Guidewire-First Rescue Versus Direct Suprapubic Cystostomy After Failed Urethral Catheterisation: A Propensity-Weighted Cohort Study

Background/Objectives: When urethral catheterisation fails in acute urinary retention, clinicians may pass a guidewire or go directly to suprapubic cystostomy. No published series compares the two after a failed attempt, and comparative trials enrol men in whom either route remains available. We compared the two. Methods: We studied 352 consecutive men at one centre from 2019 to 2025: 246 went directly to cystostomy, 106 to an ultrasound-confirmed bedside guidewire attempt. Time zero was the documented failure of catheterisation, and patients were analysed by the strategy first attempted. The primary outcome, overall strategy-associated complications, was any new Clavien–Dindo grade II or higher complication within 30 days, whichever route produced it; conditions present at time zero did not count. Overlap weighting on 19 covariates gave risk differences with operator-level bootstrap intervals. Follow-up used the hospital and national health records for every patient. Results: The guidewire attempt placed a catheter in 84.9% of men (95% confidence interval [CI] 76.9 to 90.5). After weighting, overall strategy-associated complications affected 17.6% of the cystostomy arm and 5.3% of the guidewire-first arm (−12.2 points, 95% CI −19.0 to −5.5). Grade III or higher events occurred in 7.7% (19/246) of the cystostomy arm and none of the guidewire-first arm. Shared complications, those either route could produce, affected 9.5% and 5.3%, respectively, a difference of −4.2 (−11.2 to 3.8) after weighting and −0.3 (−6.0 to 5.4) when unweighted. Conclusions: An ultrasound-confirmed bedside guidewire attempt was associated with fewer overall strategy-associated complications at 30 days. For shared complications the difference was smaller and no longer excluded zero. Ascertainment was record-based and asymmetric: cystostomy-specific harms are readily recorded, whereas urethral harms such as false passage or later stricture were not captured, and time to definitive drainage was not measured. These findings describe initial rescue strategies and do not establish that either procedure is intrinsically safer.