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Post-prostatectomy Bleeding Managed by Endovascular Embolization
0022-5347/03/1691-0276/0 THE JOURNAL OF UROLOGY® Copyright © 2003 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 169, 276 –277, January 2003 Printed in U.S.A.
DOI: 10.1097/01.ju.0000042060.73886.7f
POST-PROSTATECTOMY BLEEDING MANAGED BY ENDOVASCULAR EMBOLIZATION RODOLFO IBARRA, CHRIS MAGEE, HECTOR FERRAL
AND
IAN M. THOMPSON
From the Department of Radiology and Division of Urology, University of Texas Health Science Center at San Antonio, San Antonio, Texas KEY WORDS: prostatectomy; prostate; hemorrhage; embolization, therapeutic; postoperative complications
Prostate cancer is the second most common cause of cancer related mortality in males in the United States. Radical prostatectomy is a common treatment for localized prostate cancer. Significant post-prostatectomy hemorrhage is a rare but serious complication, occurring in less than 0.5% of cases.1 Treatment options include surgical exploration with ligation of bleeding sites, observation with ultimate tamponade and endovascular control. Intraoperative internal iliac artery ligation has previously been recommended to decrease blood loss.2 However, postoperative endovascular control is another option.3 We report the results of this approach in a patient with postoperative bleeding from the artery to the seminal vesicle.
pelvic hematoma (fig. 1). Repeat hematocrit was 20.7% and the patient was again transfused with 2 units of blood. Because of the appearance of the hematoma, a bleeding artery of the seminal vesicle was suspected. Selective catheterization of the left internal iliac artery revealed active bleeding from a branch to the seminal vesicle. Super-selective catheterization of the bleeding vessel was performed using a Renegade microcatheter and Transend wire (Boston Scientific Corp., Natick, Massachusetts) (fig. 2). Embolization was
CASE REPORT
A 70-year-old man with Gleason score 4 ⫹ 3, prostate specific antigen 4.7 ng./ml., T2a prostate cancer underwent uneventful nerve sparing radical retropubic prostatectomy and pelvic lymphadenectomy. Estimated blood loss was 900 cc. The following morning the patient complained of pelvic pain, and hemoglobin and hematocrit were 7.4 gm./dl. (normal 13.5 to 17.5) and 21.5% (normal 41% to 53%), respectively. There was minimal output from the pelvic drain. Two units of blood were transfused, and computerized tomography of the abdomen and pelvis demonstrated a large Accepted for publication August 9, 2002.
FIG. 2. Anterior digital subtraction angiogram before intervention FIG. 1. Computerized tomography of pelvis shows large left extra- demonstrates tip of catheter (arrow) in branch of internal iliac arperitoneal hematoma (arrow) displacing bladder to right side. tery, which displays active bleeding site (arrowhead). 276
ENDOVASCULAR EMBOLIZATION FOR POST-PROSTATECTOMY BLEEDING
accomplished using 500 to 700 m. Embospheres (BioSphere Medical, Inc., Rockland, Maine) and completed with a complex helical microcoil (Target Therapeutics, San Clemente, California). Although embolization was successful, because of hematuria with clots and difficulty irrigating the catheter, clot evacuation was performed. The urethrovesical anastomosis was intact and no bleeding was observed. Ultimately the patient recovered and he currently has excellent urinary continence.
277
seminal vesicle. Persistent bleeding mandated intervention. Consideration was given to reexploration but ligation of the artery would have required takedown and repeat urethrovesical anastomosis. In lieu of this procedure endovascular embolization was accomplished successfully. Given the excellent outcome in this case, we encourage consideration of this methodology if others encounter similar clinical circumstances. REFERENCES
DISCUSSION
Postoperative bleeding after radical prostatectomy is uncommon and generally of venous origin. In most cases compression of the retropubic space with tissue-to-tissue contact leads to rapid resolution. While hemostasis was observed at the termination of prostatectomy in our patient, it appears that arterial bleeding developed from the artery of the
1. Hedican, S. P. and Walsh, P. C.: Postoperative bleeding following radical retropubic prostatectomy. J Urol, 152: 1181, 1994 2. Kavoussi, L. R., Myers, J. A. and Catalona, W. J.: Effect of temporary occlusion of hypogastric arteries on blood loss during radical retropubic prostatectomy. J Urol, 146: 362, 1991 3. Appelton, D. S., Sibley, G. N. and Doyle, P. T.: Internal iliac artery embolisation for the control of severe bladder and prostate haemorrhage. Br J Urol, 61: 45, 1988
Vol. 169, 276 –277, January 2003 Printed in U.S.A.
