes between early and delayed urethral repair across various patient populations and injury types. Methods: A systematic search of PubMed, Embase, and Scopus (through June 2025) was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Comparative studies evaluating early (within initial hospitalization or ≤1 month) versus delayed (>1–3 months post-injury) urethral repair were included. Primary outcomes were urethral stricture formation, erectile dysfunction (ED), and urinary incontinence (UI). Risk of bias was assessed using a modified Newcastle-Ottawa Scale. Results: Of 125 records screened, four retrospective cohort studies met inclusion criteria, encompassing 343 patients with anterior and posterior urethral injuries across pediatric and adult populations. Three studies found no significant difference in stricture, ED, or UI rates between early and delayed repair. One study (Chen et al., 2024) reported higher complication rates in the delayed group (stricture: 47% vs. 22%; ED: 37% vs. 3%; UI: 27% vs. 11%). Across the limited and heterogeneous studies available, no clear superiority was demonstrated between early and delayed urethral repair in terms of long-term stricture and functional outcomes. Conclusions: In carefully selected stable patients, early repair does not increase the risk of complications and may reduce catheterization time. When performed by experienced surgeons, early intervention does not increase stricture, ED, or UI risk, and may improve overall morbidity. Patient selection remains critical, but routine deferral of urethroplasty for several months should be reconsidered.
1. Introduction
Urethral injuries, whether due to blunt trauma (such as pelvic fractures or straddle injuries) or iatrogenic causes, present a challenging management dilemma. One key controversy in urologic trauma is the optimal timing of definitive urethral repair: early (immediate or acute) versus delayed (deferred) intervention [1]. Traditionally, many clinicians have advocated delayed repair (often waiting ~3 months post-injury) to allow resolution of local inflammation, hematoma, and tissue necrosis [2]. This delay often involves initial management with a suprapubic catheter for urinary diversion, followed by a formal urethroplasty at a later date. The rationale is that operating in an acute, inflamed field might increase complications such as bleeding, infection, stricture, incontinence, or erectile dysfunction (ED). However, this conventional 3-month delay has never been rigorously validated [2], and delaying repair means the patient must endure a long period with a suprapubic tube and will inevitably develop a urethral defect requiring future reconstruction.
On the other hand, some evidence suggests that early repair or realignment of the injured urethra, performed in the acute phase (if the patient’s condition permits), may be safe and could potentially reduce overall complication rates and the need for multiple procedures [2,3]. Early repair might promptly restore urethral continuity, shortening the duration of urinary diversion and possibly simplifying any subsequent interventions. The debate spans all patient populations and injury types—from pediatric to adult patients, and for both anterior urethral injuries (e.g., bulbar urethral disruptions from straddle injuries) and posterior urethral injuries (e.g., distraction defects from pelvic fractures). Key outcomes of interest include urethral stricture formation (a marker of successful lumen restoration) and functional sequelae such as ED and urinary incontinence (UI), which greatly impact quality of life.
In this systematic review, we aim to compare the outcome between early and delayed urethroplasty in urethral injury cases.
2. Materials and Methods
This review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The review protocol was not formally registered. Please refer to Table S1 in Supplementary Materials for the completed PRISMA checklist.
2.1. Eligibility Criteria
We included comparative studies (randomized or non-randomized) that evaluated outcomes of early (acute or primary) repair versus delayed (deferred) repair of urethral injuries. Early repair was defined as definitive urethral realignment or reconstruction performed in the acute phase (immediately or within the initial hospitalization, generally within days to a few weeks of injury), while delayed repair referred to urethroplasty or reconstruction performed after a period of initial diversion (typically at least 1–3 months post-injury). We included studies involving any patient age (pediatric or adult) and any urethral injury location (anterior or posterior). Studies had to report on relevant outcomes such as stricture formation and/or functional complications (ED, UI). We excluded case series without a comparison group, reviews, and non-English studies without translation.
2.2. Information Sources and Search
We performed a comprehensive literature search of databases including PubMed, Embase, and Scopus (through June 2025) for studies comparing early vs. delayed urethral repair. Search terms included combinations of urethral injury, urethral trauma, early repair, primary realignment, delayed repair, urethroplasty, stricture, erectile dysfunction, and incontinence. We also manually searched references of relevant articles and prior reviews for additional studies. No date restrictions were applied; we included both classic and recent studies given the evolving management trends.
