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A Clinical Study of Bacteremia and Overhydration Following Transurethral Resection
THE JOURNAL OF UROLOGY
Vol. 72, No. 6, December 1954 Printed in U.S.A.
A CLINICAL STUDY OF BACTEREMIA AND OVERHYDRATION FOLLOvVING TRANSURETHRAL RESECTION GEORGE J. BULKLEY, VINCENT J. O'CONOR J. KENNETH SOKOL
AND
From the Urologic Service of Wesley Memorial Hospital, Chicago, Ill.
During the course of transurethral resection of the prostate gland and bladder neck, the venous plexus which surrounds the capsule of the gland is often opened, thus offering a ready avenue for the introduction of irrigating fluid directly into the venous system. Following the reports of 1\/IcLaughlin, 1 Creevy2 and others, the dangers accompanying the use of distilled ·water as an irrigating medium have been widely recognized. Investigations of Landsteiner and Finch3 have shown that as much as 1,000 to 1,500 cc fluid may be forced into the vascular system during the course of a transurethral resection. Vesical and intravascular hemolysis with resultant hemoglobinemia, hemoglobinuria and renal damage has been noted and reported by a number of observers. 4 • 5 We believe it has been definitely established that the use of sterile distilled water for irrigating purposes may cause hemolysis, either within the bladder or the venous system, and, as a result, renal changes of a toxic and obstructive nature may bring about oliguria, anuria and, in rare instances, even death. For this reason, we employ a 1.1 per cent glycine solution in all transurethral procedures. This medium was first suggested by Nesbit 6 and has been preferred by us to the use of 4 per cent glucose solution advocated by Creevy. In addition to the danger of hemolysis and hemoglobinemia, there are two other potentially serious sequelae which may follow the intravenous infusion of irrigating fluid into open venous sinuses in the prostatic bed. These are bacteremia and overhydration. During the past 3 years, we have been on the alert to study both possible complications, and these observations comprise the subject of this discussion. During the years 1951 and 1952, 257 consecutive transurethral prostatic resections ·were recorded on our service at Wesley Memorial Hospital in Chicago. Of this group, 128 consecutive operative cases were studied with particular reference to the incidence of bacteremia. All of these patients were carefully watched for signs of overhydration during, and especially tovrnrd the end of the operative procedure. Accepted for publication March 17, 1954. 1 McLaughlin, W. L., Holyoke, J.B. and Bowler, J.P.: Oliguria following transurethral resection of prostate gland. J. Urol., 58: 47-60, 1947. 2 Creevy, C. D. and Webb, E. A.: A fatal hemolytic reaction following transurethra.1 resection of prostate gland: A discussion of its prevention and treatment. Surgery, 21: 5666, 1947. 3 Landsteiner, E. K. and Finch, C. A.: Hemoglobinemia accompanying transurethral resection of prostate. New Eng. J. Med., 237: 310-312, 1947. 4 Goodwin, W. E., Cason, J. F. and Scott, W.W.: Hemoglobinemia and lower nephron nephrosis following transurethral prostatic surgery. J. Urol., 65: 1075-1092, 1951. 5 Ebert, C. E.: A clinical comparison of the use of glucose and urea in irrigating solutions for transurethral prostatic resections. J. Urol., 62: 736-741, 1949. 6 Nesbit, R. M. and Glickman, S. J.: The use of glycine solution as an irrigating medium during transurethral resection. J. Urol., 59: 1212-1216, 1948. 1205
1206
BULKLEY, o'CONOR AND SOKOL
TABLE
1. Complications Per Cent
No.
Extravasation of urine (one fatal). Secondary hemorrhage ............ . Required evacuation and coagulation through the resectoscope. I Required catheter drainage. Epididymitis. Urethral stricture . Secondary resection .. Thrombophlebitis. Pulmonary embolus. Pneumonia and atelectasis ..... TABLE
2
7
0.78 2.7
4
3 8 5
13 2
1 1
3.1 1.97 5.1 0.78 0.39 0.39
2. Associated urinary tract diseases
Carcinoma of the bladder . Bladder stone . Bladder diverticulum. Prostatic calculi. Tuberculosis of the prostate. Atony of the bladder. Renal calculi .
