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Unexpected Complications of Radical Prostatectomy
Unexpected Complications of Radical Prostatectomy WALTER S. STRODE, M.D.*
Radical prostatectomy for early carcinoma of the prostate in my experience is a difficult operation to perform. This difficulty is due primarily to the inaccessible location of the prostate deep behind the pubic symphysis, in an area which affords little room for the operator's hands or instruments and limited space for the operator's assistants. Neither the perineal approach nor the retropubic approach provides truly adequate access to this gland and to its blood supply. Exposure of the prostate for radical remova,l by the transsacral approach has not become popular in this country as yet, although this may be related to the training most urologists receive. This paper covers the author's experience with a small series of 14 patients on whom radical prostatectomy was performed for early carcinoma of the prostate. Review of these patients revealed that certain unexpected complications were alarmingly frequent and were peculiar to this operation and to the limited exposure usually available. I believe that careful analysis of these complications has provided me with valuable insights into the critical areas of the operation which must be understood to avoid serious sequelae. Although the techniques of the operative procedures have been thoroughly described in the past, the commonest and most serious complications need to be emphasized and analyzed and the best means for their prevention need to be understood. The two commonly used operative techniques will be compared in the light of the complications peculiar to radical prostatectomy.
MATERIAL AND METHODS (TABLE 1) Table 1 indicates that the series consisted of five patients on whom radical perineal prostatectomy was done and nine patients who received radical retropubic prostatectomy. In general, radical prostatectomy was reserved for patients with a reasonable life expectancy of at least 10 years and whose cancer appeared to be confined to the prostate *Department of Urology, Straub Clinic, Honolulu, Hawaii Surgical Clinics of North America- Vol. 50, No.2, April, 1970
387
Table 1. Summary of Cases STAGE
OF CASE
UNEXPECTED COMPLICATIONS
AGE
APPROACH
DISEASE
1. N.A.
74
Retropubic
B
Rectovesical fistula; anastomotic stricture
Anastomosis water-tight; fistula closed perineally 5 weeks postoperatively
2. S.R.
60
Perineal
A
Transected ureteral orifices
Anastomosis water-tight; suprapubic cystotomy; bilateral ureterotomies to identify ureteral orifices
3. R. T.
65
Perineal
B
None
Anastomosis water-tight; preop ureteral catheters
c.s.
48
Perineal
A
None
Drained urine, 13 days; local recurrence, 9 yrs postoperatively; preop ureteral catheters
5. K.D.
65
Perineal
B
Left ureteral block; Death directly attributable to pyelonephritis; neureteral obstruction and phrectomy; died 24 bacteremia days postoperatively
6. L.M.
64
Perineal
c
Right ureterocutaneous fistula drained for 3 weeks
Completely occluded distal right ureter 1 yr. postoperatively with nonfunctioning kidney; died 7 yr postoperatively from distant metastasis
7. B.G.
58
Retropubic
B
Anastomotic stricture; bilateral distal ureteral strictures
Drained urine 10 days from anastomosis; Bricker procedure 9 months postoperatively; pyelonephritis, bacteremia, death
8. M.S.
57
Retropubic
B
Deep wound hematoma; scrotal urinary extravasation
Bled from inferior epigastric vessels, obstructing catheter; died 4 years postoperatively of cerebral metastasis
9. J.M.
68
Retropubic
B
None
Anastomosis water-tight
c.
59
Retropubic
c
Anastomotic stricDrained urine 11 days; severe ture; bilateral rescarring distal ureters and flux; recurrent pyebladder neck; metastasis to lonephritis acetabulum 2 years postoperatively
11. A. B.
59
Retropubic
A
Hepatic insufficiency; gastrointestinal hemorrhage; wound disruption; died 15 days postoperatively
Chronic alcoholic; jaundice on fifth and dehiscence on seventh postoperative day; massive gastrointestinal bleeding (replaced 18 units)
12. S.F.
54
Retropubic
B
None
Anastomosis water-tight
13. N.T.
48
Retropubic
B
Anastomotic stricture; deep wound abscess
Anastomosis water-tight; preoperative Co-60 teletherapy 4500 rads
14. J. Y.
62
Retropubic
B
Wound abscess
Anastomosis water-tight
4.