2.3. Study Selection
Two reviewers independently screened the titles and abstracts of retrieved records. Full-text articles of potentially relevant studies were then assessed against the inclusion criteria. Any discrepancies in selection were resolved by discussion or by a third reviewer.
2.4. Data Extraction
From each included study, we extracted key characteristics (study design, setting, sample size, patient population, urethral injury type/location, and definition of early vs. delayed intervention) and outcomes. Primary outcomes of interest were urethral stricture incidence after treatment, and secondary outcomes included erectile dysfunction and urinary incontinence rates. We also noted other relevant findings, such as the number of procedures required, time to catheter removal or voiding, and follow-up duration.
2.5. Risk of Bias Assessment
Two reviewers independently assessed the risk of bias of each included study. Given that all included studies were non-randomized observational studies, we used a modified Newcastle-Ottawa Scale (NOS) for cohort studies, focusing on (1) Selection bias (representativeness of patients and whether the allocation to early vs. delayed was susceptible to confounding), (2) Comparability (whether outcomes were adjusted for baseline differences, e.g., injury severity), and (3) Outcome assessment (follow-up adequacy and objectivity of outcome measurements). Each study was judged to have low, moderate, or high risk of bias in key domains, and an overall risk-of-bias judgment was assigned. These assessments are summarized in the Results.
2.6. Data Synthesis
We qualitatively synthesized the results, as the heterogeneity in study populations and designs precluded a formal meta-analysis. We compared complication rates between early and delayed groups as reported in each study and looked for consistent patterns. We constructed summary tables to aid in comparing study characteristics and outcomes. No statistical pooling was performed, but we comment on statistical significance reported in the individual studies. The strength of evidence was interpreted in light of the risk of bias.
3. Results
3.1. Study Characteristics and Patient Populations
A total of 125 records were identified through database searches and other sources. After removing duplicates, 110 unique records were screened, of which 90 were excluded based on title/abstract. Twenty full-text articles were assessed for eligibility; 16 were excluded (e.g., no direct comparison of timing or lacking relevant outcomes), leaving 4 studies for inclusion in the qualitative synthesis [1,2,3,4]. The study selection process is summarized in the PRISMA flow diagram (Figure 1). Table 1 provides an overview of the included studies and their key characteristics and outcomes. The studies span a range of patient populations and injury types. Gong et al. (2012) studied adult men with anterior (bulbar) urethral injuries from blunt straddle trauma [3]. This was a retrospective single-center study in Korea including 60 men; 17 underwent immediate primary repair of the bulbar urethral disruption, and 43 had initial suprapubic diversion followed by delayed urethroplasty months later. Median follow-up was ~20 months. Qu et al. (2014) studied pediatric patients (boys) with posterior urethral distraction defects due to pelvic fracture (PFUDD) [1]. This was a large 20-year retrospective series from a Chinese pediatric center with 177 boys followed (out of 210 cases). Thirty-five (35) boys received an immediate repair (primary urethral realignment/anastomosis during the acute phase if stable), and 142 underwent delayed urethroplasty after initial management with diversion. Average follow-up was about 58 months. Scarberry et al. (2018)—Adult men with posterior urethral injuries (pelvic fracture urethral injury, PFUI) [2]. This was a retrospective multi-center study (Cleveland, OH, USA, and Chile) of 39 men who all had initial suprapubic tube placement for PFUI and later underwent urethral reconstruction. Patients who had undergone immediate endoscopic realignment were excluded, focusing only on those managed definitively with a formal posterior urethroplasty. They compared those repaired “early” (within ≤6 weeks of injury, n = 22) versus “delayed” (≥12 weeks after injury, n = 17). Median follow-up was long (median ~5.3 years). Chen et al. (2024) studied adult male trauma patients (from a Level I trauma center in Taiwan) with various urethral injuries (both anterior and posterior) in the context of polytrauma [4]. This retrospective cohort of 67 men compared those who received definitive urethral injury repair early (defined as within <1 month of injury, n = 37) versus delayed (≥1 month after, n = 30). Notably, many patients had severe associated injuries (over 45% had an Injury Severity Score ≥ 16). The authors also analyzed subgroups by urethral injury location (anterior vs. posterior). Median follow-up was not explicitly stated but all patients had records of complications in the study period.
Figure 1.
PRISMA Flow Diagram.
Table 1.
Study Characteristics.