17 4
5 2 2 4 1
6.6 1.5 1. 9 0.78 0.78 1. 5 0.39
In this group of 257 patients, there was one operative death. This occurred five days after operation and was due to extravasation of urine and cardiac failure. The mortality rate, therefore, was 0.38 per cent for the two-year period. Complications following transurethral resection for the entire period have been carefully compiled in table 1. The associated urinary tract diseases which often complicated the treatment are listed in table 2. BACTEREMIA AND SEPTICEMIA
Numerous reports in the past have given evidence of the common occurrence of bacteremia and septicemia following manipulation of the prostate and male urethra. Scott,7 in 1929, reported 82 patients who were found to have bacteremia following various urethral manipulations, and of this group there was a mortality of 18 per cent. In 1930, Barrington and ·wright8 showed bacteremia occurring in a high percentage of patients following urethral dilatation. Creevy and Feeney9 recently published a report indicating that 45.4 per cent of patients had positive blood cultures following transurethral resection of the prostate when they had received no preoperative medication. In a comparable group of their patients, the preoperative administration of aureomycin reduced this incidence to 17 .4 per cent. Another report of Biorn, Browning and Thomp7 Scott, W. W.: Blood stream infections in urology: A report of 82 cases. J. U rol., 21: 527-566, 1929. 8 Barrington, F. J. F. and Wright, H. D.: Bacteremia following operations on the urethra. J. Path. & Bact., 33: 871-888, 1930. 9 Creevy, C. D. and Feeney, M. J.: Infection following transurethral resection of prostate gland. Bull. Univ. Minn. Hosp. and Minn. Med. Found., 20: 314-327, 1949.
BACTEREMIA AND OVERHYDRA'l'ION FOLLOWING RESECTION
1207
son10 gave an incidence of 1203 per cent positive blood cultures occurring postoperatively in a series of 106 patientso No mention is made of preoperative medicationo Gray and Scott at Rochester, New York11 found an incidence of 5503 per cent positive blood cultures following transurethral resection in a series of 47 patientso Another group of 93 patients subjected to open prostatectomy showed positive blood cultures in 2608 per cento All of these patients had received aureomycin for 24 hours preoperativelyo There was no evidence in these reports to indicate any increase in morbidity or mortality in those patients who were reported as having had positive blood cultures postoperativelyo Recent reports also have demonstrated the relationship between urologic procedures and subacute bacterial endocarditiso Merritt12 reports a 10 per cent incidence of bacterial endocarditis following transurethral prostatic resection in patients who had previous valvular heart disease, We have studied 128 consecutive cases of transurethral resection of the prostate with pre- and postoperative blood cultures taken immediately before and immediately after the operative procedureo Cultures were inoculated within a few hours on enriched tryptose phosphate broth, incubated at 37° for 48 hourso Each day for 3 weeks the broth cultures were subcultured on blood agar plateso A gram stain was made at the same timeo Positive cultures were isolated and identifiedo All preoperative cultures were negative with one exceptiono This patient showed a positive culture for Staphylococcus aureus on the blood taken before operation, but a negative culture after the procedureo This undoubtedly was due to contamination, and was the only such instance encountered in the group studiedo Only two patients in the entire series had a positive postoperative blood culture; an incidence of L56 per cent, Both of these patients had a negative preoperative blood culture. The first patient had received no preoperative medicationo The urinalysis showed many leukocytes and a trace of albumino Following the resection of 25 gm, benign prostatic tissue, his blood culture was positive for Pseudomonas aeruginosao The temperature rose to 103F on the second postoperative day, and did not return to normal until the fifth postoperative dayo This man received gantrisin and terramycin by mouth during the postoperative periodo There were no complications and no evidence of any harmful effects as a result of the bacteremia, The second patient had received preoperative gantrisin and penicillin in therapeutic doseso A preoperative urine culture showed Pseudomonas aeruginosa in