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Evaluation of Oxycel-bag Catheter Technique in Suprapubic Prostatectomy
THE JOURNAL OF UROLOGY
Vol. 67, No. 1, January 1952 Printed in U.S.A.
EVALUATION OF OXYCEL-BAG CATHETER TECHNIQUE IN SUPRAPUBIC PROSTATECTOMY WILLIAM J. BAKER
AND
EDWIN C. GRAF
From the Urological Service, St. Luke's Hospital, Chicago, Ill.
It is proposed to set forth our clinical experiences with the use of oxycel and the bag catheter to control hemorrhage after suprapubic prostatectomy. The clinical histories of 100 private patients who were subjected to suprapubic enucleation of the prostate gland have been reviewed. The last 50 suprapubic enucleations of the prostate gland in which the older packing method was used are compared with the first 50 suprapubic prostatectomies in which the oxycel-bag catheter technique was used. A brief description of our routine is presented. A single layer of oxycel is draped about the bag which is then distended partially with sterile water. The bag is drawn into the prostatic fossa and then it is further inflated with sterile water to fit snugly in the prostatic fossa. The bladder is closed in the routine manner around a 20F de Pezzer catheter which is placed high in the cystotomy wound. Tension on the distended bag may or may not be necessary. We have not used tension. Normal saline solution is used to determine the patency of the catheters. The catheters are not irrigated if they drain, regardless of the amount of bleeding. The bag is deflated 6 hours postoperatively if the drainage is not too bloody. The urethral catheter is removed 24 hours postoperatively. The suprapubic catheter remains until the tenth postoperative day. The suprapubic sinus is allowed to close spontaneously. If healing is slow, the closure is expedited by an indwelling urethral catheter which should keep the sinus dry from 48 to 72 hours. Eighteen days was the average required to realize a dry suprapubic sinus and normal voiding when the prostatic bed was packed with gauze. An average of 15½ days was required when the oxycel technique was used. This latter figure included two patients who required 42 and 36 days for closure. A transurethral revision of the bladder neck was necessary to correct the postoperative scarring in the first of these two patients. The second patient had exsanguinating primary and secondary hemorrhages. Total visible blood loss was less when using the oxycel-bag catheter technique. No mathematical estimates were made. Goodyear and Beard found that the oxycel-bag catheter technique reduced blood loss by approximately one half as compared to the conventional methods of handling the prostatic bed. Although bleeding was generally less, severe hemorrhage was noted 3 times in the 50 patients. Two of these 3 patients had Paget's disease. Paget's disease was not found among any of the other 100 patients. CASE ABSTRACTS
Case 1. Mr. A.G. was a 70 year old, well developed and well nourished white man. His past history included a reference to excessive bleeding which followed Read at annual meeting, North Central Section, American Urological Association, Milwaukee, Wis., October 12, 1950. 101
102
WILLIAM J. BAKER AKD EDWIN C. GRAF
a tooth extraction. This fact prompted a complete study of the blood. An elevated blood alkaline phosphatase was the single abnormal finding. The diagnosis of Paget's disease was confirmed by x-ray examination. See table 1. There was no residual urine. Penicillin, 300,000 u, streptomycin gm. 1 and vitamin C 100 mg. were given daily. Morphine sulfate 1 \- gr. and scopolamine 2 ½0 gr. were given as pre-anesthetic medication. Pentothal sodium, nitrous oxide anesthesia was used. It was supplemented with ether. The prostate gland weighed 104 gm. Morphine sulfate ½ gr. was given every 4 hours for postoperative pain. Moderate bleeding was noted when the patient was returned to bed. The bleeding peraisted and became so profuse and uncontrollable that the patient was returned to the operating room 12 hours after the prostatectomy. Three transfusions of 500 cc whole blood was given during this interval. The surgical incision was opened and the bleeding controlled with gauze packing with much difficulty. TABLE
R. B. C.
1
Hemoglobin W. B. C.
4, 660,000/c.m.m. 14.1 gm.% 6,750/c.m.m.
