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The Influence of Vasectomy Upon the Incidence of Epididymitis Following Transurethral Prostatectomy
THE INFLUENCE OF VASECTOMY UPON THE INCIDENCE OF EPIDIDYMITIS FOLLOWING TRANSURETHRAL PROSTATECTOMY JACK M. LYNN
AND
REED M. NESBIT
Ligation and section of the vas deferens as a prophylaxis against epididymitis is an accepted procedure used in conjunction with open prostatectomy, i.e. when enucleation of the adenoma is done either suprapubically or perineally. Considerable interest has been manifested in this subject as evidenced by many essays in the literature of 2 to 3 decades ago. Routine vas section at the time of prostatectomy became popular following the work of Goldstein in 1927, though the procedure had been introduced much earlier (by Proust in 1896). The reported incidence of epididymitis after open prostatectomy is high: 21.4 per cent in 1624 patients recorded by Crabtree and Brodny; 20 per cent in 1049 perineal prostatectomies reported by Young, and 6 per cent of resections reported by Abeshouse. Vas section as a preventative for this complication seems to be a perfectly logical procedure in view of the work of Rolnick who demonstrated a retrograde progression of foreign material up the lumen of the vas, presumably by reflux; of Kreutzmann who cultured bacteria from the vas; and of O'Conor who observed the extension of silver salt to the epididymis 24 hours after its instillation into the bladder. Also Kreutzmann reports a patient who passed a stream of urine out the cut end of the vas at each micturition; and a similar case has occurred in the University of Michigan Hospital. Certainly the ideal time for vas interruption is prior to introduction of infection by cystoscopy or catheterization, but the incidence of wound infection is considerable when this is done as an outpatient procedure without the aseptic facilities afforded by an operating room. Very little has been written concerning postoperative epididymitis within the last 6 years, and there is no report on the use of prophylactic vas section in a large series of transurethral prostatectomies. During this period the administration of sulfonamides while the patient is on catheter drainage has become almost universal; and this factor alone may have reduced the incidence of genital complications following all prostate operations. In an effort to answer several specific questions regarding the value of vasectomy a review was made of a series of cases who had undergone transurethral resection at University of Michigan Hospital. Information desired was: 1) the incidence of postoperative epididymitis following resection when sulfonamides are employed routinely; 2) whether or not this complication is significantly reduced by interruption of the vas deferens at the time of prostatectomy; and 3) if vas section reduces the severity of a subsequently developing epididymitis. Material consisted of 300 cases of transurethral prostatectomy in which the patients had ligation and section of the vas deferens at the time of operation, and 300 cases in which the patients had not been subjected to interruption of the vas deferens. All 600 patients received sulfadiazine 0.5 gm. 4 72
73
EPIDIDYMITIS FOLLOWING TRANSURETHRAL PROSTATECTOMY
times per day from the time of insertion of the catheter, whether before or at the time of operation, until the catheter was removed-usually on the third postoperative day. Two categories were excluded: 1) those patients who had clinical evidence of epididymitis at the time of operation, and 2) all patients who had orchectomy as an adjuvant in the treatment of carcinoma of the prostate. This study was made several months after the date of the most recently performed TABLE
1. Non-section
DAY OF DAY ON ONSET OTHER POST-OP. WHICH OF CATHETER EPIDIDY- COMPLICATIONS POST-OP,
NO.
DAYS ON
PREOP.
CATHETER
URINE
PRE-OP.
REMOVED
MI.TIS
---
--
1
Inf.
9
3
4
2
Inf.
4
4
6
3
Neg.
0
3
10
4
Neg.
0
3
11
5
Inf.
98
8
17
- --
(sup. pub.)
NATURE DAYS OF OF TISSUE FEVER REOVER 100° M:OVED
TEMP.
YAX. POSTOP. TEMP.
TREATMENT OF EPIDIDYMITIS
99.8
103.6
Elevation
0
Ca
2
HemoIThage
99.4
100.2
Elevation Sulfadiaz
0
BPH
1
Late Hem. Cath. Replaced
98.6
104
Elevation Sulfadiaz Orchectomy
Yes
BPH
3
99
104.2
Elevation Sulfadiaz Orchectomy
0
BPH
4
Severe Urethritis
98.6
101
Sulfadiaz
Yes
BPH
?•
YAX. PREOP.
i~
--- 0
0
4
Neg.
0
12
7
Pleurisy
98.6
105
Vasectomy Sulfadiaz
0
BPH
3
7
Inf.
11
12
7
HemoIThage Slow to void
98.6
105
Sulfadiaz
0
BPH
4
8
Neg.
