Small Animals
Use of poliglecaprone 25 for perineal urethrostomy
in cats: 61 cases (2007–2013)
Daniel L. Frem dvm
Heidi A. Hottinger dvm
Suzanne L. Hunter dvm
Nicholas J. Trout ma, vet mb
From Gulf Coast Veterinary Specialists, 1111 West
Loop South, Houston, TX 77027 (Frem, Hottinger,
Hunter); and Angell Animal Medical Center, 350 S
Huntington Ave, Boston, MA 02130 (Trout). Dr. Frem
and Dr. Hunter’s present address is Las Vegas Vet-
erinary Specialty Center, 8650 W Tropicana Ave, Ste
B-107, Las Vegas, NV 89147.
Address correspondence to Dr. Frem (fremdvm@gmail.
com).
P erineal urethrostomy is predominantly performed
in male cats to bypass the distal portion of the
urethra and create a permanent opening between the
pelvic urethra and perineal skin. Primary indications
for PU include recurrent distal urethral obstruction
secondary to FLUTD or urolithiasis (especially when
medical attempts to prevent recurrent obstruction
have failed), trauma to the distal portion of the ure-
thra, and idiopathic distal urethral obstruction.1–11
Most surgeons currently use a variation of the PU
technique described by Wilson and Harrison.11 Clo-
sure of the urethrostomy site requires accurate ap-
position of mucosa to skin to reduce the risk of urine
extravasation, inflammation, irritation, and excessive
granulation tissue formation, all of which predispose
the site to scarring and stricture.1,12–14 The ideal su-
ture for closure would maintain tissue apposition,
ABBREVIATIONS
FLUTD Feline lower urinary tract disease
PU Perineal urethrostomy
JAVMA • Vol 251 • No. 8 • October 15, 2017 935
OBJECTIVE
To determine frequency of postoperative complications in cats undergoing
perineal urethrostomy (PU) in which poliglecaprone 25 was used for closure
and identify possible predisposing factors for development of complications.
DESIGN
Retrospective case series.
ANIMALS
61 cats that underwent PU.
PROCEDURES
Medical records for cats that underwent PU at Gulf Coast Veterinary Spe-
cialists between 2007 and 2012 were reviewed. Information regarding sig-
nalment, perioperative conditions, surgical procedures, treatments, and
postoperative complications were obtained from medical records and by
telephone follow-up.
RESULTS
11 of 61 (18%) cats developed minor short-term (ie, ≤ 2 months after
surgery) complications, 1 of 61 (1.6%) cats developed a major short-term
complication requiring surgical revision, and 16 of 38 (42%) cats developed
minor long-term complications. No major long-term complications were
identified. Preoperative urinary tract infection was significantly associated
with development of minor short-term complications, but use of an in-
dwelling urinary catheter after surgery was not significantly associated with
development of postoperative complications.
CONCLUSIONS AND CLINICAL RELEVANCE
Results suggested that poliglecaprone 25 may be an acceptable suture
for apposition of mucosa to skin in cats undergoing PU. Short- and long-
term complication rates and percentage of cats requiring revision surgery
were comparable to values reported in previous studies in which slow-
ly absorbable or nonabsorbable sutures were used. ( J Am Vet Med Assoc
2017;251:935–940)
degrade at a rate commensurate with the rate of tis-
sue healing, have minimal tissue reactivity, and with-
stand repeated exposure to urine.15
Traditionally, the urethral mucosa has been su-
tured to the skin in a simple interrupted pattern with
a nonabsorbable suture such as nylon or polypropyl-
ene.1,11,16 However, use of a nonabsorbable suture ne-
cessitates suture removal approximately 2 weeks after
surgery, which may require heavy sedation or general
anesthesia.1 Apposition of the mucosa and skin in a
simple continuous pattern with polydioxanone, a syn-
thetic absorbable monofilament suture, was found to
be a viable closure option for PU, eliminating the need
for suture removal.1 However, several studies17,18 have
questioned the use of rapidly absorbable sutures in the
urinary tract, especially when exposure to infected
urine is possible. Despite these concerns, poliglecap-
rone 25, a rapidly absorbing suture, has been routinely
used for closure of PU by numerous surgeons.19 To the
authors’ knowledge, however, complications associ-
ated with the use of poliglecaprone 25 for PU closure
in cats have not been clinically evaluated.
 Small Animals
The purposes of the study reported here were to
determine the frequency of postoperative complica-
tions in cats undergoing PU in which poliglecaprone
25 was used for closure and identify possible predis-
posing factors for development of complications. We
hypothesized that the use of poliglecaprone 25 would
be associated with short- and long-term complication
rates comparable to rates previously reported for oth-
er sutures.