10. J.
388
COMMENT
RADICAL PROSTATECTOMY
389
and its capsule. Preoperative needle biopsy of the suspected area was done on all patients, using either the Vim-Silverman needle or the Veenema punch on most; the Travenol disposable needle is now used and appears to be satisfactory. Irradiation was employed in this series in only one patient; he was young (48 years), the biopsy revealed anaplastic carcinoma, and rectal examination suggested possible invasion of the right seminal vesicle. It was felt that an inoperable situation could possibly be converted to an operable one by preoperative irradiation. CASE REPORTS
Examination of this series of patients immediately revealed two prominent groups of complications peculiar to this operation. The first involved trauma to, or obstruction of, the distal ureters at the trigone level, and the second involved vesicourethral anastomotic problems, primarily obstruction. It also seemed to be clear that the perineal approach to radical prostatectomy often affords insufficient ureteral exposure to prevent ureteral injury during surgery. The problem in radical perineal prostatectomy is that the ureters often cannot be visualized before transection of the vesical neck, and the author has found that by the time the ureters are visualized injury may already have occurred. This was found to be true even though intravenous indigo carmine was routinely given in an attempt to visualize the ureteral orifices. Preoperative cystoscopic placement of ureteral catheters seemed, in two patients, to help to prevent injury to the ureters, but even then blind transection of the vesical neck posteriorly was extremely close to the orifices, and subsequent anastomosis of the vesical neck to the urethral stump was difficult because of this. In Case 2 both intramural ureters were transected at the time of perineal prostatectomy. Suprapubic cystotomy and bilateral ureterotomies were required in order to identify the ureteral orifices by antegrade catheterization. Fortunately no permanent injury occurred. Case 5 exemplifies how serious ureteral complication at the time of total prostatectomy can be. This patient's perineal prostatectomy was difficult because of a narrow space between the ischial tuberosities and excessive bleeding (6 units blood replacement), with poor visualization of the bladder neck at the time of anastomosis. For 36 hours postoperatively there was pronounced oliguria, following which diuresis occurred. On the ninth postoperative day the patient developed spiking fever to 103° F., which did not respond to antibiotic therapy. Radioisotope renogram showed complete outflow obstruction of the left kidney. A lifesaving left nephrostomy was attempted, which turned into a difficult nephrectomy because of a friable, infected, massively bleeding kidney (10 units blood replacement). The patient probably would still have survived, but on the sixth day after nephrectomy he developed a complete flank wound disruption requiring secondary closure. He was in shock throughout this procedure and died 3 days after the secondary wound closure from massive right pneumonitis. Certainly this surgical death was directly attributable to ureteral obstruction, caused essentially by poor exposure at the time of surgery. Case 6 was similar to Case 5, but fortunately had a better outcome. Both ureteral orifices were visualized at the time of division of the
390
WALTERS. STRODE
vesical neck, but the vesical incision was close to the right orifice because of previously unsuspected tumor invasion of the right seminal vesicle. The orifice was carefully protected and the anastomosis was thought to be quite adequate. However, a ureterocutaneous fistula drained urine for 3 weeks after the prostatectomy. This leakage was not decreased by replacing the urethral catheter and obviously came from the right ureter. Subsequent intravenous urograms showed mild right hydronephrosis, but by 1 year after surgery the right kidney had become totally nonfunctioning. The patient subsequently died 7 years postoperatively from distant metastasis, possibly reflecting the stage of the disease at the time of prostatectomy. Probably because of my unhappy experiences with ureteral problems in radical perineal prostatectomy I turned to the retropubic approach in 1962 and have used this technique since. My experience suggests that ureteral problems are easier to avoid in the retropubic approach; at least the identification of the ureteral orifices and their protection from direct injury during surgery seems to be simpler. Analysis of the retropubic cases, however, reveals that at least initially the vesical neck-urethral anastomosis was not completely satisfactory. What ureteral problems we did have seemed quite clearly to stem from inadequate vesicourethral anastomosis. The single patient in whom a Flocks bladder tube was used for the urethral anastomosis (Case 1) developed outlet obstruction, which we felt to be due to the smallness of the tube. This patient did not drain urine from the retropubic wound postoperatively at all. However, this may have been decompressed by the rectovesical fistula which he did develop proximal to the anastomosis and which subsequently was closed perineally 5 weeks later. No ureteral problems ensued, probably because urinary drainage around the trigone was avoided. Two of the radical retropubic prostatectomies developed severe problems with the anastomosis, emphasizing the importance of making every possible effort to obtain a water-tight vesicourethral closure. The importance of