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EMPHYSEMATOUS PROSTATIC ABSCESS AFTER TRANSURETHRAL MICROWAVE THERMOTHERAPY
0022-5347/01/1662-0625/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 166, 625, August 2001 Printed in U.S.A.
EMPHYSEMATOUS PROSTATIC ABSCESS AFTER TRANSURETHRAL MICROWAVE THERMOTHERAPY DENNIS C. S. LIN, YUNG-MING LIN*
AND
YAT-CHING TONG
From the Department of Urology, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan, Republic of China KEY WORDS: prostate; emphysema; abscess; hypothermia, induced
Emphysematous prostatic abscess is a rare condition characterized by gas and abscess collection in the prostate gland. First described by Mariani et al in 1983, 4 cases of emphysematous prostatic abscess have been reported in the literature.1 Transurethral microwave thermotherapy is an attractive alternative to transurethral resection of the prostate, potentially simplifying the management of benign prostatic hyperplasia (BPH) and reducing morbidity.2 We report a case of prostatic abscess with emphysematous change after transurethral microwave thermotherapy. CASE REPORT
A 55-year-old man presented with perineal discomfort, rectal tenesmus and intermittent fever 1 month in duration. He had a 15-year history of cirrhosis of the liver with annual esophageal variceal hemorrhage, a 13-year history of diabetes mellitus with regular treatment and a history of hepatoma after wedge resection 4 years previously. BPH with several episodes of acute urinary retention had occurred about 4 months earlier and, despite medical treatment, a transurethral Foley catheter had been indwelling since then. However, there were neither difficult catheterizations nor a history of urinary tract infections. Transurethral microwave thermotherapy had been performed twice in outpatient treatment sessions with the patient under local anesthesia about 2 and 3 months earlier. The apparatus used was the Prostcare system (Bruker Spectrospin, Wissembourg, France). The protocol for therapeutic temperature mode was low energy, for which the maximal therapeutic power was set at 52 watts. The calculated maximal intraprostatic temperatures were in the range of 45 to 48C. Perineal crepitus was present and the prostate was uniformly enlarged, boggy and moderately tender. Pertinent abnormal laboratory findings included an increased white blood count with left shift, anemia, severe hypoalbuminemia and coagulopathy. Urinalysis revealed pyuria and bacteriuria. Contrast computerized tomography of the pelvis demonstrated a prostatic abscess with gas formation extending to the periurethral and perineal areas (see figure). Emergency incision and drainage of the perineum and a suprapubic punch cystostomy were performed. Operative findings revealed air and abscess collections in the periurethral area and prostate cavity, and 1 spontaneous rupture lesion at the prostate capsule. Abscess and urine cultures yielded Klebsiella pneumoniae. Massive esophageal variceal bleeding refractory to medical treatment and hypovolemic shock developed on postoperative day 4. Emergency gastrotomy and suture ligation of the bleeder were performed. Hepatic encephalopathy developed on day 5. The condition of the patient worsened rapidly. Multiple organ failure occurred
Pelvic computerized tomography shows abscess and gas accumulation in prostate gland extending to periurethral and perineal area.
and the patient died on day 26. An autopsy was suggested but the family refused. DISCUSSION
Transurethral microwave thermotherapy is minimally invasive with no absolute contraindications, can be safely performed and is easily controlled. The morbidity is relatively low. The most common complications include urinary tract infection, urinary retention and hematuria. The most severe complication is rectoprostatic fistula.2 In our case 2 months after transurethral microwave thermotherapy emphysematous prostatic abscess due to K. pneumoniae developed. To our knowledge we report the first case of this unusual complication after microwave thermotherapy. The histopathology of prostatic tissue after transurethral hyperthermia consists of periurethral edema, parenchymal hemorrhage and coagulation necrosis of smooth muscle in acute changes, and interstitial hemorrhages, complete obliteration of blood vessel lumina and hemorrhagic necrosis in late changes.3 Therefore, we believe that this complication may be a delayed result of coagulation necrosis and hemorrhages of prostate parenchyma combined with urinary tract infection in a diabetes mellitus, compromised immune system (cirrhosis of the liver) with a bleeding tendency condition. We recommend that this rare complication be considered when using transurethral microwave thermotherapy in clinically immunocompromised patients with BPH and coagulopathy.
Accepted for publication March 9, 2001. * Requests for reprints: Department of Urology, National Cheng Kung University Medical College and Hospital, 138 Sheng-Li Road, Tainan, Taiwan 704 Republic of China.
625
REFERENCES
1. Mariani, A. J., Jacobs, L. D., Clapp, P. R. et al: Emphysematous prostatic abscess: diagnosis and treatment. J Urol, 129: 385, 1983 2. Lindner, A., Siegel, Y. I., Saranga, R. et al: Complications in hyperthermia treatment of benign prostatic hyperplasia. J Urol, 144: 1390, 1990 3. Lauweryns, J., Baert, L., Vandenhove, J. et al: Histopathology of prostatic tissue after transurethral hyperthermia. Int J Hyperthermia, 7: 221, 1991
Vol. 166, 625, August 2001 Printed in U.S.A.