DOI: 10.1097/01.ju.0000042060.73886.7f
POST-PROSTATECTOMY BLEEDING MANAGED BY ENDOVASCULAR EMBOLIZATION RODOLFO IBARRA, CHRIS MAGEE, HECTOR FERRAL
AND
IAN M. THOMPSON
From the Department of Radiology and Division of Urology, University of Texas Health Science Center at San Antonio, San Antonio, Texas KEY WORDS: prostatectomy; prostate; hemorrhage; embolization, therapeutic; postoperative complications
Prostate cancer is the second most common cause of cancer related mortality in males in the United States. Radical prostatectomy is a common treatment for localized prostate cancer. Significant post-prostatectomy hemorrhage is a rare but serious complication, occurring in less than 0.5% of cases.1 Treatment options include surgical exploration with ligation of bleeding sites, observation with ultimate tamponade and endovascular control. Intraoperative internal iliac artery ligation has previously been recommended to decrease blood loss.2 However, postoperative endovascular control is another option.3 We report the results of this approach in a patient with postoperative bleeding from the artery to the seminal vesicle.
pelvic hematoma (fig. 1). Repeat hematocrit was 20.7% and the patient was again transfused with 2 units of blood. Because of the appearance of the hematoma, a bleeding artery of the seminal vesicle was suspected. Selective catheterization of the left internal iliac artery revealed active bleeding from a branch to the seminal vesicle. Super-selective catheterization of the bleeding vessel was performed using a Renegade microcatheter and Transend wire (Boston Scientific Corp., Natick, Massachusetts) (fig. 2). Embolization was
CASE REPORT
A 70-year-old man with Gleason score 4 ⫹ 3, prostate specific antigen 4.7 ng./ml., T2a prostate cancer underwent uneventful nerve sparing radical retropubic prostatectomy and pelvic lymphadenectomy. Estimated blood loss was 900 cc. The following morning the patient complained of pelvic pain, and hemoglobin and hematocrit were 7.4 gm./dl. (normal 13.5 to 17.5) and 21.5% (normal 41% to 53%), respectively. There was minimal output from the pelvic drain. Two units of blood were transfused, and computerized tomography of the abdomen and pelvis demonstrated a large Accepted for publication August 9, 2002.
FIG. 2. Anterior digital subtraction angiogram before intervention FIG. 1. Computerized tomography of pelvis shows large left extra- demonstrates tip of catheter (arrow) in branch of internal iliac arperitoneal hematoma (arrow) displacing bladder to right side. tery, which displays active bleeding site (arrowhead). 276
ENDOVASCULAR EMBOLIZATION FOR POST-PROSTATECTOMY BLEEDING
accomplished using 500 to 700 m. Embospheres (BioSphere Medical, Inc., Rockland, Maine) and completed with a complex helical microcoil (Target Therapeutics, San Clemente, California). Although embolization was successful, because of hematuria with clots and difficulty irrigating the catheter, clot evacuation was performed. The urethrovesical anastomosis was intact and no bleeding was observed. Ultimately the patient recovered and he currently has excellent urinary continence.
277
seminal vesicle. Persistent bleeding mandated intervention. Consideration was given to reexploration but ligation of the artery would have required takedown and repeat urethrovesical anastomosis. In lieu of this procedure endovascular embolization was accomplished successfully. Given the excellent outcome in this case, we encourage consideration of this methodology if others encounter similar clinical circumstances. REFERENCES
DISCUSSION
Postoperative bleeding after radical prostatectomy is uncommon and generally of venous origin. In most cases compression of the retropubic space with tissue-to-tissue contact leads to rapid resolution. While hemostasis was observed at the termination of prostatectomy in our patient, it appears that arterial bleeding developed from the artery of the
1. Hedican, S. P. and Walsh, P. C.: Postoperative bleeding following radical retropubic prostatectomy. J Urol, 152: 1181, 1994 2. Kavoussi, L. R., Myers, J. A. and Catalona, W. J.: Effect of temporary occlusion of hypogastric arteries on blood loss during radical retropubic prostatectomy. J Urol, 146: 362, 1991 3. Appelton, D. S., Sibley, G. N. and Doyle, P. T.: Internal iliac artery embolisation for the control of severe bladder and prostate haemorrhage. Br J Urol, 61: 45, 1988