As shown in Table 1, all four studies were comparative cohort studies (no randomized trials were found). Two studies focused on posterior urethral injuries associated with pelvic fractures (Scarberry 2018 in adults, Qu 2014 in children) [1,2], one study focused on anterior (bulbar) injuries from straddle trauma [3], and one study included a mix of anterior/posterior injuries in a trauma population [4]. The sample sizes ranged from 39 to 210 patients (with 35–60 patients in the early repair groups across studies). Early intervention was defined slightly differently in each: immediate or within days (Gong, Qu), within 6 weeks (Scarberry), or within 1 month (Chen), but conceptually all represent acute phase repair. Delayed intervention in all studies meant a planned urethroplasty or reconstruction after an initial period of diversion (typically performed at 3–6 months post-injury, except Scarberry’s “delayed” group had ≥12 weeks and Chen’s had ≥1 month). Follow-up durations varied but were at least 1 year on average in all studies, and much longer in some (5+ years in Scarberry). All studies evaluated stricture formation, impotence/ED and incontinence rates in each group.
It is important to note that none of the studies were randomized; the assignment to early vs. delayed repair was determined by clinical factors (e.g., patient stability, surgeon preference, era of treatment). For example, Qu et al. noted that immediate repair was undertaken only if the child’s condition was sufficiently stable and without severe associated injuries [1]. Similarly, Scarberry et al. only attempted early (<6 week) urethroplasty in patients who had stabilized from their injuries and had a soft, non-hematoma perineum on exam [2].
In summary, three out of four studies found no statistically significant difference in stricture rates between early and delayed management [1,2,3]. The largest difference was noted by Chen et al., where delayed repair patients had a considerably higher stricture incidence (47% vs. 22%), although confounding by injury severity was likely (their delayed group had more severe injuries). Notably, none of the studies reported higher stricture rates in the early repair group compared to the delayed—in other words, early repair did not worsen stricture outcomes in any cohort. If anything, the trend (though not always significant) was toward equal or lower stricture formation with early intervention.
3.2. Risk of Bias Assessment
All included studies were retrospective cohort studies without randomized assignment, which inherently introduces potential bias and confounding. Table 2 summarizes the risk-of-bias assessment for each study. All studies had high to moderate quality at best.
Table 2.
Risk of Bias Assessment. The stars (★) represent the scoring system used in the Newcastle-Ottawa Scale (NOS) for assessing risk of bias in case–control studies. Hollow star indicates a score of 0/1 for that category. Each star indicates that the study has met the NOS criteria for that domain (Selection, Comparability, or Outcome/Exposure). The total number of stars reflects the overall methodological quality of each included study.
4. Discussion
This systematic review compared early versus delayed repair of urethral injuries across four studies, encompassing both pediatric and adult populations and both anterior and posterior injury patterns. The overarching finding is that early (acute) repair—when performed in appropriately selected patients—is not associated with higher complication rates compared to delayed repair. In fact, early intervention appears to offer some advantages, without a detectable penalty in terms of stricture, incontinence, or erectile dysfunction rates.
Historically, the fear has been that operating early, in a field of hematoma and inflammation, could lead to worse scarring and thus higher stricture rates. The evidence from our review does not support this fear. In all series, stricture incidence was statistically similar between early and delayed groups [1,2,3]. For instance, Gong et al. found no significant difference in stricture rates after immediate bulbar repair vs. delayed, echoing findings from earlier trauma studies that primary realignment can achieve outcomes equivalent to delayed urethroplasty [3]. Qu et al.’s pediatric data also showed no increase in strictures with immediate anastomosis [1]. The only study showing a disparity was Chen et al., where delayed repairs had nearly double the strictures of early repairs [4]. This aligns with some prior observations that early realignment may actually reduce stricture length and complexity for subsequent repair [5]. One can hypothesize that early realignment may preserve urethral continuity to some degree, leading to less extensive scar formation, whereas in a delayed repair scenario, the urethral ends are separated for months, and dense scar tissue develops in between. Even when strictures occur after early repair, they might be shorter and more amenable to simple endoscopic treatment [1], as Qu et al. suggested. Therefore, an acute management strategy does not compromise stricture outcomes and may, in some cases, simplify later management. However, the higher complication rate observed in the delayed group of Chen et al. (47% vs. 22%) may be confounded by a greater proportion of severely injured patients (Injury Severity Score [ISS] ≥ 16 > 45%), which likely impacted outcomes independently of repair timing [4]. It is noteworthy that in the Qu et al. cohort, some patients underwent primary endoscopic realignment acutely but still proceeded to delayed urethroplasty after appropriate healing. While the final reconstructive approach aligns with delayed repair, the initial management strategy adds heterogeneity and should be considered when comparing outcomes.