heavy growtho Following the resection of 38 gmo benign obstructing prostate, the blood culture was positive with a heavy growth of Pseudomonas aeruginosa, The postoperative course was complicated by epididymitis which appeared on the fourth day and was accompanied by a persistent pyuria which lasted for over 10 Biorn, C, L., Browning, WO Ho and Thompson, Lo: Transient bacteremia immediately following transurethral prostatic resectiono Jo Urol., 63: 155--161, 19500 ll Grey, Do No and Scott, WO WO: The incidence and type of bacteremia at the time of various prostatectomy procedureso Presented at meeting of Clinical Society of GenitoUrinary Surgeons, Rochester, No Y,, Feb. 5, 19530 12 Merritt, Wo A,: Bacterial endocarditis as a complication of transurethral prostatic resection. Jo UroL, 65: 100-107, 195L
1208
BULKLEY, o'coNOR AND SOKOL
three months. This finally responded to intensive chemotherapy and healing of the vesical neck. The postoperative temperature was elevated to 102F and fell to normal on the twelfth postoperative day after continuation of penicillin and gantrisin therapy. The final functional result was very satisfactory in this patient. Of the remaining 125 cases in which both pre- and postoperative blood cultures were negative, 67 had received no preoperative medication for control of infection. The others had received sulfa drugs, penicillin, streptomycin or aureomycin or a combination of these agents in the usual therapeutic dosage. These results offer great contrast to those reported by the other authors cited. The results indicate that in our experience postoperative bacteremia is a rare occurrence, and, when it does occur, is not of any apparent significance. Many of these patients had preoperative urinary infection, and, in some, venous sinuses were entered during the course of the resection so that the possibility of transient bacteremia was certainly present. Most of our patients with severe urinary infection did receive preoperative medication, and this may have lessened the possibility of obtaining a positive postoperative blood culture. However, the discrepancy between the low incidence of bacteremia in the series studied by us as compared to the high incidence noted by others, even in patients who had received preoperative medication, is indeed difficult for us to explain. Our technical and laboratory facilities have been excellent, and in the hands of personnel with an extensive bacteriological experience. OVERHYDRATION
An occasional complication, not as yet mentioned in the literature, but which we wish to emphasize here, is that of overhydration during transurethral surgery. Prior to this present study, O'Conor and Sokol had observed 4 patients who indicated this additional danger when irrigating fluid was forced through the prostatic plexus during a transurethral resection. Two phenomena were observed. The first was the occurrence of acute pulmonary edema in patients undergoing transurethral resections during which considerable venous bleeding was encountered. This was necessarily accompanied by prolonged irrigation and coagulation. The second was the observation that there was an output of a very large volume of urine in the immediate postoperative period; usually the day of the operation and throughout the first postoperative day. This occurred despite a normal or restricted intake of fluid during the same period. This had also been noted in patients who had considerable venous sinus bleeding during their operative procedure. It is our belief that these phenomena are due to overhydration from the introduction of large quantities of fluid through the prostatic venous plexus during the surgical period. Two patients were observed who had sudden left heart failure and acute pulmonary edema toward the end of a transurethral resection. There seemed to be no apparent cause for this sudden development other than overloading of the circulation with irrigating fluid. Two other patients were observed who did not present the above complication, but who were noted to have excessively high
BACTEREMIA AND OVERHYDRATION FOLLOWING RESECTION TABLE
3. Intake and output, case 3
Intake (cc) ....................... Output (cc) ...................... TABLE
1209
Oper. Day
1st P. 0.
2nd P. 0.
3 P. 0.
4th P. 0.
1800 3025
2554 4850
3020 2400
2400 1800
2700 2050
2900 2850
2770 3400
4. Intake and output, case 4
Intake (cc) ...................... · I Output (cc) ..................... .
