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Blake Drain

The Blake drain (Ethicon) is a closed-suction, negative-pressure silicone drain distinguished from the Jackson-Pratt drain by its four longitudinal external channels along a solid-walled silicone tube — not perforations.[1][2] Fluid enters via capillary action and negative pressure along the channels rather than through holes, which eliminates the tissue-ingrowth pathway that drives painful removal of perforated drains. This page is scoped to reconstructive urology and urogynecology — out-of-scope cardiac, thoracic, breast, and general-surgery drain literature is excluded per the WARWIKI scope rule.

Design and construction​

FeatureBlakeJackson-Pratt
Drainage mechanism4 longitudinal external channels (capillary + suction)Perforations (round) or internal flutes (flat)
WallSolid silicone — no holesPerforated or fluted
Cross-sectionRound with external channelsFlat (fluted) or round (perforated)
TipClosed, rounded; trocar-assisted placementClosed
Tissue ingrowth pathwayNone (no holes)Possible through perforations
Removal force / painLowerHigher when ingrowth has occurred
Clogging in debris-rich fluidLower (channels remain patent)Flat JP clogs each time in vitro[3]
Sizes7, 10, 15, 19, 24 Fr7 mm flat / 10 mm round typical
EvacuatorBulb or spring-loaded canisterCompressible bulb 100 / 400 mL

How the channels work. The four longitudinal channels create a large effective drainage surface area along the entire intracavitary segment of the drain. Fluid is drawn into the channels by capillary action plus the negative pressure of the attached evacuator. Drainage capability is proportional to the length of the channeled segment within the cavity — so positioning the maximum length of fluted tube in the dependent dead space is critical.[2]

Why the channel design matters in reconstructive practice​

  • No perforations → no tissue ingrowth. Removal is generally less traumatic than perforated drains, particularly when the drain has been in place long enough for granulation tissue to form. Tissue ingrowth into perforations is the dominant mechanism of difficult / painful removal of standard drains.[1][2]
  • Resistance to clogging. In an experimental drainage model, flat JP drains clogged each time in debris-containing fluid while channeled designs maintained patency.[3] This favors the Blake when significant blood, fibrin, or tissue debris is anticipated — Fournier's debridement, large hematoma cavity, post-fistula-repair pelvis after radiation.
  • Soft, flexible silicone profile. Tolerated well in retroperitoneal and pelvic dead spaces.

Urologic and urogynecologic applications​

The reconstructive surgeon should think of the Blake as functionally equivalent to a JP in most pelvic / retroperitoneal applications, with the channel design preferred when prolonged dwell, debris-rich output, or patient comfort during removal are priorities.

  • Radical / partial cystectomy and urinary diversion — pelvic dead-space drainage, monitoring for urine leak and lymphatic collections via drain creatinine.
  • Radical prostatectomy and bladder-neck reconstruction — pelvic drain when used; see Selective Drainage section below.
  • Partial nephrectomy / renal autotransplantation — perinephric drainage when collecting-system entry creates urine-leak risk.
  • Pyeloplasty / ureteroureterostomy / ureteral reimplantation / ileal ureter — retroperitoneal drainage.
  • Vesicovaginal / rectovaginal / rectourethral / urethroperineal fistula repair — pelvic drainage; the channel design's resistance to clogging is useful in radiation / debris contexts.
  • Phalloplasty / vaginoplasty — donor and recipient sites.
  • Fournier's debridement, scrotal / vulvar / perineal reconstruction — under flap or graft cover.
  • Augmentation cystoplasty / catheterizable channels.
  • Inguinal lymphadenectomy in penile-cancer reconstructive context.

The modern paradigm — selective rather than routine drainage​

Across uro-oncologic surgery, routine drain placement has been progressively replaced by selective, indication-based drainage. The strongest evidence is the Kowalewski 2020 World J Urol systematic review and meta-analysis of 3,664 patients across radical prostatectomy, cystectomy, and partial nephrectomy.[4]

Radical prostatectomy​

The Kowalewski meta showed omitting drains actually reduced postoperative complications (OR 0.62, 95% CI 0.44–0.87, p = 0.006), with no differences in re-intervention, lymphocele, hematoma, or urinary retention rates.[4]