Aside from comparable complication rates, early repair offers clear advantages in reducing morbidity. Patients can avoid a prolonged period of suprapubic catheter dependence. The psychological and physical burden of living with a suprapubic tube for months (infection risk, inconvenience, impact on body image and activity) is non-trivial. Early repair short-circuits this, allowing earlier catheter removal [3]. Fewer surgical interventions are needed on average [1]. This translates to less cumulative anesthesia risk, lower healthcare costs, and less time off work or school for patients. Early restoration of urethral continuity can potentially preserve urethral length and blood supply, making any subsequent interventions easier. Some reconstructive experts argue that primary (early) alignment, even if it does not completely obviate a stricture, often converts a complex distraction defect into a simpler short stricture that is easier to fix later [2]. The studies by Qu and Chen indirectly support this: their early groups, if strictures occurred, were managed by simpler means, whereas the delayed group often needed formal urethroplasty [1,4]. From the patient’s perspective, an earlier return to normal voiding and sexual activity is a huge benefit. Many trauma patients are young and otherwise healthy; being able to urinate normally and potentially resume sexual life sooner can improve quality of life and mental health during recovery.
It must be emphasized that patient selection is critical. The findings of these studies apply to patients who were stable enough to undergo early repair. In practice, one would not attempt an acute urethral repair in a hemodynamically unstable patient with multiple other injuries or in one with gross pelvic contamination or risk of fatal complications. In those situations, a delayed approach (stabilize the patient first, manage life-threatening issues, place a suprapubic catheter for urine diversion, and defer urethroplasty) is still the appropriate course. Our review does not suggest abandoning delayed repair in scenarios where early surgery would clearly endanger the patient. Rather, it suggests that when conditions are favorable, early repair is a valid and perhaps underutilized option.
Modern trauma management often involves damage control principles; once the patient is past that phase and stable, if the expertise is available, addressing the urethral injury during the index hospitalization can be beneficial. Scarberry et al. concluded that there is no need to arbitrarily wait 3 months if the patient is ready at 6 weeks [2]. In fact, performing the urethroplasty at 4–6 weeks post-injury yielded outcomes as good as waiting longer. This has implications for trauma protocols: instead of automatically scheduling urethroplasty at 3–6 months, trauma surgeons and urologists should re-evaluate the patient at a few weeks post-injury. If pelvic fractures have stabilized and the local tissue conditions are suitable, proceeding with reconstruction earlier can spare the patient a lengthy wait.
In the clinical setting, arterial embolization is required in only about 1–3% of all pelvic fracture cases, highlighting that significant vascular injury is a concern limited to a specific subgroup of patients [6]. Such interventions can compromise urethral perfusion, especially in the bulbar segment, leading to ischemic necrosis or strictures. In patients who have undergone transarterial embolization (TAE), early definitive repair should be approached with caution. Restoration of blood supply, either by recanalization of embolized internal pudendal arteries or maturation of collateral circulation, may require several months. Definitive urethroplasty should therefore be delayed until vascular integrity and tissue viability are adequately reestablished to reduce the risk of complications.
Our review included both pediatric (Qu 2014) and adult studies [1,2,3,4]. Interestingly, the results are concordant across ages. Historically, there might have been even more hesitancy to perform acute urethral surgery in children due to concerns about future growth and anesthesia risk. Qu et al.’s 20-year experience demonstrates that even in children, immediate repair of a pelvic fracture urethral injury is feasible and yields outcomes equivalent to delayed repair. They highlighted that immediate repair in boys did not increase strictures or incontinence and could reduce the need for repeat surgeries. This is important because managing a suprapubic tube in a small child (for months) is very challenging for families. Their work suggests that in pediatric centers with the requisite surgical expertise, early repair should be considered for a stable child with urethral disruption, rather than reflexively deferring to puberty or many months later. Of course, the child’s growth and long-term outcomes must be monitored, but at least up to 5-year follow-ups, those who had early repairs did well.
