Penrose Drain
The Penrose drain is the prototypical open, passive, gravity-dependent surgical drain — a soft, flat rubber (or silicone) tube that functions as a simple conduit for fluid to exit a surgical site by capillary action and gravity, without any evacuator or closed collection system.[1] It is named after Charles Bingham Penrose (1862–1925), an American gynecologist and surgeon at the University of Pennsylvania, who introduced the soft latex-rubber passive drain in the late 19th century. The Penrose dominated surgical drainage for much of the 20th century before being progressively supplanted by closed-suction systems (JP, Blake).[1] This page is scoped to reconstructive urology — non-urologic drain literature is filtered out per the WARWIKI scope rule.
Design
- Material: thin-walled natural latex rubber (traditional) or silicone (latex-allergic alternatives).
- Shape: flat, collapsed tube that lies as a wick when empty.
- Sizes: typically ¼ in (6 mm), ½ in (12 mm), ¾ in (19 mm), 1 in (25 mm) width; cut to length intraoperatively.
- Construction: open at both ends; one end may sit within the wound, the other exits through a small skin incision.
- Radiopaque stripe in modern versions for radiographic identification.
Mechanism — passive
The Penrose has no evacuator, no reservoir, and no negative pressure. Fluid exits the body via two physical principles[1]:
- Capillary action along the latex–tissue interface.
- Gravity — fluid flows passively to the dependent skin exit, where it is absorbed into external dressings or gauze.
This open architecture means the drain exit site is in direct communication with the external environment — the central limitation that drives infection risk.
Open vs closed drain — the central trade-off
| Feature | Penrose (open) | JP / Blake (closed) |
|---|---|---|
| System type | Open | Closed |
| Drainage mechanism | Passive (gravity + capillary) | Active negative pressure |
| Collection | External dressings (no reservoir) | Sealed bulb / canister |
| Suction | None | Up to ~ −175 mmHg |
| Bacterial barrier | None — open to environment | Closed system — barrier present |
| Output quantification | Not possible | Volumetric, by reservoir |
| Drain fluid creatinine for urine-leak detection | Difficult — fluid mixed with skin / dressing | Reliable — direct sampling |
Retrograde bacterial migration — the central limitation
A landmark experimental study (rabbit splenectomy model) compared no drain vs Penrose vs JP. After inoculating the skin near the drain exit site with Streptococcus, intraperitoneal cultures at 72 hours were[2]:
| Group | Positive intraperitoneal cultures |
|---|---|
| No drain (control) | 0% |
| Penrose drain | 90% |
| Jackson-Pratt | 20% |
A large prospective observational study confirmed clinical relevance: open drains carry a 3.68-fold increased SSI risk vs closed drains (OR 3.68, 95% CI 1.88–6.89).[3]
This bacteriologic disadvantage is the dominant reason Penrose use has declined across reconstructive urology.
Urologic applications
Partial nephrectomy — the historical Penrose niche
The most-cited urology-specific Penrose study is the Sánchez-Ortiz 2004 MD Anderson series of 197 partial nephrectomies in 184 patients comparing closed-suction vs Penrose[4]:
| Parameter | Closed suction (n=123) | Penrose (n=74) | p |
|---|---|---|---|
| Mean tumor size | 3.1 cm | 3.1 cm | NS |
| Mean drainage duration | 7.8 d | 7.1 d | NS |
| Prolonged urinary drainage | 8.9% | 5.4% | NS |
| Wound infection / perinephric abscess | 2.4% | 5.4% | NS |
| Delayed hemorrhage | 2.4% | 0% | NS |
| Overall complications | — | — | NS |
No statistically significant differences in any complication. This is the study historically cited by urologists who prefer a Penrose after open partial nephrectomy.
Rationale for Penrose preference in PN. Some surgeons argued that closed-suction negative pressure could[4]:
- Prolong urinary leak by actively suctioning urine from the collecting-system repair, preventing healing.
- Promote delayed hemorrhage by disrupting clot formation at the resection bed.
The MD Anderson data did not confirm either concern (both were numerically slightly higher with closed suction but not statistically). The rationale persists in some practices but is not evidence-based.
Tubeless PCNL — a niche where Penrose still works
The Penrose has a defined role as an overnight tract drain after tubeless PCNL when the access tract is cauterized and a DJ stent is left.[5]
- 51-patient series of tubeless PCNL with tract cauterization and overnight Penrose.
- Only 1 patient had urine leak > 24 h.
- No transfusion required.
- Mean LOS 2.2 days.
- No urinomas on follow-up ultrasound.
The Penrose serves as a brief, low-profile drain that allows residual bleeding or fluid to exit the access tract without the bulk and discomfort of a nephrostomy tube — removed the next day.
Ureteral reimplantation
A prospective ureteroneocystostomy study and a pediatric urologist survey found that drain fluid urea and creatinine were consistent with serum, not urine — challenging the assumption that drainage fluid contains a urine component. 73.1% routinely placed external abdominal drains, but 26.5% of those who did believed the drains were probably unnecessary.[6]
Kidney transplantation
Drain use in transplant surgery is variable; both Penrose and closed-suction are still used.[7][8] The infection-risk data favor closed systems given immunosuppression, but consensus is lacking. See JP drain for full transplant-drain evidence.
Complications
- Retrograde bacterial migration / SSI — the central limitation. 90% intraperitoneal positive cultures in the rabbit model; 3.68-fold higher SSI in clinical observational data.[2][3]
- Inability to quantify output — output flows directly into dressings; drain fluid creatinine cannot be reliably sampled. This eliminates the cardinal urology-specific diagnostic test for urine leak (drain creatinine ≫ serum creatinine).