3945 2400
3220 5775
2290 2450
urinary output postoperatively as compared with the fluid intake. None of these patients were in any way edematous before surgery. This discrepancy in output of urine also was considered to be due directly to excretion of fluid from the body following introduction of large amounts through open venous sinuses during the resection. These latter two patients showed no evidence of pulmonary edema during surgery, indicating that they could tolerate excess fluid without circulatory failure. The intake and output records of the latter 2 patients are presented in tables 3 and 4. In an attempt to determine the incidence of overhydration as well as its degree, we have studied the pre- and postoperative blood hematocrit levels immediately before and immediately after transurethral prostatic resection on the same 128 consecutive cases also studied with blood cultures. Of this group 29 were rejected as unsatisfactory due to clotting or insufficient blood leaving 99 patients with technically satisfactory readings. Sixteen of these showed no change in the hematocrit following transurethral resection. Forty-six patients showed a decrease in the reading ranging from one-half to four per cent and indicating some hemodilution. However 37 patients showed an increase in the hematocrit of ½ to 3 per cent indicating hemoconcentration. There was no correlation between the cases showing hemodilution and the size of the gland or extent of the resection. There were no instances of clinical overhydration observed during the period these hematocrit studies were carried out. The significance of the hematocrit studies was disappointing and apparently not of any real clinical or laboratory value. More accurate methods of studying blood volume immediately pre- and postoperatively will be necessary in order to evaluate the incidence and importance of overhydration. Further studies using radioactive isotopes to determine blood volume more accurately are contemplated. The possibility of temporary salt-depletion by overhydration is the subject of a present study. SUMMARY
A group of 257 consecutive transurethral prostatic resections done over a two-year period were studied. One hundred and twenty-eight of these patients were followed in detail with pre- and postoperative blood culture and hematocrit determinations in order to determine the incidence of bacteremia and overhydration.
1210
BULKLEY, O'CONOR AND SOKOL
Bacteremia occurred in only 1.56 per cent of this group and did not seem to offer serious complications. The reason for the discrepancy between this figure and that reported by other authors is not apparent. Preoperative chemotherapy seems indicated in cases with significant urinary tract infections, and in those with valvular heart disease, but not as "routine." Hematocrit determinations were not sufficiently accurate as a method of estimating blood volume or hemodilution and in this group showed no significant pattern. However our previous clinical observations of overhydration, as manifested by acute pulmonary edema during transurethral resection and unusually large fluid output during the postoperative period, would indicate that more accurate methods of study are needed. Recognition of overhydration is important as cardiac and systemic treatment must be accompanied by withholding additional fluid until proper water balance has become established.
Vol. 72, No. 6, December 1954 Printed in U.S.A.
A CLINICAL STUDY OF BACTEREMIA AND OVERHYDRATION FOLLOvVING TRANSURETHRAL RESECTION GEORGE J. BULKLEY, VINCENT J. O'CONOR J. KENNETH SOKOL
AND
From the Urologic Service of Wesley Memorial Hospital, Chicago, Ill.
During the course of transurethral resection of the prostate gland and bladder neck, the venous plexus which surrounds the capsule of the gland is often opened, thus offering a ready avenue for the introduction of irrigating fluid directly into the venous system. Following the reports of 1\/IcLaughlin, 1 Creevy2 and others, the dangers accompanying the use of distilled ·water as an irrigating medium have been widely recognized. Investigations of Landsteiner and Finch3 have shown that as much as 1,000 to 1,500 cc fluid may be forced into the vascular system during the course of a transurethral resection. Vesical and intravascular hemolysis with resultant hemoglobinemia, hemoglobinuria and renal damage has been noted and reported by a number of observers. 