relocating the new vesical neck far up anteriorly on the anterior bladder wall, closing the old vesical neck in the form of an inverted Y, was not fully appreciated at first by the author. This maneuver displaces the ureteral orifices well away from the anastomosis. Complete and thorough mobilization of the bladder dome by stripping away all the peritoneum and by dividing the urachus (or the fibrous strand representing the urachus) is critical and absolutely essential in enabling the new bladder neck to be brought down to the urethral stump. The author has not found it possible to obtain a direct sutured anastomosis between the new vesical neck and the urethral stump, but I have found that Vest type of perineal sutures are quite adequate to provide a water-tight anastomosis, provided that the bladder is well liberated and the new bladder neck is placed well anteriorly. Case 7 clearly illustrates these points. The patient's bladder neckurethral anastomosis was not water-tight and drained urine for 10 days postoperatively. By the thirteenth postoperative day complete ureteral obstruction at the trigone level occurred. Immediate suprapubic cystostomy revealed an empty bladder with a severe anastomotic stricture between the vesical neck and the urethra Unfortunately both ureteral
391
RADICAL PROSTATECTOMY
orifices were not visible because of the severe fibrotic and inflammatory trigone reaction. Bilateral ureterostomy in situ was done as a life-saving measure, initiating a long series of procedures over the next 10 months. Incontinence, outlet obstruction, and severely damaged distal ureters eventually required an ileal conduit, but the patient survived this for only a short time,, dying from recurrent pyelonephritis with bacteremia. We felt that this patient's death was directly attributable to the inadequate vesical neck anastomosis and ensuing complications. Autopsy revealed no evidence of residual carcinoma. In patient No. 10 almost an identical operative complication occurred, with an inadequate vesical neck anastomosis draining urine for 11 days postoperatively. This resulted not only in anastomotic stricture but in bilateral vesicoureteral reflux and recurrent severe right-sided pyelonephritis. Eventually the patient required an indwelling urethral catheter before he left my care to attend another urologist. He now has metastatic disease in the pelvic girdle, possibly reflecting the fact that this was a stage C carcinoma at the time of surgery, when unexpected extension of tumor through the capsule and into both seminal vesicles was found. The patient's ureteral complication, I feel sure, was directly due to the faulty vesical neck anastomosis. The only other operative death in the series, Case 11, was not related to any technical difficulties during surgery. The retropubic approach provided adequate visualization of the ureters, and thorough mobilization of the bladder produced an excellent water-tight vesical neck anastomosis. The patient did not drain urine postoperatively but developed hepatic insufficiency, apparently because of an underlying severe chronic alcoholism. (His preoperative liver examination had been normal.) Death was due to upper gastrointestinal hemorrhage, which was believed to be directly related to the patient's underlying severe liver disease. Patient No. 13 developed a vesical neck anastomotic stricture despite an adequate water-tight anastomosis, which was accomplished with thorough mobilization of the bladder. The stricture was felt to be due both to preoperative irradiation with cobalt teletherapy and to a deep wound abscess which required incision and drainage. Preoperative irradiation was used because of the patient's young age, an anaplastic biopsy specimen, and clinical evidence of seminal vesicle invasion. The irradiation did not make the surgery more difficult, but it may have contributed to the development of postoperative infection. Patient No. 14 developed a wound infection but no other complication. His anastomosis was water-tight and he has developed no urinary problem since surgery.
DISCUSSION Table 2 lists the unexpected complications of radical prostatectomy which occurred in this series. It is quite clear that distal ureteral and vesical neck .anastomotic problems far overshadow all other complications. Wound abscess, hematoma and dehiscence of the wound are cer-
392
WALTERS. STRODE
Table 2. Unexpected Surgical Complications
Ureteral injury Anastomotic problems Wound infection Wound dehiscence (hepatic insufficiency) Wound hematoma
PERINEAL
RETROPUBIC
TOTAL
3 0 0 0
2
5 4 2 1
4
2' 1
0
tainly not peculiar to this type of surgery and can occur, particularly in radical cancer surgery, in this age group following any type of surgical procedure. It seems in this small series of patients that the distal ureteral problems were primarily encountered in the patients undergoing radical perineal prostatectomy, and these were due chiefly to poor visualization of the ureters and direct ureteral injury at the time of surgery. Those patients undergoing radical retropubic prostatectomy who had ureteral complications were all patients with poor anastomosis of the vesical neck, and the ureteral complications represented a part of the reaction to the anastomotic leakage of urine. These should be, and indeed can be, prevented by careful water-tight vesical neck anastomosis. Unfortunately, in my experience, ureteral injuries associated with perineal prostatectomy cannot be so easily prevented because of the nature of the exposure from the perineal approach.
