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Arteriographic embolization treatment for postprostatectomy hemorrhage
ARTERIOGRAPHIC
EMBOLIZATION
FOR POSTPROSTATECTOMY RAUL V. PEREIRAS, W. LOUIS MEIER,
TREATMENT
HEMORRHAGE
JR., M.D. M.D.
EDWARD
R. KATZ, M.D.
MANUEL
VIAMONTE,
JR., M.D.
From the Departments of Radiology and Urology, Veterans Administration Hospital, Jackson Memorial Hospital, and the University of Miami School of Medicine, Miami, Florida
- Arteriographic localization and successful embolization of severe postprostatectomy bleeding in a sixty-nine-year-old man with bleeding diathesis is reported and emphasized as an important therapeutic modality.
ABSTRACT
Postoperative hemorrhage in patient with prostatectomy can be a very serious complication. Many types of management of this problem have been reported, including repeat fulguration of bleeding points, packing of prostatic fossa, hemostatic balloon catheters in the bladder or in the prostatic fossa, and ligation of the internal iliac arteries.’ Rapid irrigation with a l/10,000 silver nitrate solution has been used.’ The use of arteriography for the diagnosis and treatment of hemorrhage, especially in the gastrointestinal tract, is widely known; however, its specific use in postprostatectomy bleeding has not been emphasized. Case Report The patient is a sixty-nine-year-old white man admitted for urinary retention. He had a history of prolonged bleeding after teeth extraction, and admitted to excessive alcohol intake for many years. Physical examination revealed hepatosplenomegaly, ascites, pedal edema, and mild scleral icterus. The prostate was diffusely enlarged and appeared benign. Laboratory examination showed the following: hematocrit 43, hemoglobin 15 Gm. per 100 ml., platelets 132,000 per cu. mm., total bilirubin 3 mg. per
UROLOGY
I
JUNE 19’77 /
VOLUME
IX, NUMBER
6
100 ml., alkaline phosphatase slightly elevated, normal serum glutamic oxaloacetic transaminase and lactic dehydrogenase, prothrombin time (PT) 13/12 sec., partial thromboplastin time (PIT) 58/45 sec., normal Ivy bleeding time and thrombin time, and mildly elevated fibrinogen. Urography showed normal upper urinary tracts. Cystogram revealed a trabeculated bladder with midline basilar defect representing prostatomegaly. After admission on June 23 the patient underwent extensive preoperative medical evaluation for suspected bleeding diathesis and liver disease. A liver-spleen scan showed hepatomegaly and increased vertebral uptake of colloid, consistent with cirrhosis. The patient refused liver biopsy. Hematologic evaluation revealed only elevated PTT, reflecting decreased factors VIII or IX, either congenital or secondary to liver disease. He was cleared for urologic surgery contingent on availability of fresh frozen plasma (FFP). On July 21, he underwent a suprapubic prostatectomy, requiring two units of whole blood and one unit of FFP. On the second postoperative day, while being treated with catheter traction and through and through irrigation, he began bleeding which required multiple transfusions. On July 28, he had
705
FIGURE 1. (A) Pelvic aortogram with arrow pointing to contrast extravasation from right vesical arterial branch, indicating active bleeding. (B) Late film; selective injection of right hypogastric artery showing persistent extravasated contrast. (C) Midarterial phase: post Gelfoam embolization showing occluded branches of anterior division of right hypogastric artery.