0
3
9
0
98.6
102.2
Elevation Sulfadiaz
0
BPH
3
9
Inf.
4
4
>8
0
98.6
?
Bed Rest
0
Ca
?*
10
Inf.
8
3
>8
0
98.6
?
0
Ca
?•
11
Inf.
5
3
5
0
Elevation Penioillin
0
BPH
1
12
Inf.
0
3
27
0
Elevation Sulfadiaz
0
BPH
?•
100
98.6
101.2
?
?
• Epididymitis began after patient left hospital.
operation, so that all patients who developed epididymitis subsequent to discharge and returned to University Hospital for treatment are included in the series. Table 1 records the pertinent data on patients in whom epididymitis developed among 300 resections of the prostate and who did not have section of the vas deferens performed. Twelve cases of clinical epididymitis occurred, an incidence of 4 per cent. The urine of these patients was usually infected preoperatively; onset of epididymitis varied from 4 to 27 days postoperatively, though it usually
74
JACK M. LYNN AND REED M. NESBIT
began at the end of a week or later. Febrile reaction as a result of the complication was usually of short duration, though two progressed to suppurative orchitis necessitating unilateral orchectomy. Table 2 supplies similar information on epididymal complications among 300 patients who had interruption of the vas deferens at the time of transurethral prostatectomy. The same technique of vas section was employed in all cases. The vas deferens was palpatBd in the upper portion of the scrotum and was encircled with the prongs of a towel clip. A 1 to 2 cm. incision was made in the skin and the vas was cleaned, doubly suture-ligated with O chromic catgut and severed between these two points. Significant complications of this procedure TABLE 2.
NO.
P:REOP. URINE
DAYS ON CATHETER PRE-OP,
--
-
POST-OP. DAY ON WHICH CATHETER REMOVED
DAY OF ONSET OF EPIDIDYMITIS
---
--
Vas se,ction
OTHER POST-OP. COMPLICATIONS
MAX. PREOP. TEMP.
MAX, POSTOP. TEMP.
~
TREATMENT OF EPIDIDYMITIS
~0
.,
l:l
--
NATURE
DAYS
OF OF TISSUE FEVER REOVER 100° MOVED
-- - - --
1
Neg.
0
3
4
0
99.4
102.6
Elevation
0
BPH
2
2
Inf.
21
3
6
0
99.2
101
Elevation
0
BPH
2
3
Inf.
7
3
10
0
99.2
100.6
Elevation Penicillin
0
BPH
2
4
Inf.
6
3
8
0
101.2
Elevation Penicillin
0
BPH
l
5
Inf.
11
3
18
0
100
Sulfadiaz
0
BPH
?*
6
Neg.
0
3
12
?
Penicillin
0
BPH
?*
7
Neg.
0
3
3
0
98.6
100.4
Elevation Sulfadiaz Penicillin
0
BPH
3
8
Inf.
0
2
8
0
98.6
103.6
Elevation
Yoo
BPH
5
Hemorrhage Hemostasis
100
98.6 99
l
• Epididymitis began after patient left the hospital.
were abscess of the operative site, requiring drainage in 2 cases, and 1 scrotal hematoma. Epididymitis occurred in 8 patients (2.7 per cent) who had been subjected to prophylactic section of the vas deferens. Again, the urine was usually infected preoperatively, onset was most frequently at 6 or more days, and duration of fever was short. There are no undeniable facts to explain the lower incidence of postoperative epididymitis after transurethral than after open prostatectomy, but it is believed that it might be due to the shorter period of postoperative catheter drainage. Despite the fact that 2 cases of suppurative orchitis occurred among patients who did not have vas section, there is no conclusive proof that interruption of the vas at the time of operation decreases the morbidity when postoperative epididymitis does occur.
EPIDIDYMITIS FOLLOWING TRANSURETHRAL PROSTATECTOMY
75
CONCLUSIONS
Epididymitis is not a frequent complication following transurethral prostatic resection. In 600 consecutive resections there was a 3.3 per cent incidence. Vas section at the time of transurethral prostatectomy does not significantly reduce the occurrence of postoperative epididymitis. REFERENCES ABESHOUSE, B. S.: Am. J. Surg., 32: 8, 1936. CRABTREE, E.G. AND BRODNY, M. L.: Quoted by GOLDSTEIN, A. E.: J. Urol., 17: 25, 1927. KREUTZMANN, H. A. R.: J. Urol., 39: 123, 1938. O'CONNOR, V. J.: J. Urol., 33: 422, 1935.
RoLNICK, H. C.: Surg., RoLNICK, H. C.: Surg., YouNG, H. H.: Quoted
Abeshouse.