Bleeding time Coagulation time
2' 30" 3' 30"
Platelets Prothrombin time
302, 820/c.m.m. 32" (C. A. 06.0%)
urea nitrogen N. P. N. Sugar carbon dioxide Alk. phosphatase
14.6 mg.% 35 mg.% 03 mg.% 50.4 mg. % 22..!
Acid phosphatase Eahn
0
Kegative
There was a general oozing from the prostatic bed. Ko bleeding points were noted. The patient was returned to bed in poor condition but he responded to supportive measures. Brisk bleeding occurred when the packs were removed; it subsided spontaneously. Brisk bleeding also recurred on the thirteenth postoperative day but it again subsided spontaneously. In an effort to control the bleeding tendency, protamine and synkavite were gi,,en without any appreciable effect. The patient made an excellent recovery after a prolonged hospitalization. His present condition and operative result are excellent. Case 2. Mr. F. S. was a Negro 50 years of age. A transurethral resection of the prostate gland was performed 6 months before the enucleation. He continued to have a weak urinary stream and grossly infected urine. His bladder was irritable and he voided small amounts at frequent intervals. There was no residual urine. Cystoscopy revealed intra-urethral lateral prostatic lobes which met in the midline. The prostate gland was enlarged grade 2 on rectal examination. He was advised to have a suprapubic enucleation of the prostate gland. See table 2.
OXYCEL-BAG CATHETER IN SUPRAPUBIC PROSTATECTOMY
103
Penicillin 300,000 u, streptomycin gm. 1 and vitamin C 100 mg. were given daily. Morphine sulfate½ gr. and scopolamine 2 h gr. were given as pre-anesthetic medication. The prostatectomy was done under pentothal sodium, nitrous oxide anesthesia. This was supplemented with curare. The prostate gland weighed 39 gm. Brisk bleeding was noted when the patient was returned to bed. Th_e bleeding persisted and the patient was returned to the operating room 8 hours after prostatectomy. Arterial bleeding was noted and was controlled by fulguration. The oxycel-bag catheter technique was used again. The remainder of the postoperative course was uneventful. The functional result was excellent. Case 3. Mr. B. G. was 70 years old. Paget's disease of the bone was found on x-ray examination. The patient had acute urinary retention for 4 days. Catheter TABLE
2
R. B. C. Hemoglobin W. B. C.
4,300,000/c.m.m. 11.4 gm. % 6,650/c.m.m.
Bleeding time Coagulation time
w
Urea nitrogen N. P. N. Sugar Carbon dioxide
15 mg.% 32 mg.% 95 mg.% 57 .9 vols.
2' 20"
TABLE
3
R. B. C. Hemoglobin W.B. C.
4, 160,000/P..rn.m. 12.6 gm.% 12,400/c.m.m.
Bleeding time Coagulation time
l' 30" 2' 10"
Urea nitrogen N. P. N. Sugar Carbon dioxide
14.8 mg.% 34 mg.% 90 mg.% 57 vols. %
drainage was used for 12 days preoperatively before the elevated blood chemistry approached normal. See table 3. Penicillin 300,000 u, streptomycin gm. 1 vitamin C 100 mg. were given daily. Morphine sulfate gr. -hand scopolamine 's~o gr. were given as pre-anesthetic medication. Pentothal sodium, nitrous oxide anesthesia were used. The removed prostate weighed 56 gm. The bleeding was brisk but diminished in amount after the first 3 hours. Brisk bleeding recurred on the third postoperative day. The urethral catheter was replaced for 48 hours and the bleeding gradually subsided. This patient's clinical course was complicated by osteitis pubis. The final result was excellent. Bleeding was well controlled before the bladder was closed in each of these patients. The blood picture was normal in each of these patients. The blood
104
WILLIAM J. BAKER AND EDWIN C. GRAF
pressure was at a safe level before the patient was removed from the operating room table. Medication did not seem to predispose to the bleeding. DISCUSSION
Freedom from the painful ordeal of removing packs through the suprapubic wound is a remarkable benefit derived from the oxycel-bag technique. Our patients suffered much more when the packs were removed than they did during the immediate postoperative period. The prospects of having a second pack removed the following day was almost too much for many of them to bear. Morphine sulfate was given before the packs were removed but it was ineffective. General anesthesia was used in the latter years for the removal of the packs. The risk of an additional anesthetic seemed appreciable. Nitrous oxide and oxygen was tried and was found unsatisfactory. Cyclopropane, which has the advantage of rapid induction and rapid recovery, seemed to predispose to excessive bleeding. Pentothal sodium and nitrous oxide with oxygen were the best TABLE
4
OXYCEL TECHNIQUE (50 CASES)
1. 2. 3. 4. 5. 6. 7.