CONCLUSION On the basis of the material evaluated in our small series of patients, I must conclude that the retropubic approach in radical prostatectomy is superior to the perineal. I base this on the fact that not only can the regional nodes be examined for metastasis before commiting oneself to radical surgery, but also the exposure of the prostate and its blood supply, and of the ureters, is far better from above than from below. The urologic complications peculiar to radical prostatectomy in our series were primarily related to difficulties in obtaining adequate exposure, not only of the prostate gland, but also of the distal ureters and urethral stump. Radical prostatectomy for early carcinoma of the prostate is a valuable operation, but one which may be associated with complications peculiar to this particular procedure. These complications fall into two groups: those involving the distal ureters, and those involving the bladder neck-urethral anastomosis. Ureteral complications are primarily due to the poor exposure often found in this operation and are less common when the operation is done from the retropubic approach. Difficulty visualizing and protecting the ureteral orifices at the time of radical perineal prostatectomy suggests that preoperative cystoscopic ureteral catheterization may be a valuable prophylactic measure. The retropubic approach affords adequate visualization of the trigone and ureteral orifices and more reliable protection of the distal ureters during the removal of the gland and during the vesicourethral anastomosis.
RADICAL PROSTATECTOMY
393
The vesicourethral anastomosis must be water-tight in order to prevent urinary leakage with subsequent anastomotic stricture formation and ureteral scarring at the site of the trigone. The perineal approach probably affords a better opportunity to perform an adequate anastomosis, but the retropubic approach can also be satisfactory providing care is taken in this repair. Anterior relocation of the vesical neck accompanied by total mobilization of the bladder dome with division of the urachus, and peritoneal stripping, if thoroughly done, will result in a water-tight anastomosis without tension. Vest perineal sutures will not bring the bladder neck down to the urethra unless mobilization of the bladder is adequate. This small series of 14 patients is presented to illustrate these points. In my hands the retropubic approach to radical prostatectomy is superior to the perineal operation.
Radical prostatectomy for early carcinoma of the prostate in my experience is a difficult operation to perform. This difficulty is due primarily to the inaccessible location of the prostate deep behind the pubic symphysis, in an area which affords little room for the operator's hands or instruments and limited space for the operator's assistants. Neither the perineal approach nor the retropubic approach provides truly adequate access to this gland and to its blood supply. Exposure of the prostate for radical remova,l by the transsacral approach has not become popular in this country as yet, although this may be related to the training most urologists receive. This paper covers the author's experience with a small series of 14 patients on whom radical prostatectomy was performed for early carcinoma of the prostate. Review of these patients revealed that certain unexpected complications were alarmingly frequent and were peculiar to this operation and to the limited exposure usually available. I believe that careful analysis of these complications has provided me with valuable insights into the critical areas of the operation which must be understood to avoid serious sequelae. Although the techniques of the operative procedures have been thoroughly described in the past, the commonest and most serious complications need to be emphasized and analyzed and the best means for their prevention need to be understood. The two commonly used operative techniques will be compared in the light of the complications peculiar to radical prostatectomy.
MATERIAL AND METHODS (TABLE 1) Table 1 indicates that the series consisted of five patients on whom radical perineal prostatectomy was done and nine patients who received radical retropubic prostatectomy. In general, radical prostatectomy was reserved for patients with a reasonable life expectancy of at least 10 years and whose cancer appeared to be confined to the prostate *Department of Urology, Straub Clinic, Honolulu, Hawaii Surgical Clinics of North America- Vol. 50, No.2, April, 1970
387
Table 1. Summary of Cases STAGE
OF CASE
UNEXPECTED COMPLICATIONS
AGE
APPROACH
DISEASE
1. N.A.
74
Retropubic
B
Rectovesical fistula; anastomotic stricture
Anastomosis water-tight; fistula closed perineally 5 weeks postoperatively
2. S.R.
60
Perineal
A
Transected ureteral orifices
Anastomosis water-tight; suprapubic cystotomy; bilateral ureterotomies to identify ureteral orifices
3. R. T.
65
Perineal
B
None
Anastomosis water-tight; preop ureteral catheters
c.s.