Gynec. & Obst., 41: 15, 1925. Gynec. & Obst., 47: 806, 1928. by Abeshouse.
AND
REED M. NESBIT
Ligation and section of the vas deferens as a prophylaxis against epididymitis is an accepted procedure used in conjunction with open prostatectomy, i.e. when enucleation of the adenoma is done either suprapubically or perineally. Considerable interest has been manifested in this subject as evidenced by many essays in the literature of 2 to 3 decades ago. Routine vas section at the time of prostatectomy became popular following the work of Goldstein in 1927, though the procedure had been introduced much earlier (by Proust in 1896). The reported incidence of epididymitis after open prostatectomy is high: 21.4 per cent in 1624 patients recorded by Crabtree and Brodny; 20 per cent in 1049 perineal prostatectomies reported by Young, and 6 per cent of resections reported by Abeshouse. Vas section as a preventative for this complication seems to be a perfectly logical procedure in view of the work of Rolnick who demonstrated a retrograde progression of foreign material up the lumen of the vas, presumably by reflux; of Kreutzmann who cultured bacteria from the vas; and of O'Conor who observed the extension of silver salt to the epididymis 24 hours after its instillation into the bladder. Also Kreutzmann reports a patient who passed a stream of urine out the cut end of the vas at each micturition; and a similar case has occurred in the University of Michigan Hospital. Certainly the ideal time for vas interruption is prior to introduction of infection by cystoscopy or catheterization, but the incidence of wound infection is considerable when this is done as an outpatient procedure without the aseptic facilities afforded by an operating room. Very little has been written concerning postoperative epididymitis within the last 6 years, and there is no report on the use of prophylactic vas section in a large series of transurethral prostatectomies. During this period the administration of sulfonamides while the patient is on catheter drainage has become almost universal; and this factor alone may have reduced the incidence of genital complications following all prostate operations. In an effort to answer several specific questions regarding the value of vasectomy a review was made of a series of cases who had undergone transurethral resection at University of Michigan Hospital. Information desired was: 1) the incidence of postoperative epididymitis following resection when sulfonamides are employed routinely; 2) whether or not this complication is significantly reduced by interruption of the vas deferens at the time of prostatectomy; and 3) if vas section reduces the severity of a subsequently developing epididymitis. Material consisted of 300 cases of transurethral prostatectomy in which the patients had ligation and section of the vas deferens at the time of operation, and 300 cases in which the patients had not been subjected to interruption of the vas deferens. All 600 patients received sulfadiazine 0.5 gm. 4 72
73
EPIDIDYMITIS FOLLOWING TRANSURETHRAL PROSTATECTOMY
times per day from the time of insertion of the catheter, whether before or at the time of operation, until the catheter was removed-usually on the third postoperative day. Two categories were excluded: 1) those patients who had clinical evidence of epididymitis at the time of operation, and 2) all patients who had orchectomy as an adjuvant in the treatment of carcinoma of the prostate. This study was made several months after the date of the most recently performed TABLE
1. Non-section
DAY OF DAY ON ONSET OTHER POST-OP. WHICH OF CATHETER EPIDIDY- COMPLICATIONS POST-OP,
NO.
DAYS ON
PREOP.
CATHETER
URINE
PRE-OP.
REMOVED
MI.TIS
---
--
1
Inf.
9
3
4
2
Inf.
4
4
6
3
Neg.
0
3
10
4
Neg.
0
3
11
5
Inf.
98
8
17
- --
(sup. pub.)
NATURE DAYS OF OF TISSUE FEVER REOVER 100° M:OVED
TEMP.
YAX. POSTOP. TEMP.
TREATMENT OF EPIDIDYMITIS
99.8
103.6
Elevation
0
Ca
2
HemoIThage
99.4
100.2
Elevation Sulfadiaz
0
BPH
1
Late Hem. Cath. Replaced
98.6
104
Elevation Sulfadiaz Orchectomy
Yes
BPH
3
99
104.2
Elevation Sulfadiaz Orchectomy
0
BPH
4
Severe Urethritis
98.6
101
Sulfadiaz
Yes
BPH
?•
YAX. PREOP.
i~
--- 0
0
4
Neg.
0
12
7
Pleurisy
98.6
105
Vasectomy Sulfadiaz
0
BPH
3
7
Inf.
11
12
7
HemoIThage Slow to void
98.6
105
Sulfadiaz
0
BPH
4
8
Neg.
0
3
9
0
98.6
102.2
Elevation Sulfadiaz
0
BPH
3
9
Inf.
4
4
>8
0
98.6
?