Dry sinus Urosepsis Epididymitis Thrombophlebitis Osteitis pubis Calculus Deaths
15.5 days None 3 2
1 1 (oxycel) 1 (embolus)
GAUZE PACKING
(50 CASES)
18 days 7 3
None None None 2 (endocarditis) (shock)
agents but the severe stimulation engendered by removing the packs causeddistressing laryngospasm on more than one occasion. Escape from the added risk of a second anesthetic came with the advent of the oxycel-bag catheter technique. Severe and persistent infection of the urine, which was a problem when the prostatic bed was packed, has not been noted in the last 50 patients. The decrease in the amount of infection is also reflected in the minimal febrile reaction when the suprapubic sinus closes and the intravesical tension is re-established. Antibiotics were used prophylactically in both series of patients. There have been few complications directly attributable to the oxycel-bag catheter technique. See table 4. Stress incontinence has been noted for a few weeks in 2 patients. Stockwell has written about incontinence that follows traction of more than 3 to 4 hours. We have not used tension. Early decompression of the bag eliminates pressure on the sphincters as well as actually aiding hemostasis. A nidus of oxycel which became impregnated with calcium salts ,vas removed cystoscopically on one occasion. Riba has written of a similar experience. The use of a single layer of oxycel instead of multiple layers around the bag has eliminated the aspiration of appreciable amounts of "jelled" oxycel and
OXYCEL-BAG CATHETER IN SUPRAPUBIC PROSTATECTOMY
105
the danger of foreign body complications. An inflated bag in the prostatic bed ·will cause bladder spasms. This complication can be avoided by gently and partially distending the bag. The bag is deflated in 6 hours, which eliminates all pressure in the prostatic fossa. The one death which occurred in the oxycel group was due to a massive embolus on the eighth postoperative day. This patient was an obese, ,vhite man 66 years old. His blood pressure preoperatively was 172 millimeters of mercury systolic and 106 millimeters of mercury diastolic and he had a tachycardia of 100 per minute. His electrocardiogram was within normal limits. The blood picture was normal. Two of the 50 patients who were packed after suprapubic prostatectomy died. One of these was a 72 year old white man, who had a marked systolic heart murmur. He died from bacterial endocarditis 19 days after surgery. The second patient was an obese white man, 64 years of age, who suffered severe shock after surgery and did not respond to the usual therapy. He died 48 hours postoperatively. CONCLUSIOKS
The oxycel-bag catheter technique is an improved method for control of hemorrhage after suprapubic enucleation of the prostate gland. There is a decrease in blood loss. There is a decrease in the amount of infection. The is more comfortable. There is shorter hospitalization. 'l W. Madison
2, Ill. REFERENCES
DEVRIES, J. K. AND BucHANAN, R. W.: J. Urol., 57: 816, 1947. EIKNER, W. C.: J. Urol., 60: 124, 1948. F1sH, G. W.: J. Urol., 56: 375, 1946. GOLDSTEIN, A. E. AND RuBrn, S. W.: J. Urol., 60: 743, 1948. GooDYEAR, W. E. AND BEARD, D. E.: J. Urol., 62: 849, 1949. REINLE, G. G. AND MACDONALD, J. L.: J. Urol., 60: 495, 1948. RrnA, L. W.: J. A. l\lL A., 141: 532, 1949. SHIVERS, C.H. DE T. AND GROOM, C. E.: J. Urol., 59: 893, 1948. STOCKWELL, A. L.: J. Urol., 60: 128, 1948. STUMP, G.D. AND THUMANN, R C.: J. Urol., 59: 202, 1948. WILHELM, S. F. AND LEVINE, B.: J. Urol., 57: 291, 1947.