- Skin maceration at the exit site — drainage fluid contacts skin directly.
- Unpredictable drainage — depends on patient positioning; supine patients drain poorly. Passive drainage is more prone to obstruction.
- Latex allergy — traditional Penrose is natural-latex; silicone alternatives are less commonly stocked.
- Retained drain — rare but possible if inadvertently sutured to surrounding tissues.
Niche advantages — when Penrose still earns a place
- No suction on healing tissues — a theoretical attraction after collecting-system or vascular repair, though clinical data do not show a difference.[4]
- Simplicity and low cost — no evacuator, no patient-education burden.
- Easy bedside removal with minimal discomfort.
- No risk of high-pressure tissue injury — closed-suction drains can transiently generate up to ~ −175 mmHg during stripping; Penrose generates none.
- Brief drainage — overnight or short-term, e.g., tubeless PCNL tract drainage.[5]
Antibiotic prophylaxis
Perioperative antibiotic prophylaxis should not be continued solely because a drain is in place — including a Penrose, despite higher infection risk.[9] The IDSA notes drain cultures > 3 days after insertion are difficult to interpret because of colonization; expected pathogens from gravity drains originate from skin or GI flora.[10] See Perioperative Antibiotic Prophylaxis.
The decline — Penrose in contemporary urology
Multiple converging factors explain the progressive replacement of the Penrose with closed-suction drains and ultimately with drain omission:
- Infection evidence — the Raves rabbit-model 90% positive-culture rate fundamentally shifted practice.[2]
- SSI data — open drains carry 3.68-fold higher SSI risk in clinical observational data.[3]
- Output monitoring — inability to quantify drainage volume or analyze drain creatinine makes the Penrose unsuitable for the modern post-partial-nephrectomy monitoring protocol (D/S ratio > 1.2 = leak).[4]
- Drain-omission paradigm — the contemporary uro-oncologic question is increasingly whether to place any drain at all, not which one. Drain omission after RP reduces complications (Kowalewski meta OR 0.62); PN drain omission is non-inferior. See JP drain for the full selective-drainage evidence.[11]
- Minimally invasive surgery — robotic and laparoscopic approaches generate smaller wounds with less dead space and lower complication rates regardless of drain choice.[12][13]
Decision summary
| Procedure | Penrose role | Status |
|---|---|---|
| Open partial nephrectomy | Historical preference for some surgeons to avoid suction on the collecting-system repair | Declining — no outcome difference vs closed suction; broader trend toward no drain at all |
| Robotic / laparoscopic PN | Rarely used | Drains omitted in the majority of cases |
| Tubeless PCNL | Overnight tract drainage after nephrostomy-tube omission with cauterization + DJ stent | Niche, still used |
| Radical prostatectomy | Rarely used; closed-suction preferred when drained | Drains omitted in the majority of cases |
| Radical cystectomy | Rarely used | Emerging drainless evidence |
| Kidney transplant | Variable; Penrose and closed-suction both used | No consensus; consider closed system in immunosuppressed |
| Ureteral reimplantation | Used by some pediatric urologists | ~ 27% of urologists do not place any drain |
| Fournier's debridement / contaminated open wounds | Wick / open-cavity drainage | Niche use; closed-suction also commonly used |
The Penrose remains a historically important device that shaped the evolution of surgical drainage. In contemporary reconstructive urology its use is limited to overnight tract drainage after tubeless PCNL, occasional open partial nephrectomy by surgeons preferring no suction on the renal repair, and contaminated / infected-field wound applications. The broader paradigm trend is toward omitting drains entirely rather than choosing between drain types.
See Also
Jackson-Pratt Drain · Blake Drain · Fournier's Gangrene · Perioperative Antibiotic Prophylaxis
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. Raves JJ, Slifkin M, Diamond DL. A bacteriologic study comparing closed suction and simple conduit drainage. Am J Surg. 1984;148(5):618-620. doi:10.1016/0002-9610(84)90336-2
3. Mujagic E, Zeindler J, Coslovsky M, et al. The association of surgical drains with surgical site infections — a prospective observational study. Am J Surg. 2019;217(1):17-23. doi:10.1016/j.amjsurg.2018.06.015
4. 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
5. Jou YC, Cheng MC, Sheen JH, Lin CT, Chen PC. Cauterization of access tract for nephrostomy tube-free percutaneous nephrolithotomy. J Endourol. 2004;18(6):547-549. doi:10.1089/end.2004.18.547
6. Chow SH, LaSalle MD, Stock JA, Hanna MK. Ureteroneocystostomy: to drain or not to drain. J Urol. 1998;160(3 Pt 2):1001-1003.
7. Lakha AS, Ahmed S, Hunter J, O'Callaghan J. Prophylactic peri-nephric drain placement in renal transplant surgery: a systematic review and meta-analysis. Transpl Int. 2024;37:13030. doi:10.3389/ti.2024.13030
8. Derweesh IH, Ismail HR, Goldfarb DA, et al. Intraoperative placing of drains decreases the incidence of lymphocele and deep vein thrombosis after renal transplantation. BJU Int. 2008;101(11):1415-1419. doi:10.1111/j.1464-410X.2007.07427.x
9. Allegranzi B, Zayed B, Bischoff P, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016;16(12):e288-e303. doi:10.1016/S1473-3099(16)30402-9
10. Miller JM, Binnicker MJ, Campbell S, et al. Guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2024 update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clin Infect Dis. 2024;ciae104. doi:10.1093/cid/ciae104
11. 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
12. 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
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