SeriesDesignPatientsKey finding
Araki 2006[5]Prospective552 RRPDrains omitted in 76% with no increase in morbidity if anastomosis was watertight on bladder fill
Sharma 2007[6]Single-surgeon325Drains omitted in 78% (73% open / 90% robotic) — similar complication rates
Musser 2014 (MSK)[7]Cohort651 RALPRoutine drainage did not confer significant complication advantage
Chenam 2018[8]Prospective non-inferiority189 RARPNo-drain not inferior for 90-day overall (17.4% vs 26.8%) or major complications (5.4% vs 5.2%)
Porcaro 2021[9]RCT112 RARP ± ePLNDNo difference Clavien-Dindo (28.9% vs 20.4%, p = 0.254), LOS, readmission
Huang 2021[10]Prospective comparative498No difference in overall / major complications, symptomatic fluid collections, or opioid use

Practice consensus: drains can be safely omitted after RP / RARP when the urethrovesical anastomosis is watertight (confirmed by a saline bladder-fill test). Drains remain appropriate when anastomotic integrity is uncertain or after difficult bladder-neck reconstruction.

Partial nephrectomy​

Kowalewski found no differences in overall complications (OR 0.99, 95% CI 0.65–1.51) or re-intervention (OR 1.16, 95% CI 0.31–4.38) between drain and no-drain groups after PN.[4]

SeriesDesignPatientsKey finding
Sánchez-Ortiz 2004[11]ComparativePN cohortNo difference closed-suction vs Penrose: prolonged urinary drainage 8.9% vs 5.4%, wound infection 2.4% vs 5.4%, delayed hemorrhage 2.4% vs 0%
Kriegmair 2016[12]RCT106 open PNNo advantage to drain placement (p = 0.249) even with collecting-system violation; drained patients had higher pain (p = 0.01) and prolonged mobilization
Abaza 2013[13]Single-surgeon160 RPNDrains omitted in 93% including 78 with collecting-system entry; only 1.3% developed small urinomas, all managed conservatively
Beksac 2020[14]Multi-institutional904 RPNNon-routine drain approach yielded shorter hospital stay (IRR 0.72)

Drain-fluid creatinine — the cardinal urology-specific test​

When drains are placed after partial nephrectomy or any urologic reconstruction at risk for urine leak, the drain-to-serum creatinine ratio (D/S ratio) is the diagnostic test that justifies drain presence[15]:

  • D/S ratio > 1.2 on POD 1 indicates urine leak.
  • In a 140-RAPN series, 21 patients (17%) had D/S > 1.2; elevated D/S correlated with significantly longer drain time (4.2 vs 2.4 days, p = 0.001) and LOS (3.3 vs 2.7 days, p = 0.036).
  • Renal masses 4–7 cm had increased likelihood of elevated D/S (OR 2.78, p = 0.041).
  • The Williams 2017 conclusion: most RAPN do not require a surgical drain, and quantitative drain creatinine analysis identifies the minority who benefit.

Urine leak after partial nephrectomy — incidence and management​

Urine leak occurs in 0.78–17.4% of partial nephrectomies depending on approach and complexity.[16][17][18]

  • Risk factors: larger tumor size, endophytic location, hilar tumors, collecting-system entry, longer warm-ischemia time, reoperative cases.[16][17][18]
  • Robotic approach is associated with lower urine-leak rates (OR 0.376).[16]
  • Conservative management (postoperative drain + Foley alone) resolves 44.9%; addition of ureteral stent, percutaneous drain, or nephrostomy resolves 98.9%.[16]
  • Median time to fistula resolution ~ 43–50 days regardless of management.[19]

Radical cystectomy​

Evidence for drain omission is more limited and emerging.[4]

  • Rich 2023 drainless robotic-assisted radical cystectomy with intracorporeal urinary diversion (n = 381): only 5.5% developed urine leak or intra-abdominal infectious collection. The only significant risk factor was prior radiation therapy (OR 15.12, p = 0.02).[20]
  • When fluid collections do occur after RC, percutaneous drainage is highly successful (technical 100%, clinical 96.9%); collections most often form near the uretero-ileal anastomosis in the right pelvic cavity (80.6%), and lymphoceles increase primary clinical-failure risk (OR 22.67).[21]

Routine omission cannot yet be broadly recommended after open cystectomy or in irradiated patients.