Materials and Methods
Electronic medical records of Gulf Coast Veteri-
nary Specialists were searched to identify all cats that
underwent PU between January 2007 and December
2012. Cats were included in the study if PU had been
performed for resolution of distal urethral obstruc-
tion, the medical record was complete and avail-
able for review, and follow-up evaluation had been
performed a minimum of 10 days after surgery. Cats
undergoing revision of a previous PU procedure were
excluded. Cats that required a second surgical pro-
cedure during the same anesthetic episode were eli-
gible for inclusion in the study.
Information recorded from medical records of
cats included in the study consisted of age, breed,
weight, whether urinary tract infection was pres-
ent (ie, positive bacterial culture results or clinically
relevant bacteriuria on urinalysis), composition of
urinary stones or crystals (if recorded), additional
surgical procedures performed, whether a urinary
catheter was placed after surgery, and any surgeon
comments regarding visible trauma to the urethra at
the time of surgery. All procedures were performed
by 1 of 3 board-certified surgeons.
Surgical procedure
The PU procedure was a variation of that pre-
viously described by Wilson and Harrison.11 When
exploratory laparotomy or cystotomy was to be per-
formed concurrently with PU, the patient was posi-
tioned in dorsal recumbency. In all other instances,
the patient was positioned in sternal or dorsal recum-
bency on the basis of surgeon preference.
In all cases, the tendinous attachments of the is-
chiocavernosus muscles to the pelvis were transect-
ed to facilitate mobilization of the urethra. When pos-
sible, the bulbourethral glands were visualized and
used as a landmark for proximal dissection of the ure-
thra. The urethral incision was made with tenotomy
scissors or a scalpel blade and was extended proxi-
mal to the bulbourethral glands or just proximal to
the caudal margin of the pelvis. The aperture of the
urethra was considered adequate if an 8F or 10F red
rubber catheter could be easily passed through the
urethral opening or if a closed Halsted mosquito he-
mostat could be easily inserted to the level of the box
locks. In rare instances, a 6F red rubber catheter was
the largest diameter catheter that could be passed
through the urethral opening. The urethral mucosa
was sutured to the skin with 4-0 or 5-0 poliglecap-
936 JAVMA • Vol 251 • No. 8 • October 15, 2017
rone 25 on a taper-cut swaged-on needle. The nee-
dle was inserted from the urethral mucosa through
the skin. The dorsal aspect of the urethrostomy was
closed with 3 to 5 simple interrupted sutures or with
a simple continuous pattern between the 10 o’clock
and 2 o’clock positions. The remainder of the ure-
throstomy was closed with 2 simple continuous su-
ture patterns as previously described.
An indwelling urinary catheter was placed postop-
eratively at the surgeon’s discretion. All patients were
allowed to recover with an Elizabethan collar in place.
Follow-up evaluation
Follow-up information was obtained through
recheck examinations performed at Gulf Coast Vet-
erinary Specialists or by the referring veterinarian.
Short-term follow-up was defined as evaluation of
the PU site by the surgeon or referring veterinarian
a minimum of 10 days and up to 2 months after sur-
gery. Long-term follow-up was defined as reexami-
nation at Gulf Coast Veterinary Specialists or by the
referring veterinarian > 2 months after surgery. If a
long-term follow-up examination was not performed,
the owner was contacted by telephone.
All owners were asked about the occurrence of
complications, including clinical signs associated
with FLUTD (dysuria, hematuria, or inappropriate
urination), bacterial urinary tract infections (iden-
tified on the basis of compatible clinical signs or
confirmed by means of bacterial culture), signs of
stricture or narrowing of the urethrostomy site, and
whether revision surgery had been performed.
Data analysis
Perioperative conditions were classified into the
following groups for statistical analysis: whether ad-
ditional surgical procedures were performed, preop-
erative urinary tract infection had been identified,
cystic calculi were present, urethral trauma was not-
ed at the time of surgery, and an indwelling urinary
catheter was placed postoperatively. Minor and ma-
jor short-term and long-term postoperative complica-
tions were compiled. Short-term complications were
defined as any complications occurring within the
first 2 months after surgery; long-term complications
were defined as any complications occurring > 2
months after surgery. Minor complications included
those that resolved with medical management alone
or without treatment; major complications were de-
fined as those requiring surgical intervention.
For categorical data, the aforementioned groups
were compared with the Pearson χ2 test for indepen-
dence or, if the expected frequency in ≥ 1 cell was
< 5, the Fisher exact test. Values of P < 0.05 were
considered significant. All statistical analyses were
performed with commercially available software.a
Results
The electronic medical record search identified
72 cats that underwent PU during the study period.