Vol. 67, No. 1, January 1952 Printed in U.S.A.
EVALUATION OF OXYCEL-BAG CATHETER TECHNIQUE IN SUPRAPUBIC PROSTATECTOMY WILLIAM J. BAKER
AND
EDWIN C. GRAF
From the Urological Service, St. Luke's Hospital, Chicago, Ill.
It is proposed to set forth our clinical experiences with the use of oxycel and the bag catheter to control hemorrhage after suprapubic prostatectomy. The clinical histories of 100 private patients who were subjected to suprapubic enucleation of the prostate gland have been reviewed. The last 50 suprapubic enucleations of the prostate gland in which the older packing method was used are compared with the first 50 suprapubic prostatectomies in which the oxycel-bag catheter technique was used. A brief description of our routine is presented. A single layer of oxycel is draped about the bag which is then distended partially with sterile water. The bag is drawn into the prostatic fossa and then it is further inflated with sterile water to fit snugly in the prostatic fossa. The bladder is closed in the routine manner around a 20F de Pezzer catheter which is placed high in the cystotomy wound. Tension on the distended bag may or may not be necessary. We have not used tension. Normal saline solution is used to determine the patency of the catheters. The catheters are not irrigated if they drain, regardless of the amount of bleeding. The bag is deflated 6 hours postoperatively if the drainage is not too bloody. The urethral catheter is removed 24 hours postoperatively. The suprapubic catheter remains until the tenth postoperative day. The suprapubic sinus is allowed to close spontaneously. If healing is slow, the closure is expedited by an indwelling urethral catheter which should keep the sinus dry from 48 to 72 hours. Eighteen days was the average required to realize a dry suprapubic sinus and normal voiding when the prostatic bed was packed with gauze. An average of 15½ days was required when the oxycel technique was used. This latter figure included two patients who required 42 and 36 days for closure. A transurethral revision of the bladder neck was necessary to correct the postoperative scarring in the first of these two patients. The second patient had exsanguinating primary and secondary hemorrhages. Total visible blood loss was less when using the oxycel-bag catheter technique. No mathematical estimates were made. Goodyear and Beard found that the oxycel-bag catheter technique reduced blood loss by approximately one half as compared to the conventional methods of handling the prostatic bed. Although bleeding was generally less, severe hemorrhage was noted 3 times in the 50 patients. Two of these 3 patients had Paget's disease. Paget's disease was not found among any of the other 100 patients. CASE ABSTRACTS
Case 1. Mr. A.G. was a 70 year old, well developed and well nourished white man. His past history included a reference to excessive bleeding which followed Read at annual meeting, North Central Section, American Urological Association, Milwaukee, Wis., October 12, 1950. 101
102
WILLIAM J. BAKER AKD EDWIN C. GRAF
a tooth extraction. This fact prompted a complete study of the blood. An elevated blood alkaline phosphatase was the single abnormal finding. The diagnosis of Paget's disease was confirmed by x-ray examination. See table 1. There was no residual urine. Penicillin, 300,000 u, streptomycin gm. 1 and vitamin C 100 mg. were given daily. Morphine sulfate 1 \- gr. and scopolamine 2 ½0 gr. were given as pre-anesthetic medication. Pentothal sodium, nitrous oxide anesthesia was used. It was supplemented with ether. The prostate gland weighed 104 gm. Morphine sulfate ½ gr. was given every 4 hours for postoperative pain. Moderate bleeding was noted when the patient was returned to bed. The bleeding peraisted and became so profuse and uncontrollable that the patient was returned to the operating room 12 hours after the prostatectomy. Three transfusions of 500 cc whole blood was given during this interval. The surgical incision was opened and the bleeding controlled with gauze packing with much difficulty. TABLE
R. B. C.
1
Hemoglobin W. B. C.
4, 660,000/c.m.m. 14.1 gm.% 6,750/c.m.m.
Bleeding time Coagulation time
2' 30" 3' 30"
Platelets Prothrombin time
302, 820/c.m.m. 32" (C. A. 06.0%)
urea nitrogen N. P. N. Sugar carbon dioxide Alk. phosphatase
14.6 mg.% 35 mg.% 03 mg.% 50.4 mg. % 22..!