Nephroureterectomy​

A matched-pair analysis of 108 patients undergoing laparoscopic nephroureterectomy with open distal ureterectomy found that omitting drainage did not increase complications or lymphocele rates and shortened hospital stay (11 vs 8 days).[22]

When a drain is still indicated in urology​

Despite the trend toward drainless surgery, drains remain appropriate in specific reconstructive scenarios[4][15]:

  • Uncertain anastomotic integrity after radical prostatectomy (visible leak on bladder-fill test) or vesicourethral / ureteric anastomoses.
  • Complex partial nephrectomy with significant collecting-system violation, large tumors (4–7 cm with elevated D/S risk), or reoperative cases.
  • Radical cystectomy — particularly open approaches and prior pelvic radiation (the strongest predictor of postoperative fluid collection after cystectomy).
  • Significant intraoperative bleeding or coagulopathy.
  • Extended pelvic lymph node dissection with concern for clinically significant lymphocele.
  • Complex fistula repair, vesicovaginal / rectovaginal / rectourethral, especially after radiation.
  • Posterior urethroplasty (Webster / abdominoperineal) for PFUI.
  • Reconstructive procedures with large dead spaces — phalloplasty, vaginoplasty, scrotal / perineal / vulvar reconstruction, Fournier's debridement.

NSQIP signal — drain placement is not free​

A NSQIP analysis comparing drain vs no-drain across multiple urologic procedures (nephrectomy, cystectomy, prostatectomy) found that for nephrectomy and prostatectomy, drain patients had significantly longer length of stay.[23] Drains are an LOS driver across surgical specialties; in low-leak-risk cases, the cost is real.

When to choose Blake over JP​

In urology the two drains are clinically interchangeable in most pelvic / retroperitoneal applications. Blake-favoring scenarios:

  • Anticipated long dwell (multi-week drainage in complex fistula or post-radiation cases) — less tissue ingrowth at removal.
  • Debris-rich output (Fournier's debridement, large hematoma cavity, post-pelvic-radiation reconstruction) — channels less prone to clogging than flat JP.[3]
  • Patient comfort priority for removal — consistent with the device's design intent.

JP-favoring scenarios: routine pelvic / retroperitoneal drainage in low-complexity reconstruction, and where lower cost matters.

Management​

Identical to JP drain management: daily output volume / character / trajectory; drain creatinine when urine leak is suspected (D/S > 1.2 = leak); drain culture only with purulent output or SIRS, with the IDSA caveat that cultures > 3 days post-insertion are difficult to interpret; removal when output is < 30–50 mL / 24 hr of non–urine-like fluid with declining trajectory; do not continue antibiotic prophylaxis solely because a drain is in place.

See Also​

Jackson-Pratt Drain · Penrose Drain · Foley Catheter · Suprapubic Catheter · Perioperative Antibiotic Prophylaxis · Upper Tract Reconstruction · Bladder Neck Reconstruction · Urinary Diversion · Quilting Stitch

References​

1. Meyerson JM. A brief history of two common surgical drains. Ann Plast Surg. 2016;77(1):4-5. doi:10.1097/SAP.0000000000000734

2. Khansa I, Khansa L, Meyerson J, Janis JE. Optimal use of surgical drains: evidence-based strategies. Plast Reconstr Surg. 2018;141(6):1542-1549. doi:10.1097/PRS.0000000000004413

3. Swartz AL, Azuh O, Obeid LV, et al. Developing an experimental model for surgical drainage investigations: an initial report. Am J Surg. 2012;203(3):388-391. doi:10.1016/j.amjsurg.2011.09.015

4. Kowalewski KF, Hendrie JD, Nickel F, et al. Prophylactic abdominal or retroperitoneal drain placement in major uro-oncological surgery: a systematic review and meta-analysis of comparative studies on radical prostatectomy, cystectomy and partial nephrectomy. World J Urol. 2020;38(8):1905-1917. doi:10.1007/s00345-019-02978-2

5. Araki M, Manoharan M, Vyas S, Nieder AM, Soloway MS. A pelvic drain can often be avoided after radical retropubic prostatectomy — an update in 552 cases. Eur Urol. 2006;50(6):1241-1247. doi:10.1016/j.eururo.2006.05.026

6. Sharma S, Kim HL, Mohler JL. Routine pelvic drainage not required after open or robotic radical prostatectomy. Urology. 2007;69(2):330-333. doi:10.1016/j.urology.2006.09.044