EMPHYSEMATOUS PROSTATIC ABSCESS AFTER TRANSURETHRAL MICROWAVE THERMOTHERAPY DENNIS C. S. LIN, YUNG-MING LIN*
AND
YAT-CHING TONG
From the Department of Urology, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan, Republic of China KEY WORDS: prostate; emphysema; abscess; hypothermia, induced
Emphysematous prostatic abscess is a rare condition characterized by gas and abscess collection in the prostate gland. First described by Mariani et al in 1983, 4 cases of emphysematous prostatic abscess have been reported in the literature.1 Transurethral microwave thermotherapy is an attractive alternative to transurethral resection of the prostate, potentially simplifying the management of benign prostatic hyperplasia (BPH) and reducing morbidity.2 We report a case of prostatic abscess with emphysematous change after transurethral microwave thermotherapy. CASE REPORT
A 55-year-old man presented with perineal discomfort, rectal tenesmus and intermittent fever 1 month in duration. He had a 15-year history of cirrhosis of the liver with annual esophageal variceal hemorrhage, a 13-year history of diabetes mellitus with regular treatment and a history of hepatoma after wedge resection 4 years previously. BPH with several episodes of acute urinary retention had occurred about 4 months earlier and, despite medical treatment, a transurethral Foley catheter had been indwelling since then. However, there were neither difficult catheterizations nor a history of urinary tract infections. Transurethral microwave thermotherapy had been performed twice in outpatient treatment sessions with the patient under local anesthesia about 2 and 3 months earlier. The apparatus used was the Prostcare system (Bruker Spectrospin, Wissembourg, France). The protocol for therapeutic temperature mode was low energy, for which the maximal therapeutic power was set at 52 watts. The calculated maximal intraprostatic temperatures were in the range of 45 to 48C. Perineal crepitus was present and the prostate was uniformly enlarged, boggy and moderately tender. Pertinent abnormal laboratory findings included an increased white blood count with left shift, anemia, severe hypoalbuminemia and coagulopathy. Urinalysis revealed pyuria and bacteriuria. Contrast computerized tomography of the pelvis demonstrated a prostatic abscess with gas formation extending to the periurethral and perineal areas (see figure). Emergency incision and drainage of the perineum and a suprapubic punch cystostomy were performed. Operative findings revealed air and abscess collections in the periurethral area and prostate cavity, and 1 spontaneous rupture lesion at the prostate capsule. Abscess and urine cultures yielded Klebsiella pneumoniae. Massive esophageal variceal bleeding refractory to medical treatment and hypovolemic shock developed on postoperative day 4. Emergency gastrotomy and suture ligation of the bleeder were performed. Hepatic encephalopathy developed on day 5. The condition of the patient worsened rapidly. Multiple organ failure occurred
Pelvic computerized tomography shows abscess and gas accumulation in prostate gland extending to periurethral and perineal area.
and the patient died on day 26. An autopsy was suggested but the family refused. DISCUSSION
Transurethral microwave thermotherapy is minimally invasive with no absolute contraindications, can be safely performed and is easily controlled. The morbidity is relatively low. The most common complications include urinary tract infection, urinary retention and hematuria. The most severe complication is rectoprostatic fistula.2 In our case 2 months after transurethral microwave thermotherapy emphysematous prostatic abscess due to K. pneumoniae developed. To our knowledge we report the first case of this unusual complication after microwave thermotherapy. The histopathology of prostatic tissue after transurethral hyperthermia consists of periurethral edema, parenchymal hemorrhage and coagulation necrosis of smooth muscle in acute changes, and interstitial hemorrhages, complete obliteration of blood vessel lumina and hemorrhagic necrosis in late changes.3 Therefore, we believe that this complication may be a delayed result of coagulation necrosis and hemorrhages of prostate parenchyma combined with urinary tract infection in a diabetes mellitus, compromised immune system (cirrhosis of the liver) with a bleeding tendency condition. We recommend that this rare complication be considered when using transurethral microwave thermotherapy in clinically immunocompromised patients with BPH and coagulopathy.
Accepted for publication March 9, 2001. * Requests for reprints: Department of Urology, National Cheng Kung University Medical College and Hospital, 138 Sheng-Li Road, Tainan, Taiwan 704 Republic of China.
625
REFERENCES
1. Mariani, A. J., Jacobs, L. D., Clapp, P. R. et al: Emphysematous prostatic abscess: diagnosis and treatment. J Urol, 129: 385, 1983 2. Lindner, A., Siegel, Y. I., Saranga, R. et al: Complications in hyperthermia treatment of benign prostatic hyperplasia. J Urol, 144: 1390, 1990 3. Lauweryns, J., Baert, L., Vandenhove, J. et al: Histopathology of prostatic tissue after transurethral hyperthermia. Int J Hyperthermia, 7: 221, 1991