Acid phosphatase Eahn
0
Kegative
There was a general oozing from the prostatic bed. Ko bleeding points were noted. The patient was returned to bed in poor condition but he responded to supportive measures. Brisk bleeding occurred when the packs were removed; it subsided spontaneously. Brisk bleeding also recurred on the thirteenth postoperative day but it again subsided spontaneously. In an effort to control the bleeding tendency, protamine and synkavite were gi,,en without any appreciable effect. The patient made an excellent recovery after a prolonged hospitalization. His present condition and operative result are excellent. Case 2. Mr. F. S. was a Negro 50 years of age. A transurethral resection of the prostate gland was performed 6 months before the enucleation. He continued to have a weak urinary stream and grossly infected urine. His bladder was irritable and he voided small amounts at frequent intervals. There was no residual urine. Cystoscopy revealed intra-urethral lateral prostatic lobes which met in the midline. The prostate gland was enlarged grade 2 on rectal examination. He was advised to have a suprapubic enucleation of the prostate gland. See table 2.
OXYCEL-BAG CATHETER IN SUPRAPUBIC PROSTATECTOMY
103
Penicillin 300,000 u, streptomycin gm. 1 and vitamin C 100 mg. were given daily. Morphine sulfate½ gr. and scopolamine 2 h gr. were given as pre-anesthetic medication. The prostatectomy was done under pentothal sodium, nitrous oxide anesthesia. This was supplemented with curare. The prostate gland weighed 39 gm. Brisk bleeding was noted when the patient was returned to bed. Th_e bleeding persisted and the patient was returned to the operating room 8 hours after prostatectomy. Arterial bleeding was noted and was controlled by fulguration. The oxycel-bag catheter technique was used again. The remainder of the postoperative course was uneventful. The functional result was excellent. Case 3. Mr. B. G. was 70 years old. Paget's disease of the bone was found on x-ray examination. The patient had acute urinary retention for 4 days. Catheter TABLE
2
R. B. C. Hemoglobin W. B. C.
4,300,000/c.m.m. 11.4 gm. % 6,650/c.m.m.
Bleeding time Coagulation time
w
Urea nitrogen N. P. N. Sugar Carbon dioxide
15 mg.% 32 mg.% 95 mg.% 57 .9 vols.
2' 20"
TABLE
3
R. B. C. Hemoglobin W.B. C.
4, 160,000/P..rn.m. 12.6 gm.% 12,400/c.m.m.
Bleeding time Coagulation time
l' 30" 2' 10"
Urea nitrogen N. P. N. Sugar Carbon dioxide
14.8 mg.% 34 mg.% 90 mg.% 57 vols. %
drainage was used for 12 days preoperatively before the elevated blood chemistry approached normal. See table 3. Penicillin 300,000 u, streptomycin gm. 1 vitamin C 100 mg. were given daily. Morphine sulfate gr. -hand scopolamine 's~o gr. were given as pre-anesthetic medication. Pentothal sodium, nitrous oxide anesthesia were used. The removed prostate weighed 56 gm. The bleeding was brisk but diminished in amount after the first 3 hours. Brisk bleeding recurred on the third postoperative day. The urethral catheter was replaced for 48 hours and the bleeding gradually subsided. This patient's clinical course was complicated by osteitis pubis. The final result was excellent. Bleeding was well controlled before the bladder was closed in each of these patients. The blood picture was normal in each of these patients. The blood
104
WILLIAM J. BAKER AND EDWIN C. GRAF
pressure was at a safe level before the patient was removed from the operating room table. Medication did not seem to predispose to the bleeding. DISCUSSION
Freedom from the painful ordeal of removing packs through the suprapubic wound is a remarkable benefit derived from the oxycel-bag technique. Our patients suffered much more when the packs were removed than they did during the immediate postoperative period. The prospects of having a second pack removed the following day was almost too much for many of them to bear. Morphine sulfate was given before the packs were removed but it was ineffective. General anesthesia was used in the latter years for the removal of the packs. The risk of an additional anesthetic seemed appreciable. Nitrous oxide and oxygen was tried and was found unsatisfactory. Cyclopropane, which has the advantage of rapid induction and rapid recovery, seemed to predispose to excessive bleeding. Pentothal sodium and nitrous oxide with oxygen were the best TABLE
4
OXYCEL TECHNIQUE (50 CASES)
1. 2. 3. 4. 5. 6. 7.