4 • 5 We believe it has been definitely established that the use of sterile distilled water for irrigating purposes may cause hemolysis, either within the bladder or the venous system, and, as a result, renal changes of a toxic and obstructive nature may bring about oliguria, anuria and, in rare instances, even death. For this reason, we employ a 1.1 per cent glycine solution in all transurethral procedures. This medium was first suggested by Nesbit 6 and has been preferred by us to the use of 4 per cent glucose solution advocated by Creevy. In addition to the danger of hemolysis and hemoglobinemia, there are two other potentially serious sequelae which may follow the intravenous infusion of irrigating fluid into open venous sinuses in the prostatic bed. These are bacteremia and overhydration. During the past 3 years, we have been on the alert to study both possible complications, and these observations comprise the subject of this discussion. During the years 1951 and 1952, 257 consecutive transurethral prostatic resections ·were recorded on our service at Wesley Memorial Hospital in Chicago. Of this group, 128 consecutive operative cases were studied with particular reference to the incidence of bacteremia. All of these patients were carefully watched for signs of overhydration during, and especially tovrnrd the end of the operative procedure. Accepted for publication March 17, 1954. 1 McLaughlin, W. L., Holyoke, J.B. and Bowler, J.P.: Oliguria following transurethral resection of prostate gland. J. Urol., 58: 47-60, 1947. 2 Creevy, C. D. and Webb, E. A.: A fatal hemolytic reaction following transurethra.1 resection of prostate gland: A discussion of its prevention and treatment. Surgery, 21: 5666, 1947. 3 Landsteiner, E. K. and Finch, C. A.: Hemoglobinemia accompanying transurethral resection of prostate. New Eng. J. Med., 237: 310-312, 1947. 4 Goodwin, W. E., Cason, J. F. and Scott, W.W.: Hemoglobinemia and lower nephron nephrosis following transurethral prostatic surgery. J. Urol., 65: 1075-1092, 1951. 5 Ebert, C. E.: A clinical comparison of the use of glucose and urea in irrigating solutions for transurethral prostatic resections. J. Urol., 62: 736-741, 1949. 6 Nesbit, R. M. and Glickman, S. J.: The use of glycine solution as an irrigating medium during transurethral resection. J. Urol., 59: 1212-1216, 1948. 1205
1206
BULKLEY, o'CONOR AND SOKOL
TABLE
1. Complications Per Cent
No.
Extravasation of urine (one fatal). Secondary hemorrhage ............ . Required evacuation and coagulation through the resectoscope. I Required catheter drainage. Epididymitis. Urethral stricture . Secondary resection .. Thrombophlebitis. Pulmonary embolus. Pneumonia and atelectasis ..... TABLE
2
7
0.78 2.7
4
3 8 5
13 2
1 1
3.1 1.97 5.1 0.78 0.39 0.39
2. Associated urinary tract diseases
Carcinoma of the bladder . Bladder stone . Bladder diverticulum. Prostatic calculi. Tuberculosis of the prostate. Atony of the bladder. Renal calculi .
17 4
5 2 2 4 1
6.6 1.5 1. 9 0.78 0.78 1. 5 0.39
In this group of 257 patients, there was one operative death. This occurred five days after operation and was due to extravasation of urine and cardiac failure. The mortality rate, therefore, was 0.38 per cent for the two-year period. Complications following transurethral resection for the entire period have been carefully compiled in table 1. The associated urinary tract diseases which often complicated the treatment are listed in table 2. BACTEREMIA AND SEPTICEMIA
Numerous reports in the past have given evidence of the common occurrence of bacteremia and septicemia following manipulation of the prostate and male urethra. Scott,7 in 1929, reported 82 patients who were found to have bacteremia following various urethral manipulations, and of this group there was a mortality of 18 per cent. In 1930, Barrington and ·wright8 showed bacteremia occurring in a high percentage of patients following urethral dilatation. Creevy and Feeney9 recently published a report indicating that 45.4 per cent of patients had positive blood cultures following transurethral resection of the prostate when they had received no preoperative medication. In a comparable group of their patients, the preoperative administration of aureomycin reduced this incidence to 17 .4 per cent. Another report of Biorn, Browning and Thomp7 Scott, W. W.: Blood stream infections in urology: A report of 82 cases. J. U rol., 21: 527-566, 1929. 8 Barrington, F. J. F. and Wright, H. D.: Bacteremia following operations on the urethra. J. Path. & Bact., 33: 871-888, 1930. 9 Creevy, C. D. and Feeney, M. J.: Infection following transurethral resection of prostate gland. Bull. Univ. Minn. Hosp. and Minn. Med. Found., 20: 314-327, 1949.
