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Anastomotic stricture with foreign-body reaction and stone formation following radical retropubic prostatectomy
ANASTOMOTIC STRICTURE WITH FOREIGNBODY REACTION AND STONE FORMATION FOLLOWING RADICAL RETROPUBIC PROSTATECTOMY JEFFREY I. MILLER, M.D. RANDIL L. CLARK, M.D. CHARLES E. JENNINGS, M.D. GEORGE W. DRACH, M.D.
From the Department of Surgery, Section of Urology. University of Arizona Health Sciences Center, Tucson, Arizona
ABSTRACTWe report 4 cases of anastomotic stricture after radical retropuhit prostatectomy caused by erosion of suture material used to ligate the dorsai vein complex. In 2 patients there was overlying stone formation. The clinicai features of this complication. management options, and means of prevention are reviewed.
Anastomotic stricture between the bladder neck and proximal urethra following radical retropubic prostatectomy can cause significant longterm voiding dysfunction. Its incidence ranges from 1.3 to 22 percent. Factors for increased risk include excessive intraoperative blood loss, persistent postoperative urinary extravasation, and a history of prior transurethral prostate surgery.’ An unusual, but probably under-reported, cause of stricture formation involves inflammation with foreign-body reaction and fibrosis at the site of an eroded silk suture on the ventral aspect of the anastomosis. The source of the silk suture appears to be that used to ligate the dorsal vein complex.’ 4 We report 4 such cases of anastomotic stricture following radical retropubic prostatectomy. In 2 cases, the foreign-body reaction was associated with stone formation. Material and Methods All .i patients underwent radical retropubic prostatectomy for localized prostate adenocarcinema. The dorsal vein complex was ligated with a single O-silk suture as described by Reiner and Vl’alsh.” The direct mucosa-to-mu-
cosa urethrovesical anastomosis was completed with interrupted 2-O chromic sutures. There were no unusual intraoperative or postoperative complications. A 22F Foley catheter was left indwelling for three weeks. Prior to the diagnosis of their anastomotic stricture, all patients presented with irritative and obstructive voiding symptoms including weakened stream, nocturia, frequency, dribbling, and dysuria. All had new onset or worsening of urinary incontinence. One patient presented with intermittent gross hematuria. Patient data are summarized in Table I. All patients were managed endoscopically. In each case, strands of black braided silk suture were seen embedded in dense scar tissue at the ventral aspect of the anastomosis. In 2 patients (including one with gross hematuria), overlying stone formation was noted. The stones were soft and easily broken with the beak of the cystoscope or a grasping forceps. They were totally extracted in multiple fragments. 6igure 1 shows a typical extracted silk suture with attached stone. After treatment, all patients reported resolution of their voiding symptoms with return to
areas of calcification (Fig. 2). Two patients have required periodic urethral dilation to manage their anastomotic stricture. FIGURE 1. Extracted silk suture (dark) with attached stone (pale).
FIGURE 2. High-power photomicrograph of local acute and chronic inflammation surrounding area of calcification (upper right). Foreign body (silk) not visualized.
baseline continence levels. Although surgical resection margins were positive in 1 patient, no patient had endoscopic or clinical evidence of tumor recurrence. In 1 patient, cold cup biopsy of the scar tissue was obtained. Histologic analysis showed no evidence of neoplasm with both acute and chronic inflammation surrounding
Comment Ligation of the dorsal vein complex has been shown to significantly decrease the amount of blood lost during radical retropubic prostatectomy. The technique was originally developed by Reiner and Walsh.2 Although many modifications have been described,” R the basic technique involves placement of a large-caliber silk suture around the dorsal penile veins just under the pubic arch after dividing the puboprostatic ligaments. Anastomotic strictures occurring after radical prostatectomy are for the most part unrelated to ligation of the dorsal vein complex. In fact, reduced intraoperative hemorrhage probably contributes to their decreased incidence. However, persistence of the silk ligature with erosion into the ventral portion of the anastomosis can initiate an intense inflammatory response. Scheidler et ~1.~ reported 2 cases of symptomatic suture granuloma (one with overlving stone formation). Each contained a silk ligature that eroded through the ventral portion of the anastomosis. No mention of actual stricture formation was made. These patients presented with sterile urine, irritative and obstructive voiding symptoms, and gross hematuria. They were successfully managed endoscopically. Of 18 patients with anastomotic stricture following radical retropubic prostatectomy, Surya et al. ’ described 2 with ventral urethrovesical erosion of silk suture. These sutures, which evoked an inflammatory response leading to fibrosis, were thought to have persisted after dorsal vein ligation.