cystoscopy for bladder clot retention and no bleeding site was seen. Pathology report on the prostatic tissue showed nodular hyperplasia with focal adenocarcinoma, Stage A. Factor VIII assay results showed decreased values, and the patient was thought to have a variant of von Willebrand’s disease. Bleeding continued with clot retention, and on August 1, at cystoscopy, a small arterial bleeder on the bladder neck was fulgurated. On August 3, open cystoscopy was required and several arterial bleeders in the bladder neck and mucosa were seen. The prostatic fossa was packed. Repeat PT, PIT, and thrombin time were normal, and bleeding was thought to be due to localized fibrinolytic products in the bladder. Aminocaproic acid (Amicar) irrigation was tried unsuccessfully, and exploration of the bladder on August 5 was performed. Active bleeding in the prostatic fossa was seen and packing done. Klebsiella septicemia developed while the patient was taking cephalothin (Keflin) and gentamicin. Renal function gradually deteriorated, and by August 30, serum creatinine was approximately 6 mg. per 100 ml. By this time the patient had received approximately 60 units of whole blood and 65 units FFP. On September 2, pelvic arteriography was performed and showed extravasation from a right vesical arterial branch (Fig. 1A and B). The right hypogastric artery was selectively catheterized and embolized with approximately 1 cc. of Gelfoam material. Postembolization in-
706
jection showed occlusion of all major branches of the anterior division of the hypogastric artery with no extravasation (Fig. 1C). Following arteriography the patient had no significant bleeding from the bladder or prostatic bed. Progressive pulmonary disease developed requiring tracheostomy. Further transfusions were required for bleeding from the abdominal surgical wound and tracheostomy site. The patient died on October 9 of respiratory failure after having received approximately 110 units whole blood and 100 units of FFP during his four-month hospital stay. Autopsy showed micronodular cirrhosis of the liver, bilateral bronchopneumonia with abscesses, and chronic ulcerative hemorrhagic cystitis. No evidence of metastatic prostatic carcinoma was present. Comment Postprostatectomy mortality has been reported to occur between 0.9 and 5.9 per cent. Wines, Lane, and 0’Flynn3 in 1973 reported a series of 3,219 prostatectomies in which their over-all mortality rate was 1.6 per cent. In 132 of their patients serious postoperative bleeding developed which was managed by early endoscopic evacuation of the bladder clot or packing. There were seven deaths, a mortality of 5.3 per cent in this group. Another series of 1,200 retropubic prostatectomies reported 97 patients with heavy postoperative bleeding, 29 who subsequently died, a mortality of 30 per cent.4 It
UROLOGY
/
JUNE 1977
/
VOLUME
IX, NUMBER
6
becomes apparent that in those patients who have significant postoperative bleeding, aggressive treatment is required. Death often results from sepsis due to retention of bladder clots with associated detrusor spasm and increased intravesical pressure.r Most postoperative bleeding in normal patients is probably due to a combination of surgical technique, postoperative care, and hyperfibrinolytic activity. The operative manipulation and trauma of the prostate, rich in fibrinolytic tissue activators, results in local and systemic release of these enzymes.5 A smaller group with underlying hemorrhagic diathesis, as seen in our patient, is certainly at a greater risk for bleeding. Lapides ’ described significant bleeding in a patient with hemophilia and 3 patients with unknown blood dyscrasias. An uncommon but serious cause of hemorrhage is disseminated intravascular coagulation. In a case report by Pickens and Lattime# disseminated intravascular coagulation developed in a patient postprostatectomy and upper gastrointestinal bleeding occurred requiring 42 units of blood. Heparin therapy was used successfully. Merland et ~1.~ in the French literature described superselective arteriography and therapeutic embolization in 6 men with severe hematuria; however, none occurred after prostatectomy. One patient had vesical angiomatosis and the other 5 had postirradiation hemorrhagic cystitis. We believe that arteriography should
UROLOGY
/ JUNE 1977 /
VOLUME IX, NUMBER 6
be performed early in the course of significant postprostatectomy bleeding for diagnosis and treatment by embolization of Gelfoam and/or autologous clots, especially in those patients with underlying bleeding diathesis, increased anesthesia risks, or sepsis. Our case dramatically illustrates the delayed use of this important modality. Radiology Department Veterans Administration Hospital Miami, Florida 33125 (DR. PEREIRAS) References
1, LAPIDES, J.:
Principles of treatment of persistent post-prostatectomy hemorrhage, J. Urol. 106: 913 (1971). of post-prostatectomy 2. PARTON, L. I.: Treatment 3 haemorrhage, Br. J. Urol. 44: 122 (1972). WINES, R. D., LANE, V., and O’FLYNN, J. D.: Post’ prostatectomy bleeding: active management by early endoscopic haemostasis and packing in a series of 3,219 prostatectomies, Aust. N.Z. J. Surg. 43: 274 (1973). 4. SALVARIS, M. : Retropubic prostatectomy and evalua5, tion of 1200 operations, Med. J. Aust. I: 370 (1960). FAM, A.: Control of bleeding during and after prostatectomy, Int. Surg. 56: 352 (1971). 6. PICKENS, R. L., and LA~IMER, J. K.: Disseminated intravascular coagulation: diagnosis and treatment of a hemorrhagic diathesis after prostatectomy, J. Urol. 108: 7 951 (1972). MERLAND, J. J., et al.: Arterographic hyperselective ’ et embolisation en pathologie genitovesicale chez l’homme. Technique, resultats, indications, Ann. Radiol. 17: 611 (1974).