Dry sinus Urosepsis Epididymitis Thrombophlebitis Osteitis pubis Calculus Deaths
15.5 days None 3 2
1 1 (oxycel) 1 (embolus)
GAUZE PACKING
(50 CASES)
18 days 7 3
None None None 2 (endocarditis) (shock)
agents but the severe stimulation engendered by removing the packs causeddistressing laryngospasm on more than one occasion. Escape from the added risk of a second anesthetic came with the advent of the oxycel-bag catheter technique. Severe and persistent infection of the urine, which was a problem when the prostatic bed was packed, has not been noted in the last 50 patients. The decrease in the amount of infection is also reflected in the minimal febrile reaction when the suprapubic sinus closes and the intravesical tension is re-established. Antibiotics were used prophylactically in both series of patients. There have been few complications directly attributable to the oxycel-bag catheter technique. See table 4. Stress incontinence has been noted for a few weeks in 2 patients. Stockwell has written about incontinence that follows traction of more than 3 to 4 hours. We have not used tension. Early decompression of the bag eliminates pressure on the sphincters as well as actually aiding hemostasis. A nidus of oxycel which became impregnated with calcium salts ,vas removed cystoscopically on one occasion. Riba has written of a similar experience. The use of a single layer of oxycel instead of multiple layers around the bag has eliminated the aspiration of appreciable amounts of "jelled" oxycel and
OXYCEL-BAG CATHETER IN SUPRAPUBIC PROSTATECTOMY
105
the danger of foreign body complications. An inflated bag in the prostatic bed ·will cause bladder spasms. This complication can be avoided by gently and partially distending the bag. The bag is deflated in 6 hours, which eliminates all pressure in the prostatic fossa. The one death which occurred in the oxycel group was due to a massive embolus on the eighth postoperative day. This patient was an obese, ,vhite man 66 years old. His blood pressure preoperatively was 172 millimeters of mercury systolic and 106 millimeters of mercury diastolic and he had a tachycardia of 100 per minute. His electrocardiogram was within normal limits. The blood picture was normal. Two of the 50 patients who were packed after suprapubic prostatectomy died. One of these was a 72 year old white man, who had a marked systolic heart murmur. He died from bacterial endocarditis 19 days after surgery. The second patient was an obese white man, 64 years of age, who suffered severe shock after surgery and did not respond to the usual therapy. He died 48 hours postoperatively. CONCLUSIOKS
The oxycel-bag catheter technique is an improved method for control of hemorrhage after suprapubic enucleation of the prostate gland. There is a decrease in blood loss. There is a decrease in the amount of infection. The is more comfortable. There is shorter hospitalization. 'l W. Madison
2, Ill. REFERENCES
DEVRIES, J. K. AND BucHANAN, R. W.: J. Urol., 57: 816, 1947. EIKNER, W. C.: J. Urol., 60: 124, 1948. F1sH, G. W.: J. Urol., 56: 375, 1946. GOLDSTEIN, A. E. AND RuBrn, S. W.: J. Urol., 60: 743, 1948. GooDYEAR, W. E. AND BEARD, D. E.: J. Urol., 62: 849, 1949. REINLE, G. G. AND MACDONALD, J. L.: J. Urol., 60: 495, 1948. RrnA, L. W.: J. A. l\lL A., 141: 532, 1949. SHIVERS, C.H. DE T. AND GROOM, C. E.: J. Urol., 59: 893, 1948. STOCKWELL, A. L.: J. Urol., 60: 128, 1948. STUMP, G.D. AND THUMANN, R C.: J. Urol., 59: 202, 1948. WILHELM, S. F. AND LEVINE, B.: J. Urol., 57: 291, 1947.