TABLE:I. Clinical features and management of patients with anastomotic stricture secondary to silk suture erosion Interval to Symptoms
Treatment
Case No.
Age (Yrs.)
Clin. Tumor Stage
1
65
A2
6 mos.
SF
No
2
70
B2
7 mos.
10F
No
3
67
Bl
18 mos.
4F
Stricture Size
Stone Formation
Yes (7 mm)
4
418
74
Bl
12 mos.
4F
Yes (5 mm)
UROLOGY
of
Stricture
Eroded Suture
Cold knife internal urethrotomy Urethral dilation with curved sounds Cold knife internal urethrotomy Urethral dilation with filiforms and followers
Cut and partially extracted Cut and totally extracted Cut and partially extracted Cut and totally extracted
i MAY1992 ! VOLUMEXXXIX,NUMRER5
All of our patients presented with irritati\re and obstructive voiding symptoms with or without gross hematuria from six to eighteen months following prostatectom>: Most noted new onset or worsening of their incontinence. All had negative urine cultures. Diagnosis of the strictures was made cystoscopically. Treatment of the stricture consisted of urethral dilation or cold knife urethrotomy. To remove the suture., it had to be cut (either during llrethrotomy or separately with a cystoscopic scissors). Both the overlying stone and free sutllre were removed with grasping or biopsy forceps. The portion containing the-knot was often difficult to remove as it was usually deeply embedded in scar tissue. In 2 patients, there were residual fragments which could not be extracted. If retained suture exists, periodic cystoscopy should be performed to rule out recurrence of stricture or stone. Incision or resection of the strictured area with electrocautery is contraindicated since this usually results in urinar!~ incontinence. ’ If there is any endoscopic or clinical suspicion of tumor recurrence. biops!’ of the stricture should be performed. Although all suture material can serve as a nidus for stone formation within the urinary tract, -it is generally accepted that the incidence is much lower when absorbable suture is used.” I’ Chromic gut is employed most often despite its decreased durability, tensile strength. and increased inflammatory response. The occurrence of local tissue reaction and calculus formation is directly related to the time of contact between the foreign body and the urinaq tract. Persistent silk suture after dorsal vein ligation can lead to an intense inflammator). reaction with subsequent fibrosis and stone for-
mation with erosion into the ~lrethrovesical anastomosis. Based OII the aforementioned. UY recommend the use of absorbable suture \,vhen ligating the dorsal vein complex during radical prostatectom\.. All sutures should be c*ut short. These measllres may help to lower the incidence of suture erosion Lvith subsequent anastomotic stricture after radical prostatectom~.
From the Department of Surgery, Section of Urology. University of Arizona Health Sciences Center, Tucson, Arizona
ABSTRACTWe report 4 cases of anastomotic stricture after radical retropuhit prostatectomy caused by erosion of suture material used to ligate the dorsai vein complex. In 2 patients there was overlying stone formation. The clinicai features of this complication. management options, and means of prevention are reviewed.
Anastomotic stricture between the bladder neck and proximal urethra following radical retropubic prostatectomy can cause significant longterm voiding dysfunction. Its incidence ranges from 1.3 to 22 percent. Factors for increased risk include excessive intraoperative blood loss, persistent postoperative urinary extravasation, and a history of prior transurethral prostate surgery.’ An unusual, but probably under-reported, cause of stricture formation involves inflammation with foreign-body reaction and fibrosis at the site of an eroded silk suture on the ventral aspect of the anastomosis. The source of the silk suture appears to be that used to ligate the dorsal vein complex.’ 4 We report 4 such cases of anastomotic stricture following radical retropubic prostatectomy. In 2 cases, the foreign-body reaction was associated with stone formation. Material and Methods All .i patients underwent radical retropubic prostatectomy for localized prostate adenocarcinema. The dorsal vein complex was ligated with a single O-silk suture as described by Reiner and Vl’alsh.” The direct mucosa-to-mu-
cosa urethrovesical anastomosis was completed with interrupted 2-O chromic sutures. There were no unusual intraoperative or postoperative complications. A 22F Foley catheter was left indwelling for three weeks. Prior to the diagnosis of their anastomotic stricture, all patients presented with irritative and obstructive voiding symptoms including weakened stream, nocturia, frequency, dribbling, and dysuria. All had new onset or worsening of urinary incontinence. One patient presented with intermittent gross hematuria. Patient data are summarized in Table I. All patients were managed endoscopically. In each case, strands of black braided silk suture were seen embedded in dense scar tissue at the ventral aspect of the anastomosis. In 2 patients (including one with gross hematuria), overlying stone formation was noted. The stones were soft and easily broken with the beak of the cystoscope or a grasping forceps. They were totally extracted in multiple fragments. 6igure 1 shows a typical extracted silk suture with attached stone. After treatment, all patients reported resolution of their voiding symptoms with return to
areas of calcification (Fig. 2). Two patients have required periodic urethral dilation to manage their anastomotic stricture. FIGURE 1. Extracted silk suture (dark) with attached stone (pale).