48
Perineal
A
None
Drained urine, 13 days; local recurrence, 9 yrs postoperatively; preop ureteral catheters
5. K.D.
65
Perineal
B
Left ureteral block; Death directly attributable to pyelonephritis; neureteral obstruction and phrectomy; died 24 bacteremia days postoperatively
6. L.M.
64
Perineal
c
Right ureterocutaneous fistula drained for 3 weeks
Completely occluded distal right ureter 1 yr. postoperatively with nonfunctioning kidney; died 7 yr postoperatively from distant metastasis
7. B.G.
58
Retropubic
B
Anastomotic stricture; bilateral distal ureteral strictures
Drained urine 10 days from anastomosis; Bricker procedure 9 months postoperatively; pyelonephritis, bacteremia, death
8. M.S.
57
Retropubic
B
Deep wound hematoma; scrotal urinary extravasation
Bled from inferior epigastric vessels, obstructing catheter; died 4 years postoperatively of cerebral metastasis
9. J.M.
68
Retropubic
B
None
Anastomosis water-tight
c.
59
Retropubic
c
Anastomotic stricDrained urine 11 days; severe ture; bilateral rescarring distal ureters and flux; recurrent pyebladder neck; metastasis to lonephritis acetabulum 2 years postoperatively
11. A. B.
59
Retropubic
A
Hepatic insufficiency; gastrointestinal hemorrhage; wound disruption; died 15 days postoperatively
Chronic alcoholic; jaundice on fifth and dehiscence on seventh postoperative day; massive gastrointestinal bleeding (replaced 18 units)
12. S.F.
54
Retropubic
B
None
Anastomosis water-tight
13. N.T.
48
Retropubic
B
Anastomotic stricture; deep wound abscess
Anastomosis water-tight; preoperative Co-60 teletherapy 4500 rads
14. J. Y.
62
Retropubic
B
Wound abscess
Anastomosis water-tight
4.
10. J.
388
COMMENT
RADICAL PROSTATECTOMY
389
and its capsule. Preoperative needle biopsy of the suspected area was done on all patients, using either the Vim-Silverman needle or the Veenema punch on most; the Travenol disposable needle is now used and appears to be satisfactory. Irradiation was employed in this series in only one patient; he was young (48 years), the biopsy revealed anaplastic carcinoma, and rectal examination suggested possible invasion of the right seminal vesicle. It was felt that an inoperable situation could possibly be converted to an operable one by preoperative irradiation. CASE REPORTS
Examination of this series of patients immediately revealed two prominent groups of complications peculiar to this operation. The first involved trauma to, or obstruction of, the distal ureters at the trigone level, and the second involved vesicourethral anastomotic problems, primarily obstruction. It also seemed to be clear that the perineal approach to radical prostatectomy often affords insufficient ureteral exposure to prevent ureteral injury during surgery. The problem in radical perineal prostatectomy is that the ureters often cannot be visualized before transection of the vesical neck, and the author has found that by the time the ureters are visualized injury may already have occurred. This was found to be true even though intravenous indigo carmine was routinely given in an attempt to visualize the ureteral orifices. Preoperative cystoscopic placement of ureteral catheters seemed, in two patients, to help to prevent injury to the ureters, but even then blind transection of the vesical neck posteriorly was extremely close to the orifices, and subsequent anastomosis of the vesical neck to the urethral stump was difficult because of this. In Case 2 both intramural ureters were transected at the time of perineal prostatectomy. Suprapubic cystotomy and bilateral ureterotomies were required in order to identify the ureteral orifices by antegrade catheterization. Fortunately no permanent injury occurred. Case 5 exemplifies how serious ureteral complication at the time of total prostatectomy can be. This patient's perineal prostatectomy was difficult because of a narrow space between the ischial tuberosities and excessive bleeding (6 units blood replacement), with poor visualization of the bladder neck at the time of anastomosis. For 36 hours postoperatively there was pronounced oliguria, following which diuresis occurred. On the ninth postoperative day the patient developed spiking fever to 103° F., which did not respond to antibiotic therapy. Radioisotope renogram showed complete outflow obstruction of the left kidney. A lifesaving left nephrostomy was attempted, which turned into a difficult nephrectomy because of a friable, infected, massively bleeding kidney (10 units blood replacement). The patient probably would still have survived, but on the sixth day after nephrectomy he developed a complete flank wound disruption requiring secondary closure. He was in shock throughout this procedure and died 3 days after the secondary wound closure from massive right pneumonitis. Certainly this surgical death was directly attributable to ureteral obstruction, caused essentially by poor exposure at the time of surgery. Case 6 was similar to Case 5, but fortunately had a better outcome. Both ureteral orifices were visualized at the time of division of the
390
WALTERS. STRODE