 Small Animals

However, 11 cats were excluded because of a lack of
follow-up a minimum of 10 days after surgery (n = 5),
conversion to a transpubic urethrostomy during the
initial surgery (3), incomplete medical records (2),
and failure to survive to discharge owing to cardiac
arrest in the immediate postoperative period (1). The
remaining 61 cats were included in the study. Long-
term (> 2 months) follow-up information was lacking
for 23 cats, and these cats were excluded from long-
term analyses.
Breeds of the 61 cats included in the study con-
sisted of domestic shorthair (n = 45), domestic me-
dium hair (8), domestic longhair (3), Siamese mix
(2), Siamese (1), Siberian (1), and exotic longhair (1).
Median age was 5.4 years (range, 1.1 to 15.0 years),
and median body weight was 5.6 kg (12.3 lb; range,
3.6 to 9.1 kg [7.9 to 20.0 lb]). Urethral obstruction was
the initial complaint for all 61 cats, with idiopathic
FLUTD most common (n = 34 [56%]), followed by
urethral calculi (21 [34%]), and urinary tract infec-
tion (10 [16%]). Four cats had both urethral calculi
and bacterial urinary tract infection.
Ten cats were considered to have a urinary tract
infection on the basis of positive bacterial culture re-
sults or clinically relevant bacteriuria on urinalysis.
Specific pathogens were identified in 6 cats, includ-
ing Escherichia coli (n = 3), Corynebacterium spp
(2), and methicillin-resistant Staphylococcus aureus
(1). The surgeon noted visible trauma to the urethra
at the time of surgery in 11 of 61 (18%) cats. Addition-
al surgical procedures were performed in 30 (49%)
cats. Additional surgical procedures included cystot-
omy in 29 cats and abdominal exploration because of
suspected uroabdomen (no abnormalities were iden-
tified) in 1. Four cats that underwent cystotomy also
underwent intestinal biopsy, urinary bladder biopsy,
repair of a tear in the urinary bladder, and ureterot-
omy to remove a ureteral calculus (1 each). An in-
dwelling urinary catheter was placed after surgery in
46 (75%) cats; median time the catheter remained in
place was 1.6 days (range, 0 to 4 days). Mean duration
of hospitalization after surgery was 2.6 days (range,
1 to 6 days).
Eleven (18%) cats developed minor short-term
complications, including dysuria (n = 2), urinary tract
infection (2), incisional dehiscence due to self-trauma
(2), incisional inflammation (1), urine scald (1), moist
dermal necrosis (1), narrowing of the urethrostomy
site (1), and obstipation (1). One (2%) cat developed a
major short-term complication. This cat developed a
stricture at the PU site 19 days after the initial surgery,
resulting in reobstruction that required revision sur-
gery. One cat in which ureterotomy was performed
in conjunction with PU underwent surgery the day
after the initial surgery because of uroabdomen. De-
hiscence of the ureterotomy site was identified, and
a ureteronephrectomy was performed. Because this
complication was unrelated to the PU procedure, it
was excluded from the data analysis.
Long-term follow-up information was available
for 38 cats, with a median follow-up time of 35.4
months (range, 7.3 to 101.6 months). Of the cats avail-

Table 1—Results of univariate analysis of potential associations between various factors and development of postoperative
complications in 61 cats undergoing PU in which poliglecaprone 25 was used for closure.
Minor short-term Major short-term Minor long-term
complications complications complications
Variable No. of cats* P value No. of cats* P value No. of cats* P value
Additional surgical 0.739 1.000 0.627
procedures performed
Yes 6/30 0/30 8/21
No 5/31 1/31 8/17
Preoperative urinary
tract infection 0.049 1.000 1.000
Yes 4/10 0/10 3/7
No 7/51 1/51 13/31
Cystic calculi or
crystalluria 0.670 1.000 0.635
Yes 3/21 0/21 6/15
No 8/40 1/40 10/23
Postoperative indwelling 0.265 0.767 1.000
urinary catheter
Yes 10/46 1/46 12/30
No 1/15 0/15 4/8
Urethral trauma noted
at surgery 0.670 0.213 0.485
Yes 1/11 1/11 3/10
No 10/50 0/50 13/28

*Data are given as No. of cats with complications/total number of cats in the category.
Short-term complications were complications occurring ≤ 2 months after surgery; long-term complications were complications occurring > 2
months after surgery. Minor complications included those that resolved with medical management alone or without treatment; major complications
were defined as those requiring surgical intervention.