FIGURE 2. High-power photomicrograph of local acute and chronic inflammation surrounding area of calcification (upper right). Foreign body (silk) not visualized.
baseline continence levels. Although surgical resection margins were positive in 1 patient, no patient had endoscopic or clinical evidence of tumor recurrence. In 1 patient, cold cup biopsy of the scar tissue was obtained. Histologic analysis showed no evidence of neoplasm with both acute and chronic inflammation surrounding
Comment Ligation of the dorsal vein complex has been shown to significantly decrease the amount of blood lost during radical retropubic prostatectomy. The technique was originally developed by Reiner and Walsh.2 Although many modifications have been described,” R the basic technique involves placement of a large-caliber silk suture around the dorsal penile veins just under the pubic arch after dividing the puboprostatic ligaments. Anastomotic strictures occurring after radical prostatectomy are for the most part unrelated to ligation of the dorsal vein complex. In fact, reduced intraoperative hemorrhage probably contributes to their decreased incidence. However, persistence of the silk ligature with erosion into the ventral portion of the anastomosis can initiate an intense inflammatory response. Scheidler et ~1.~ reported 2 cases of symptomatic suture granuloma (one with overlving stone formation). Each contained a silk ligature that eroded through the ventral portion of the anastomosis. No mention of actual stricture formation was made. These patients presented with sterile urine, irritative and obstructive voiding symptoms, and gross hematuria. They were successfully managed endoscopically. Of 18 patients with anastomotic stricture following radical retropubic prostatectomy, Surya et al. ’ described 2 with ventral urethrovesical erosion of silk suture. These sutures, which evoked an inflammatory response leading to fibrosis, were thought to have persisted after dorsal vein ligation.
TABLE:I. Clinical features and management of patients with anastomotic stricture secondary to silk suture erosion Interval to Symptoms
Treatment
Case No.
Age (Yrs.)
Clin. Tumor Stage
1
65
A2
6 mos.
SF
No
2
70
B2
7 mos.
10F
No
3
67
Bl
18 mos.
4F
Stricture Size
Stone Formation
Yes (7 mm)
4
418
74
Bl
12 mos.
4F
Yes (5 mm)
UROLOGY
of
Stricture
Eroded Suture
Cold knife internal urethrotomy Urethral dilation with curved sounds Cold knife internal urethrotomy Urethral dilation with filiforms and followers
Cut and partially extracted Cut and totally extracted Cut and partially extracted Cut and totally extracted
i MAY1992 ! VOLUMEXXXIX,NUMRER5
All of our patients presented with irritati\re and obstructive voiding symptoms with or without gross hematuria from six to eighteen months following prostatectom>: Most noted new onset or worsening of their incontinence. All had negative urine cultures. Diagnosis of the strictures was made cystoscopically. Treatment of the stricture consisted of urethral dilation or cold knife urethrotomy. To remove the suture., it had to be cut (either during llrethrotomy or separately with a cystoscopic scissors). Both the overlying stone and free sutllre were removed with grasping or biopsy forceps. The portion containing the-knot was often difficult to remove as it was usually deeply embedded in scar tissue. In 2 patients, there were residual fragments which could not be extracted. If retained suture exists, periodic cystoscopy should be performed to rule out recurrence of stricture or stone. Incision or resection of the strictured area with electrocautery is contraindicated since this usually results in urinar!~ incontinence. ’ If there is any endoscopic or clinical suspicion of tumor recurrence. biops!’ of the stricture should be performed. Although all suture material can serve as a nidus for stone formation within the urinary tract, -it is generally accepted that the incidence is much lower when absorbable suture is used.” I’ Chromic gut is employed most often despite its decreased durability, tensile strength. and increased inflammatory response. The occurrence of local tissue reaction and calculus formation is directly related to the time of contact between the foreign body and the urinaq tract. Persistent silk suture after dorsal vein ligation can lead to an intense inflammator). reaction with subsequent fibrosis and stone for-
mation with erosion into the ~lrethrovesical anastomosis. Based OII the aforementioned. UY recommend the use of absorbable suture \,vhen ligating the dorsal vein complex during radical prostatectom\.. All sutures should be c*ut short. These measllres may help to lower the incidence of suture erosion Lvith subsequent anastomotic stricture after radical prostatectom~.