The debate of early vs. delayed has traditionally been most pertinent to posterior urethral injuries (pelvic fracture-related). In anterior urethral injuries (bulbar), immediate primary repair is already commonly practiced for things like a clean-cut penetrating injury or an isolated bulbar rupture from a straddle injury—surgeons often repair those acutely if possible. Gong’s study reinforces this practice for bulbar disruptions: immediate anastomosis had equivalent results to delayed urethroplasty [3], and with the benefit of faster recovery. Thus, for anterior urethral injuries without contraindications, early repair should be the standard when technically feasible, as there is little reason to delay (no complex pelvic hematoma to wait out, etc.). For posterior injuries, the tradition of delayed repair was more ingrained. The studies by Qu, Scarberry, and Chen all indicate that with careful patient selection, early repair of posterior injuries is safe. In practice, “early” posterior repair might mean an immediate open anastomosis (as performed in Qu’s series for some children), or more commonly, an endoscopic primary realignment over a catheter in the early days after injury, or a formal urethral reconstruction at a few weeks. Notably, none of the studies in our review specifically evaluated primary endoscopic realignment versus delayed repair; that is another facet of this debate in the literature. Scarberry excluded patients who had undergone primary endoscopic realignment, focusing only on open urethroplasty timing. Other literature (outside our four studies) suggests primary endoscopic alignment can achieve success in a proportion of cases and potentially reduce stricture length, though some guidelines still favor a delayed single-stage urethroplasty as definitive management. Our review’s scope, however, is broad: any form of acute repair vs. late repair. The consistent message is outcome equivalence or superiority for the acute approach in properly selected cases, which holds true across different techniques.
The present review synthesizes a limited number of heterogeneous studies with small sample sizes, most focusing on pelvic fracture urethral injury and only one on straddle trauma. The scarcity of high-quality comparative data precludes firm conclusions about the superiority of early versus delayed repair; most are retrospective studies. Rather than promoting early intervention, our goal is to provide an objective appraisal of existing evidence and highlight the critical need for multicenter, prospective studies to inform standardized practice. We are currently developing institutional data collection protocols to contribute further to this evidence base. An additional limitation of this review is the imbalance in group composition. The delayed cohort was numerically larger and strongly influenced by a single large study [2] in which all delayed repairs were performed for PFUI. Because PFUI is associated with a higher risk of erectile dysfunction, sphincteric damage, and concomitant pelvic injuries, outcomes in the delayed group may appear worse due to underlying injury severity rather than repair timing alone.
5. Conclusions
This systematic review concludes that early repair of urethral injuries, when performed in clinically stable patients by experienced surgeons, yields outcomes comparable to or better than delayed repair, with no increased risk of stricture, erectile dysfunction, or urinary incontinence. Early intervention offers advantages such as faster return to normal voiding, fewer procedures, and potentially lower overall morbidity. While delayed repair remains appropriate for unstable or complex cases, the longstanding practice of deferring surgery for several months can be reconsidered. In carefully selected stable patients, early repair does not increase the risk of complications and may reduce catheterization time. Ultimately, management should be individualized, with early repair emerging as a safe and effective option in select cases.
Supplementary Materials
The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/siuj6060069/s1, Table S1. PRISMA checklist. Reference [7] is cited in the supplementary materials.
Author Contributions
Conceptualization, B.A.P. and K.A.; methodology, B.A.P.; validation, B.A.P. and K.A.; formal analysis, B.A.P.; investigation, B.A.P.; resources, K.A.; data curation, B.A.P.; writing—original draft preparation, B.A.P.; writing—review and editing, K.A.; visualization, B.A.P.; supervision, K.A.; project administration, K.A. All authors have read and agreed to the published version of the manuscript.
Funding
There is no funding for this study.
Institutional Review Board Statement
Not applicable.
Informed Consent Statement
Not applicable.
Data Availability Statement
All data were presented in this article.
Conflicts of Interest
The authors declare no conflicts of interest.
Abbreviations
The following abbreviations are used in this manuscript:
| ED | Erectile Dysfunction |
| UI | Urinary Incontinence |
| PRISMA | Preferred Reporting Items for Systematic Reviews and Meta-Analyses |
| NOS | Newcastle-Ottawa Scale |
| PFUI | Pelvic Fracture Urethral Injury |
| PFUDD | Pelvic Fracture Urethral Distraction Defect |
| ISS | Injury Severity Score |
| NS | Not Significant |
| TAE | Transarterial Embolization |
References
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© 2025 by the authors. Published by MDPI on behalf of the Société Internationale d’Urologie. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).