BACTEREMIA AND OVERHYDRA'l'ION FOLLOWING RESECTION
1207
son10 gave an incidence of 1203 per cent positive blood cultures occurring postoperatively in a series of 106 patientso No mention is made of preoperative medicationo Gray and Scott at Rochester, New York11 found an incidence of 5503 per cent positive blood cultures following transurethral resection in a series of 47 patientso Another group of 93 patients subjected to open prostatectomy showed positive blood cultures in 2608 per cento All of these patients had received aureomycin for 24 hours preoperativelyo There was no evidence in these reports to indicate any increase in morbidity or mortality in those patients who were reported as having had positive blood cultures postoperativelyo Recent reports also have demonstrated the relationship between urologic procedures and subacute bacterial endocarditiso Merritt12 reports a 10 per cent incidence of bacterial endocarditis following transurethral prostatic resection in patients who had previous valvular heart disease, We have studied 128 consecutive cases of transurethral resection of the prostate with pre- and postoperative blood cultures taken immediately before and immediately after the operative procedureo Cultures were inoculated within a few hours on enriched tryptose phosphate broth, incubated at 37° for 48 hourso Each day for 3 weeks the broth cultures were subcultured on blood agar plateso A gram stain was made at the same timeo Positive cultures were isolated and identifiedo All preoperative cultures were negative with one exceptiono This patient showed a positive culture for Staphylococcus aureus on the blood taken before operation, but a negative culture after the procedureo This undoubtedly was due to contamination, and was the only such instance encountered in the group studiedo Only two patients in the entire series had a positive postoperative blood culture; an incidence of L56 per cent, Both of these patients had a negative preoperative blood culture. The first patient had received no preoperative medicationo The urinalysis showed many leukocytes and a trace of albumino Following the resection of 25 gm, benign prostatic tissue, his blood culture was positive for Pseudomonas aeruginosao The temperature rose to 103F on the second postoperative day, and did not return to normal until the fifth postoperative dayo This man received gantrisin and terramycin by mouth during the postoperative periodo There were no complications and no evidence of any harmful effects as a result of the bacteremia, The second patient had received preoperative gantrisin and penicillin in therapeutic doseso A preoperative urine culture showed Pseudomonas aeruginosa in heavy growtho Following the resection of 38 gmo benign obstructing prostate, the blood culture was positive with a heavy growth of Pseudomonas aeruginosa, The postoperative course was complicated by epididymitis which appeared on the fourth day and was accompanied by a persistent pyuria which lasted for over 10 Biorn, C, L., Browning, WO Ho and Thompson, Lo: Transient bacteremia immediately following transurethral prostatic resectiono Jo Urol., 63: 155--161, 19500 ll Grey, Do No and Scott, WO WO: The incidence and type of bacteremia at the time of various prostatectomy procedureso Presented at meeting of Clinical Society of GenitoUrinary Surgeons, Rochester, No Y,, Feb. 5, 19530 12 Merritt, Wo A,: Bacterial endocarditis as a complication of transurethral prostatic resection. Jo UroL, 65: 100-107, 195L
1208
BULKLEY, o'coNOR AND SOKOL
three months. This finally responded to intensive chemotherapy and healing of the vesical neck. The postoperative temperature was elevated to 102F and fell to normal on the twelfth postoperative day after continuation of penicillin and gantrisin therapy. The final functional result was very satisfactory in this patient. Of the remaining 125 cases in which both pre- and postoperative blood cultures were negative, 67 had received no preoperative medication for control of infection. The others had received sulfa drugs, penicillin, streptomycin or aureomycin or a combination of these agents in the usual therapeutic dosage. These results offer great contrast to those reported by the other authors cited. The results indicate that in our experience postoperative bacteremia is a rare occurrence, and, when it does occur, is not of any apparent significance. Many of these patients had preoperative urinary infection, and, in some, venous sinuses were entered during the course of the resection so that the possibility of transient bacteremia was certainly present. Most of our patients with severe urinary infection did receive preoperative medication, and this may have lessened the possibility of obtaining a positive postoperative blood culture. However, the discrepancy between the low incidence of bacteremia in the series studied by us as compared to the high incidence noted by others, even in patients who had received preoperative medication, is indeed difficult for us to explain. Our technical and laboratory facilities have been excellent, and in the hands of personnel with an extensive bacteriological experience. OVERHYDRATION