7. Musser JE, Assel M, Guglielmetti GB, et al. Impact of routine use of surgical drains on incidence of complications with robot-assisted radical prostatectomy. J Endourol. 2014;28(11):1333-1337. doi:10.1089/end.2014.0268

8. Chenam A, Yuh B, Zhumkhawala A, et al. Prospective randomised non-inferiority trial of pelvic drain placement vs no pelvic drain placement after robot-assisted radical prostatectomy. BJU Int. 2018;121(3):357-364. doi:10.1111/bju.14010

9. Porcaro AB, Siracusano S, Bizzotto L, et al. Is a drain needed after robotic radical prostatectomy with or without pelvic lymph node dissection? Results of a single-center randomized clinical trial. J Endourol. 2021;35(6):922-928. doi:10.1089/end.2018.0176

10. Huang MM, Patel HD, Su ZT, et al. A prospective comparative study of routine versus deferred pelvic drain placement after radical prostatectomy: impact on complications and opioid use. World J Urol. 2021;39(6):1845-1851. doi:10.1007/s00345-020-03439-x

11. Sánchez-Ortiz R, Madsen LT, Swanson DA, Canfield SE, Wood CG. Closed suction or Penrose drainage after partial nephrectomy: does it matter? J Urol. 2004;171(1):244-246. doi:10.1097/01.ju.0000099940.02698.38

12. Kriegmair MC, Mandel P, Krombach P, et al. Drain placement can safely be omitted for open partial nephrectomy: results from a prospective randomized trial. Int J Urol. 2016;23(5):390-394. doi:10.1111/iju.13063

13. Abaza R, Prall D. Drain placement can be safely omitted after the majority of robotic partial nephrectomies. J Urol. 2013;189(3):823-827. doi:10.1016/j.juro.2012.08.236

14. Beksac AT, Okhawere KE, Meilika K, et al. Should a drain be routinely required after transperitoneal robotic partial nephrectomy? J Endourol. 2020;34(9):964-968. doi:10.1089/end.2020.0325

15. Williams RD, Snowden C, Thiel DD. Assessment of perioperative variables that predict the need for surgical drains following robotic partial nephrectomy utilizing quantitative drain creatinine analysis. J Laparoendosc Adv Surg Tech A. 2017;27(1):43-47. doi:10.1089/lap.2016.0417

16. Blachman-Braun R, Patel M, Loebach L, et al. Urinary leak after partial nephrectomy: insights from a cohort with hereditary, multifocal, and reoperative cases. Urol Oncol. 2025;43(8):470.e11-470.e18. doi:10.1016/j.urolonc.2025.03.013

17. Meeks JJ, Zhao LC, Navai N, et al. Risk factors and management of urine leaks after partial nephrectomy. J Urol. 2008;180(6):2375-2378. doi:10.1016/j.juro.2008.08.018

18. Potretzke AM, Knight BA, Zargar H, et al. Urinary fistula after robot-assisted partial nephrectomy: a multicentre analysis of 1,791 patients. BJU Int. 2016;117(1):131-137. doi:10.1111/bju.13249

19. Ghenassia M, Bernhard JC, Margue G, et al. Management of urinary fistulas after partial nephrectomy: results from the U-Leak study (UroCCR-181). World J Urol. 2026;44(1):157. doi:10.1007/s00345-026-06272-w

20. Rich JM, Geduldig J, Cumarasamy S, et al. Eliminating the routine use of postoperative drain placement in patients undergoing robotic-assisted radical cystectomy with intracorporeal urinary diversion. Urol Oncol. 2023;41(11):457.e1-457.e7. doi:10.1016/j.urolonc.2023.08.015

21. Oh CH. Clinical efficacy and safety of percutaneous drainage for post-operative fluid collection in patients with bladder cancer undergoing radical cystectomy and urinary diversion. Medicine (Baltimore). 2023;102(49):e36488. doi:10.1097/MD.0000000000036488

22. Hagimoto H, Kambe T, Mine Y, et al. Necessity of prophylactic drainage tube in retroperitoneal laparoscopic nephroureterectomy with open distal ureterectomy: a matched-pair analysis. Int J Urol. 2023;30(7):579-584. doi:10.1111/iju.15182

23. Talwar A, Bansal A, Knight G, et al. Adverse events of surgical drain placement: an analysis of the NSQIP database. Am Surg. 2024;90(4):672-681. doi:10.1177/00031348231192063