vesical neck, but the vesical incision was close to the right orifice because of previously unsuspected tumor invasion of the right seminal vesicle. The orifice was carefully protected and the anastomosis was thought to be quite adequate. However, a ureterocutaneous fistula drained urine for 3 weeks after the prostatectomy. This leakage was not decreased by replacing the urethral catheter and obviously came from the right ureter. Subsequent intravenous urograms showed mild right hydronephrosis, but by 1 year after surgery the right kidney had become totally nonfunctioning. The patient subsequently died 7 years postoperatively from distant metastasis, possibly reflecting the stage of the disease at the time of prostatectomy. Probably because of my unhappy experiences with ureteral problems in radical perineal prostatectomy I turned to the retropubic approach in 1962 and have used this technique since. My experience suggests that ureteral problems are easier to avoid in the retropubic approach; at least the identification of the ureteral orifices and their protection from direct injury during surgery seems to be simpler. Analysis of the retropubic cases, however, reveals that at least initially the vesical neck-urethral anastomosis was not completely satisfactory. What ureteral problems we did have seemed quite clearly to stem from inadequate vesicourethral anastomosis. The single patient in whom a Flocks bladder tube was used for the urethral anastomosis (Case 1) developed outlet obstruction, which we felt to be due to the smallness of the tube. This patient did not drain urine from the retropubic wound postoperatively at all. However, this may have been decompressed by the rectovesical fistula which he did develop proximal to the anastomosis and which subsequently was closed perineally 5 weeks later. No ureteral problems ensued, probably because urinary drainage around the trigone was avoided. Two of the radical retropubic prostatectomies developed severe problems with the anastomosis, emphasizing the importance of making every possible effort to obtain a water-tight vesicourethral closure. The importance of relocating the new vesical neck far up anteriorly on the anterior bladder wall, closing the old vesical neck in the form of an inverted Y, was not fully appreciated at first by the author. This maneuver displaces the ureteral orifices well away from the anastomosis. Complete and thorough mobilization of the bladder dome by stripping away all the peritoneum and by dividing the urachus (or the fibrous strand representing the urachus) is critical and absolutely essential in enabling the new bladder neck to be brought down to the urethral stump. The author has not found it possible to obtain a direct sutured anastomosis between the new vesical neck and the urethral stump, but I have found that Vest type of perineal sutures are quite adequate to provide a water-tight anastomosis, provided that the bladder is well liberated and the new bladder neck is placed well anteriorly. Case 7 clearly illustrates these points. The patient's bladder neckurethral anastomosis was not water-tight and drained urine for 10 days postoperatively. By the thirteenth postoperative day complete ureteral obstruction at the trigone level occurred. Immediate suprapubic cystostomy revealed an empty bladder with a severe anastomotic stricture between the vesical neck and the urethra Unfortunately both ureteral
391
RADICAL PROSTATECTOMY
orifices were not visible because of the severe fibrotic and inflammatory trigone reaction. Bilateral ureterostomy in situ was done as a life-saving measure, initiating a long series of procedures over the next 10 months. Incontinence, outlet obstruction, and severely damaged distal ureters eventually required an ileal conduit, but the patient survived this for only a short time,, dying from recurrent pyelonephritis with bacteremia. We felt that this patient's death was directly attributable to the inadequate vesical neck anastomosis and ensuing complications. Autopsy revealed no evidence of residual carcinoma. In patient No. 10 almost an identical operative complication occurred, with an inadequate vesical neck anastomosis draining urine for 11 days postoperatively. This resulted not only in anastomotic stricture but in bilateral vesicoureteral reflux and recurrent severe right-sided pyelonephritis. Eventually the patient required an indwelling urethral catheter before he left my care to attend another urologist. He now has metastatic disease in the pelvic girdle, possibly reflecting the fact that this was a stage C carcinoma at the time of surgery, when unexpected extension of tumor through the capsule and into both seminal vesicles was found. The patient's ureteral complication, I feel sure, was directly due to the faulty vesical neck anastomosis. The only other operative death in the series, Case 11, was not related to any technical difficulties during surgery. The retropubic approach provided adequate visualization of the ureters, and thorough mobilization of the bladder produced an excellent water-tight vesical neck anastomosis. The patient did not drain urine postoperatively but developed hepatic insufficiency, apparently because of an underlying severe chronic alcoholism. (His preoperative liver examination had been normal.) Death was due to upper gastrointestinal hemorrhage, which was believed to be directly related to the patient's underlying severe liver disease. Patient No. 13 developed a vesical neck anastomotic stricture despite an adequate water-tight anastomosis, which was accomplished with thorough mobilization of the bladder. The stricture was felt to be due both to preoperative irradiation with cobalt teletherapy and to a deep wound abscess which required incision and drainage. Preoperative irradiation was used because of the patient's young age, an anaplastic biopsy specimen, and clinical evidence of seminal vesicle invasion. The irradiation did not make the surgery more difficult, but it may have contributed to the development of postoperative infection. Patient No. 14 developed a wound infection but no other complication. His anastomosis was water-tight and he has developed no urinary problem since surgery.