JAVMA • Vol 251 • No. 8 • October 15, 2017 937

 Small Animals
able for long-term follow up, 16 (42%) developed mi-
nor complications, including ≥ 1 recurrence of clini-
cal signs of FLUTD such as dysuria, hematuria, or in-
appropriate urination (n = 15); cystic calculi (2); and
recurrent inflammation of the urethrostomy site (1).
Thirteen of the 15 cats with recurrent signs of FLUTD
were treated with antimicrobials with subsequent
resolution of clinical signs, but only 2 of those cats
had urinary tract infections confirmed by bacterial
culture of a urine sample.
Neither the occurrence of minor complications
(yes vs no) nor the occurrence of major complications
(yes vs no) was significantly associated with whether
additional surgical procedures were performed, cys-
tic calculi or urinary crystals were present at the time
of surgery, an indwelling urinary catheter was placed
postoperatively, or trauma to the urethral mucosa was
noted by the surgeon at the time of surgery (P values
ranged from 0.213 to 1.000; Table 1). Occurrence of
minor short-term complications was significantly (P
= 0.049) associated with whether preoperative uri-
nary tract infection had been identified, with 4 of 10
(40%) cats with preoperative urinary tract infection
developing minor short-term complications (postop-
erative bacterial urinary tract infection, n = 2; moist
dermal necrosis, 1; and incisional dehiscence due to
self-trauma, 1), compared with only 7 of 51 (14%) cats
without preoperative urinary tract infection. Howev-
er, neither minor long-term complications nor major
short-term complications were significantly associat-
ed with whether preoperative urinary tract infection
had been identified.
Discussion
Results of the present study suggested that poli-
glecaprone 25 may be an acceptable suture for appo-
sition of mucosa to skin in cats undergoing PU. Short-
and long-term complication rates and percentage of
cats requiring revision surgery were comparable to
values reported in previous studies in which slowly
absorbable or nonabsorbable sutures were used. In
the present study, preoperative urinary tract infec-
tion was significantly associated with the develop-
ment of minor short-term complications, but in con-
trast to previous studies, the use of an indwelling
urinary catheter after surgery was not significantly
associated with the development of postoperative
complications. However, further studies should be
performed to evaluate both of these findings.
Poliglecaprone 25 is a rapidly absorbable synthet-
ic monofilament prepared from a copolymer of gly-
colide and epsilon-caprolactone that is virtually inert
in tissue.20 It is rapidly degraded by hydrolysis, los-
ing approximately two-thirds of its tensile strength in
vitro within 14 days and being completely absorbed
within 4 months.20,21 Degradation is hastened by im-
mersion in urine, especially in the presence of bacte-
ria or alkaline pH.17,18 Several authors15,17,18,22,23 have
questioned the use of rapidly absorbable sutures, in-
cluding poliglecaprone 25, in the urinary tract, espe-
938 JAVMA • Vol 251 • No. 8 • October 15, 2017
cially when exposure to infected urine is possible or
when healing may be delayed or compromised.
In the authors’ opinion, the rapid degradation of
poliglecaprone 25 is a benefit, rather than a drawback,
for closure of PU. The ideal suture for any application
should maintain tensile strength and tissue apposi-
tion until healing is complete and then degrade rap-
idly and predictably.18 Previous studies17,18 of poligle-
caprone 25 degradation in urine subjected samples
to continuous immersion in urine for days at a time.
This differs from the intermittent urine exposure at
a PU site. In general, the urethral mucosa regenerates
within 7 days.23,24 Therefore, for PU closure, use of a
suture that can maintain tensile strength for at least
7 days, such as poliglecaprone 25, may be sufficient.
Nonabsorbable sutures such as nylon and poly-
propylene have been recommended for PU closure
because of their low tissue reactivity, but require
removal approximately 2 weeks after surgery.25
Polydioxanone, a monofilament absorbable suture,
has been shown to be suitable for closure of PU, with
complication rates comparable to those for nonab-
sorbable sutures, but without the need for suture
removal.1 Similarly, the rapid degradation of poligle-
caprone 25 precludes the need for suture removal fol-
lowing PU.
In the present study, 12 of 61 (20%) cats devel-
oped short-term complications and 16 of 38 (42%)
cats developed long-term complications. These com-
plication rates were comparable to short-term rates
of 25% and long-term rates of 28% to 57% previous-
ly reported.1–3,5,8,9,13,14,26,27 Only 1 cat in the present
study required revision surgery because of complica-
tions associated with PU. In contrast, in a previous
study3 in which nonabsorbable polypropylene suture
was used, nearly 50% of the short-term complications
were major complications requiring revision surgery,
a rate more than 5 times the rate in the present study.