707
EMBOLIZATION
FOR POSTPROSTATECTOMY RAUL V. PEREIRAS, W. LOUIS MEIER,
TREATMENT
HEMORRHAGE
JR., M.D. M.D.
EDWARD
R. KATZ, M.D.
MANUEL
VIAMONTE,
JR., M.D.
From the Departments of Radiology and Urology, Veterans Administration Hospital, Jackson Memorial Hospital, and the University of Miami School of Medicine, Miami, Florida
- Arteriographic localization and successful embolization of severe postprostatectomy bleeding in a sixty-nine-year-old man with bleeding diathesis is reported and emphasized as an important therapeutic modality.
ABSTRACT
Postoperative hemorrhage in patient with prostatectomy can be a very serious complication. Many types of management of this problem have been reported, including repeat fulguration of bleeding points, packing of prostatic fossa, hemostatic balloon catheters in the bladder or in the prostatic fossa, and ligation of the internal iliac arteries.’ Rapid irrigation with a l/10,000 silver nitrate solution has been used.’ The use of arteriography for the diagnosis and treatment of hemorrhage, especially in the gastrointestinal tract, is widely known; however, its specific use in postprostatectomy bleeding has not been emphasized. Case Report The patient is a sixty-nine-year-old white man admitted for urinary retention. He had a history of prolonged bleeding after teeth extraction, and admitted to excessive alcohol intake for many years. Physical examination revealed hepatosplenomegaly, ascites, pedal edema, and mild scleral icterus. The prostate was diffusely enlarged and appeared benign. Laboratory examination showed the following: hematocrit 43, hemoglobin 15 Gm. per 100 ml., platelets 132,000 per cu. mm., total bilirubin 3 mg. per
UROLOGY
I
JUNE 19’77 /
VOLUME
IX, NUMBER
6
100 ml., alkaline phosphatase slightly elevated, normal serum glutamic oxaloacetic transaminase and lactic dehydrogenase, prothrombin time (PT) 13/12 sec., partial thromboplastin time (PIT) 58/45 sec., normal Ivy bleeding time and thrombin time, and mildly elevated fibrinogen. Urography showed normal upper urinary tracts. Cystogram revealed a trabeculated bladder with midline basilar defect representing prostatomegaly. After admission on June 23 the patient underwent extensive preoperative medical evaluation for suspected bleeding diathesis and liver disease. A liver-spleen scan showed hepatomegaly and increased vertebral uptake of colloid, consistent with cirrhosis. The patient refused liver biopsy. Hematologic evaluation revealed only elevated PTT, reflecting decreased factors VIII or IX, either congenital or secondary to liver disease. He was cleared for urologic surgery contingent on availability of fresh frozen plasma (FFP). On July 21, he underwent a suprapubic prostatectomy, requiring two units of whole blood and one unit of FFP. On the second postoperative day, while being treated with catheter traction and through and through irrigation, he began bleeding which required multiple transfusions. On July 28, he had
705
FIGURE 1. (A) Pelvic aortogram with arrow pointing to contrast extravasation from right vesical arterial branch, indicating active bleeding. (B) Late film; selective injection of right hypogastric artery showing persistent extravasated contrast. (C) Midarterial phase: post Gelfoam embolization showing occluded branches of anterior division of right hypogastric artery.