An occasional complication, not as yet mentioned in the literature, but which we wish to emphasize here, is that of overhydration during transurethral surgery. Prior to this present study, O'Conor and Sokol had observed 4 patients who indicated this additional danger when irrigating fluid was forced through the prostatic plexus during a transurethral resection. Two phenomena were observed. The first was the occurrence of acute pulmonary edema in patients undergoing transurethral resections during which considerable venous bleeding was encountered. This was necessarily accompanied by prolonged irrigation and coagulation. The second was the observation that there was an output of a very large volume of urine in the immediate postoperative period; usually the day of the operation and throughout the first postoperative day. This occurred despite a normal or restricted intake of fluid during the same period. This had also been noted in patients who had considerable venous sinus bleeding during their operative procedure. It is our belief that these phenomena are due to overhydration from the introduction of large quantities of fluid through the prostatic venous plexus during the surgical period. Two patients were observed who had sudden left heart failure and acute pulmonary edema toward the end of a transurethral resection. There seemed to be no apparent cause for this sudden development other than overloading of the circulation with irrigating fluid. Two other patients were observed who did not present the above complication, but who were noted to have excessively high
BACTEREMIA AND OVERHYDRATION FOLLOWING RESECTION TABLE
3. Intake and output, case 3
Intake (cc) ....................... Output (cc) ...................... TABLE
1209
Oper. Day
1st P. 0.
2nd P. 0.
3 P. 0.
4th P. 0.
1800 3025
2554 4850
3020 2400
2400 1800
2700 2050
2900 2850
2770 3400
4. Intake and output, case 4
Intake (cc) ...................... · I Output (cc) ..................... .
3945 2400
3220 5775
2290 2450
urinary output postoperatively as compared with the fluid intake. None of these patients were in any way edematous before surgery. This discrepancy in output of urine also was considered to be due directly to excretion of fluid from the body following introduction of large amounts through open venous sinuses during the resection. These latter two patients showed no evidence of pulmonary edema during surgery, indicating that they could tolerate excess fluid without circulatory failure. The intake and output records of the latter 2 patients are presented in tables 3 and 4. In an attempt to determine the incidence of overhydration as well as its degree, we have studied the pre- and postoperative blood hematocrit levels immediately before and immediately after transurethral prostatic resection on the same 128 consecutive cases also studied with blood cultures. Of this group 29 were rejected as unsatisfactory due to clotting or insufficient blood leaving 99 patients with technically satisfactory readings. Sixteen of these showed no change in the hematocrit following transurethral resection. Forty-six patients showed a decrease in the reading ranging from one-half to four per cent and indicating some hemodilution. However 37 patients showed an increase in the hematocrit of ½ to 3 per cent indicating hemoconcentration. There was no correlation between the cases showing hemodilution and the size of the gland or extent of the resection. There were no instances of clinical overhydration observed during the period these hematocrit studies were carried out. The significance of the hematocrit studies was disappointing and apparently not of any real clinical or laboratory value. More accurate methods of studying blood volume immediately pre- and postoperatively will be necessary in order to evaluate the incidence and importance of overhydration. Further studies using radioactive isotopes to determine blood volume more accurately are contemplated. The possibility of temporary salt-depletion by overhydration is the subject of a present study. SUMMARY
A group of 257 consecutive transurethral prostatic resections done over a two-year period were studied. One hundred and twenty-eight of these patients were followed in detail with pre- and postoperative blood culture and hematocrit determinations in order to determine the incidence of bacteremia and overhydration.
1210
BULKLEY, O'CONOR AND SOKOL
Bacteremia occurred in only 1.56 per cent of this group and did not seem to offer serious complications. The reason for the discrepancy between this figure and that reported by other authors is not apparent. Preoperative chemotherapy seems indicated in cases with significant urinary tract infections, and in those with valvular heart disease, but not as "routine." Hematocrit determinations were not sufficiently accurate as a method of estimating blood volume or hemodilution and in this group showed no significant pattern. However our previous clinical observations of overhydration, as manifested by acute pulmonary edema during transurethral resection and unusually large fluid output during the postoperative period, would indicate that more accurate methods of study are needed. Recognition of overhydration is important as cardiac and systemic treatment must be accompanied by withholding additional fluid until proper water balance has become established.