Despite previous reports17,18 of rapid degradation
of poliglecaprone 25 during immersion in urine, only
2 instances of incisional dehiscence were identified
in the present study. In both instances, the owners
reported self-trauma after removal of the Elizabethan
collar. Mechanical stress and tissue irritation may
have been the underlying cause of suture failure in
these cases, but rapid degradation of the suture could
not be ruled out.
Urethral stricture has been reported to occur af-
ter PU in 0% to 18.1% of cases.3,9,14,26 This compares
favorably with findings in the present study, in which
only 1 of 61 (1.6%) cats developed a stricture requir-
ing revision. This cat had a large mucosal defect (ap-
prox 1 cm in diameter) at the time of surgery. This
defect may have been a primary cause of stricture or
may have contributed to secondary edema, inflamma-
tion, urine extravasation, or granulation tissue forma-
tion, leading to stricture formation. No evidence of
bacterial urinary tract infection was noted at surgery,
and no concerns regarding self-trauma after surgery
were detailed in the medical record.

In 2 studies12,28 on surgical revision of PU, ap-
proximately 75% of cats had evidence of urethral
stricture secondary to incomplete dissection of the
penile attachments or failure to extend the urethral
incision to the level of the bulbourethral glands. In
cats, the internal diameter of the urethra at the level
of the bulbourethral glands is nearly twice the inter-
nal diameter of the penile urethra,29 and incomplete
dissection to the level of the bulbourethral glands is
the most common cause of stricture in cats undergo-
ing PU.27,29 Strictures have also been reported second-
ary to unhealthy urethral mucosa, surgical trauma,
inaccurate tissue apposition, indwelling urinary cath-
eterization, and self-mutilation.6,13,22,28,30 In a study26
that reported no postoperative strictures, the suc-
cessful outcome was attributed to surgeon experi-
ence, prevention of self-mutilation through the use
of Elizabethan collars after surgery, and avoidance of
postoperative indwelling urethral catheters.
Placement of an indwelling urethral catheter
after PU is a contentious topic. Previous studies10,28
have identified use of indwelling urinary catheters
as a potential cause of urethral stricture. In addi-
tion, the presence of a catheter can incite inflamma-
tion and may promote ascending bacterial infection.
However, urinary diversion reduces inflammation by
reducing contact between the injured mucosa and
urine and may reduce extravasation and subsequent
inflammation.31–35 In the present study, an indwell-
ing urinary catheter was placed after surgery at the
surgeon’s discretion, and a significant association be-
tween postoperative indwelling urinary catheter use
and development of postoperative complications was
not identified. The presence of preoperative urinary
tract infection was found to be significantly associ-
ated with development of minor short-term postop-
erative complications. However, this result should be
interpreted with caution, given that only 4 cats with
documented preoperative urinary tract infection de-
veloped such complications.
Fifteen of 38 (39%) cats in the present study had
long-term minor complications attributable to recur-
rent signs of FLUTD. This was comparable to previ-
ously reported rates of recurrence of FLUTD signs
even after PU.2,5,8,9,14,26,27 Development of recurrent
urinary tract infection and clinical signs of FLUTD
is likely partially due to underlying uropathy and
may not be associated with surgical intervention.27,35
Although these cats were considered to have had
complications secondary to surgery, clinical signs of
FLUTD may have recurred regardless of whether PU
was performed.
Limitations of the present study included its ret-
rospective nature, the low case number, the limited
follow-up for some cases, the inconsistent timing of
patient reevaluation, and the inevitable variations in
reporting for cats assessed by the surgeon versus the
referring veterinarian or owner. Furthermore, assess-
ment of urethral trauma at the time of surgery and
of peristomal inflammation in the postoperative pe-
riod was necessarily subjective. Thus, the incidence
JAVMA • Vol 251 • No. 8 • October 15, 2017 939
Small Animals
and severity of urethral trauma and inflammation
may have been inaccurately reported. Additionally,
because of the retrospective nature of the study and
limitations on the availability of historical medical re-
cords, no direct comparison could be made between
PUs performed at Gulf Coast Veterinary Specialists
with poliglecaprone 25 versus other absorbable or
nonabsorbable sutures. Ideally, a prospective study
with poliglecaprone 25, polydioxanone, and nylon
and comparing continuous and interrupted suture
patterns would be performed to directly compare
outcomes.
Acknowledgments
No third-party funding or support was received in connec-
tion with this study or the writing or publication of the manu-
script. The authors declare that there were no conflicts of interest.
Footnotes
a. Microsoft Excel for Mac 2011, version 14.5.5, Microsoft, Red-
mond, Wash.
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