DISCUSSION Table 2 lists the unexpected complications of radical prostatectomy which occurred in this series. It is quite clear that distal ureteral and vesical neck .anastomotic problems far overshadow all other complications. Wound abscess, hematoma and dehiscence of the wound are cer-
392
WALTERS. STRODE
Table 2. Unexpected Surgical Complications
Ureteral injury Anastomotic problems Wound infection Wound dehiscence (hepatic insufficiency) Wound hematoma
PERINEAL
RETROPUBIC
TOTAL
3 0 0 0
2
5 4 2 1
4
2' 1
0
tainly not peculiar to this type of surgery and can occur, particularly in radical cancer surgery, in this age group following any type of surgical procedure. It seems in this small series of patients that the distal ureteral problems were primarily encountered in the patients undergoing radical perineal prostatectomy, and these were due chiefly to poor visualization of the ureters and direct ureteral injury at the time of surgery. Those patients undergoing radical retropubic prostatectomy who had ureteral complications were all patients with poor anastomosis of the vesical neck, and the ureteral complications represented a part of the reaction to the anastomotic leakage of urine. These should be, and indeed can be, prevented by careful water-tight vesical neck anastomosis. Unfortunately, in my experience, ureteral injuries associated with perineal prostatectomy cannot be so easily prevented because of the nature of the exposure from the perineal approach.
CONCLUSION On the basis of the material evaluated in our small series of patients, I must conclude that the retropubic approach in radical prostatectomy is superior to the perineal. I base this on the fact that not only can the regional nodes be examined for metastasis before commiting oneself to radical surgery, but also the exposure of the prostate and its blood supply, and of the ureters, is far better from above than from below. The urologic complications peculiar to radical prostatectomy in our series were primarily related to difficulties in obtaining adequate exposure, not only of the prostate gland, but also of the distal ureters and urethral stump. Radical prostatectomy for early carcinoma of the prostate is a valuable operation, but one which may be associated with complications peculiar to this particular procedure. These complications fall into two groups: those involving the distal ureters, and those involving the bladder neck-urethral anastomosis. Ureteral complications are primarily due to the poor exposure often found in this operation and are less common when the operation is done from the retropubic approach. Difficulty visualizing and protecting the ureteral orifices at the time of radical perineal prostatectomy suggests that preoperative cystoscopic ureteral catheterization may be a valuable prophylactic measure. The retropubic approach affords adequate visualization of the trigone and ureteral orifices and more reliable protection of the distal ureters during the removal of the gland and during the vesicourethral anastomosis.
RADICAL PROSTATECTOMY
393
The vesicourethral anastomosis must be water-tight in order to prevent urinary leakage with subsequent anastomotic stricture formation and ureteral scarring at the site of the trigone. The perineal approach probably affords a better opportunity to perform an adequate anastomosis, but the retropubic approach can also be satisfactory providing care is taken in this repair. Anterior relocation of the vesical neck accompanied by total mobilization of the bladder dome with division of the urachus, and peritoneal stripping, if thoroughly done, will result in a water-tight anastomosis without tension. Vest perineal sutures will not bring the bladder neck down to the urethra unless mobilization of the bladder is adequate. This small series of 14 patients is presented to illustrate these points. In my hands the retropubic approach to radical prostatectomy is superior to the perineal operation.