cystoscopy for bladder clot retention and no bleeding site was seen. Pathology report on the prostatic tissue showed nodular hyperplasia with focal adenocarcinoma, Stage A. Factor VIII assay results showed decreased values, and the patient was thought to have a variant of von Willebrand’s disease. Bleeding continued with clot retention, and on August 1, at cystoscopy, a small arterial bleeder on the bladder neck was fulgurated. On August 3, open cystoscopy was required and several arterial bleeders in the bladder neck and mucosa were seen. The prostatic fossa was packed. Repeat PT, PIT, and thrombin time were normal, and bleeding was thought to be due to localized fibrinolytic products in the bladder. Aminocaproic acid (Amicar) irrigation was tried unsuccessfully, and exploration of the bladder on August 5 was performed. Active bleeding in the prostatic fossa was seen and packing done. Klebsiella septicemia developed while the patient was taking cephalothin (Keflin) and gentamicin. Renal function gradually deteriorated, and by August 30, serum creatinine was approximately 6 mg. per 100 ml. By this time the patient had received approximately 60 units of whole blood and 65 units FFP. On September 2, pelvic arteriography was performed and showed extravasation from a right vesical arterial branch (Fig. 1A and B). The right hypogastric artery was selectively catheterized and embolized with approximately 1 cc. of Gelfoam material. Postembolization in-
706
jection showed occlusion of all major branches of the anterior division of the hypogastric artery with no extravasation (Fig. 1C). Following arteriography the patient had no significant bleeding from the bladder or prostatic bed. Progressive pulmonary disease developed requiring tracheostomy. Further transfusions were required for bleeding from the abdominal surgical wound and tracheostomy site. The patient died on October 9 of respiratory failure after having received approximately 110 units whole blood and 100 units of FFP during his four-month hospital stay. Autopsy showed micronodular cirrhosis of the liver, bilateral bronchopneumonia with abscesses, and chronic ulcerative hemorrhagic cystitis. No evidence of metastatic prostatic carcinoma was present. Comment Postprostatectomy mortality has been reported to occur between 0.9 and 5.9 per cent. Wines, Lane, and 0’Flynn3 in 1973 reported a series of 3,219 prostatectomies in which their over-all mortality rate was 1.6 per cent. In 132 of their patients serious postoperative bleeding developed which was managed by early endoscopic evacuation of the bladder clot or packing. There were seven deaths, a mortality of 5.3 per cent in this group. Another series of 1,200 retropubic prostatectomies reported 97 patients with heavy postoperative bleeding, 29 who subsequently died, a mortality of 30 per cent.4 It
UROLOGY
/
JUNE 1977
/
VOLUME
IX, NUMBER
6
becomes apparent that in those patients who have significant postoperative bleeding, aggressive treatment is required. Death often results from sepsis due to retention of bladder clots with associated detrusor spasm and increased intravesical pressure.r Most postoperative bleeding in normal patients is probably due to a combination of surgical technique, postoperative care, and hyperfibrinolytic activity. The operative manipulation and trauma of the prostate, rich in fibrinolytic tissue activators, results in local and systemic release of these enzymes.5 A smaller group with underlying hemorrhagic diathesis, as seen in our patient, is certainly at a greater risk for bleeding. Lapides ’ described significant bleeding in a patient with hemophilia and 3 patients with unknown blood dyscrasias. An uncommon but serious cause of hemorrhage is disseminated intravascular coagulation. In a case report by Pickens and Lattime# disseminated intravascular coagulation developed in a patient postprostatectomy and upper gastrointestinal bleeding occurred requiring 42 units of blood. Heparin therapy was used successfully. Merland et ~1.~ in the French literature described superselective arteriography and therapeutic embolization in 6 men with severe hematuria; however, none occurred after prostatectomy. One patient had vesical angiomatosis and the other 5 had postirradiation hemorrhagic cystitis. We believe that arteriography should
UROLOGY
/ JUNE 1977 /
VOLUME IX, NUMBER 6
be performed early in the course of significant postprostatectomy bleeding for diagnosis and treatment by embolization of Gelfoam and/or autologous clots, especially in those patients with underlying bleeding diathesis, increased anesthesia risks, or sepsis. Our case dramatically illustrates the delayed use of this important modality. Radiology Department Veterans Administration Hospital Miami, Florida 33125 (DR. PEREIRAS) References
1, LAPIDES, J.:
Principles of treatment of persistent post-prostatectomy hemorrhage, J. Urol. 106: 913 (1971). of post-prostatectomy 2. PARTON, L. I.: Treatment 3 haemorrhage, Br. J. Urol. 44: 122 (1972). WINES, R. D., LANE, V., and O’FLYNN, J. D.: Post’ prostatectomy bleeding: active management by early endoscopic haemostasis and packing in a series of 3,219 prostatectomies, Aust. N.Z. J. Surg. 43: 274 (1973). 4. SALVARIS, M. : Retropubic prostatectomy and evalua5, tion of 1200 operations, Med. J. Aust. I: 370 (1960). FAM, A.: Control of bleeding during and after prostatectomy, Int. Surg. 56: 352 (1971). 6. PICKENS, R. L., and LA~IMER, J. K.: Disseminated intravascular coagulation: diagnosis and treatment of a hemorrhagic diathesis after prostatectomy, J. Urol. 108: 7 951 (1972). MERLAND, J. J., et al.: Arterographic hyperselective ’ et embolisation en pathologie genitovesicale chez l’homme. Technique, resultats, indications, Ann. Radiol. 17: 611 (1974).
707