Bed Rest
0
Ca
?*
10
Inf.
8
3
>8
0
98.6
?
0
Ca
?•
11
Inf.
5
3
5
0
Elevation Penioillin
0
BPH
1
12
Inf.
0
3
27
0
Elevation Sulfadiaz
0
BPH
?•
100
98.6
101.2
?
?
• Epididymitis began after patient left hospital.
operation, so that all patients who developed epididymitis subsequent to discharge and returned to University Hospital for treatment are included in the series. Table 1 records the pertinent data on patients in whom epididymitis developed among 300 resections of the prostate and who did not have section of the vas deferens performed. Twelve cases of clinical epididymitis occurred, an incidence of 4 per cent. The urine of these patients was usually infected preoperatively; onset of epididymitis varied from 4 to 27 days postoperatively, though it usually
74
JACK M. LYNN AND REED M. NESBIT
began at the end of a week or later. Febrile reaction as a result of the complication was usually of short duration, though two progressed to suppurative orchitis necessitating unilateral orchectomy. Table 2 supplies similar information on epididymal complications among 300 patients who had interruption of the vas deferens at the time of transurethral prostatectomy. The same technique of vas section was employed in all cases. The vas deferens was palpatBd in the upper portion of the scrotum and was encircled with the prongs of a towel clip. A 1 to 2 cm. incision was made in the skin and the vas was cleaned, doubly suture-ligated with O chromic catgut and severed between these two points. Significant complications of this procedure TABLE 2.
NO.
P:REOP. URINE
DAYS ON CATHETER PRE-OP,
--
-
POST-OP. DAY ON WHICH CATHETER REMOVED
DAY OF ONSET OF EPIDIDYMITIS
---
--
Vas se,ction
OTHER POST-OP. COMPLICATIONS
MAX. PREOP. TEMP.
MAX, POSTOP. TEMP.
~
TREATMENT OF EPIDIDYMITIS
~0
.,
l:l
--
NATURE
DAYS
OF OF TISSUE FEVER REOVER 100° MOVED
-- - - --
1
Neg.
0
3
4
0
99.4
102.6
Elevation
0
BPH
2
2
Inf.
21
3
6
0
99.2
101
Elevation
0
BPH
2
3
Inf.
7
3
10
0
99.2
100.6
Elevation Penicillin
0
BPH
2
4
Inf.
6
3
8
0
101.2
Elevation Penicillin
0
BPH
l
5
Inf.
11
3
18
0
100
Sulfadiaz
0
BPH
?*
6
Neg.
0
3
12
?
Penicillin
0
BPH
?*
7
Neg.
0
3
3
0
98.6
100.4
Elevation Sulfadiaz Penicillin
0
BPH
3
8
Inf.
0
2
8
0
98.6
103.6
Elevation
Yoo
BPH
5
Hemorrhage Hemostasis
100
98.6 99
l
• Epididymitis began after patient left the hospital.
were abscess of the operative site, requiring drainage in 2 cases, and 1 scrotal hematoma. Epididymitis occurred in 8 patients (2.7 per cent) who had been subjected to prophylactic section of the vas deferens. Again, the urine was usually infected preoperatively, onset was most frequently at 6 or more days, and duration of fever was short. There are no undeniable facts to explain the lower incidence of postoperative epididymitis after transurethral than after open prostatectomy, but it is believed that it might be due to the shorter period of postoperative catheter drainage. Despite the fact that 2 cases of suppurative orchitis occurred among patients who did not have vas section, there is no conclusive proof that interruption of the vas at the time of operation decreases the morbidity when postoperative epididymitis does occur.
EPIDIDYMITIS FOLLOWING TRANSURETHRAL PROSTATECTOMY
75
CONCLUSIONS
Epididymitis is not a frequent complication following transurethral prostatic resection. In 600 consecutive resections there was a 3.3 per cent incidence. Vas section at the time of transurethral prostatectomy does not significantly reduce the occurrence of postoperative epididymitis. REFERENCES ABESHOUSE, B. S.: Am. J. Surg., 32: 8, 1936. CRABTREE, E.G. AND BRODNY, M. L.: Quoted by GOLDSTEIN, A. E.: J. Urol., 17: 25, 1927. KREUTZMANN, H. A. R.: J. Urol., 39: 123, 1938. O'CONNOR, V. J.: J. Urol., 33: 422, 1935.
RoLNICK, H. C.: Surg., RoLNICK, H. C.: Surg., YouNG, H. H.: Quoted
Abeshouse.
Gynec. & Obst., 41: 15, 1925. Gynec. & Obst., 47: 806, 1928. by Abeshouse.