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Prostatitis following ureterolithotomy
PROSTATITIS
FOLLOWING
URETEROLITHOTOMY*
DAVID PRESMAN, M.D. Chicago, Illinois ECENTLY we have observed a Iate compIication folIowing ureteroIithotomy in two patients which has apparentIy not been heretofore described. This consists of Iow grade prostatitis which occurs severa weeks after surgery on the ureter for remova of a
R
TABLE SUMMARY
OF PATIENTS FOLLOWING
I
DEVELOPED
I of
SYmPLevel of tomSPoSt Ureteroperaotomy tively
Pyuria
(wk.1
PUS in Prostatic SeCr‘Ztion
Marked Marked
3
Gross Microscopic GTOSS Gross
Marked
R. P., 40 L. K., 5z
High High
6
J. G., 51
High
A. R.,
PROSTATIS
URETEROLITHOTOMY
Onset Name and Age
I
IN WHOM
5
Marked
44
LOW
5
A. L., 53
LOW
4
Marked
M. M.. 54 A. L., 63 J. N., 65
High LOW LOW
8 7 3
Marked Marked Marked
Preoperative Cystoscopy
days preoperatively 2 days preoperatively z days preoperatively NOIX NolIe 7 days preoperativety 2
caIcuIus. In order to determine the significance of this observation the records on a series of private aduIt maIe patients upon whom ureteroIithotomy was performed in the past few years have been reviewed. Of a total of fortyone consecutive patients this compIication deveIoped in eight, an incidence of 19.5 per cent. Since this figure is statisticaIIy significant, the records of these eight patients were studied in detai1 in an attempt to anaIyze the cIinica1 picture. The saIient features in each case are summarized in TabIe I. The age group ranged between forty and sixty-five years. The IeveI of the ureterotomy is apparentIy unimportant since there were four high and four Iow ureterotomies. The onset of symptoms was characteristicaIIy Iate in appearance, deveIoping as a ruIe after the patient was home and fairIy we11 through the convaIescent period. The earIiest * From the Department
occurred three weeks postoperativeIy and the Iatest eight weeks postoperativeIy. In each instance the patient compIained of typica symptoms of prostatitis such as sIowing of the stream, sIight frequency, dysuria and perinea1 discomfort. In none of these patients was there any previous history suggestive of prostatitis. Routine urologic studies performed when the patients were originaIIy seen incIuded recta1 and microscopic examinations of the massaged prostatic secretion. Both were norma in a11 cases. In five cases, after the onset of prostatic symptoms a grossIy cIoudy urine deveIoped which showed numerous pus ceIIs on microscopic examination. The urine had been grossIy cIear in a11these patients prior to onset of these symptoms. The diagnosis of prostatitis was made on each patient by the finding of a boggy prostate on recta1 examination which on massage yieIded prostatic secretion Ioaded with pus. Treatment of the prostatitis consisted of the usua1 measures of periodic prostatic massage and the administration of gantrisin.@ The symptoms subsided in a11patients and the prostatitis was cIeared up within four to six weeks. The question naturaIIy arises as to whether urethral instrumentation couId have been a factor in the etioIogy of the prostatitis. AIthough this is possibIe, it does not seem very IikeIy inasmuch as four of the eight patients had no instrumentation of any kind either before or after surgery. AIso, it has been our experience that as a ruIe prostatic reactions to cystoscopy occur within a few days and deveIop as acute, severe prostatitis with chiIIs, fever and very marked IocaI symptoms. In none of the four patients who were cystoscoped preoperativeIy did this acute compIication arise. In the four patients who were cystoscoped the symptoms of Iow grade prostatitis deveIoped from three to five weeks postoperativeIy. The fact that four patients had no instrumentation at any time wouId seem to minimize the importance of cytoscopy as a predisposing cause of the prostatitis.
of Urology, Chicago MedicaI SchooI, MichaeI Reese and Mt. Sinai Hospitals, Chicago,
718
American
Journal
III.
of Surgery
Presman-Prostatitis
Following
COMMENTS
The thesis that prostatitis may occur as a direct resutt of uretera surgery is admittedIy specmative and difficuIt to prove. It would seem, however, that certain facts tend to substantiate this supposition. The reIatively high incidence of this complication (19.5 per cent) in a consecutive series of forty-one patients is very suggestive of a causal relationship. The characteristic clinical picture in a11 of the eight patients in whom prostatitis deveIoped is very simiIar in severa respects. Symptoms did not appear unti1 several weeks following surgery, the Iongest period being eight weeks. In most cases the urine was grossly pyuric and in each instance the massaged prostatic secretion was loaded with pus. There was no correIation with the IeveI at which the ureteroIithotomy was performed since the upper and lower portions of the ureter were involved in an equal number of cases. When a11 these facts are considered, it appears that there may be a definite correIation between ureteroIithotomy and appearance of postoperative prostatitis. The exact pathogenesis of the prostatitis is conjectura1 but certain anatomic factors may be considered. The periureteral sheath extends down to and is continuous with the fascia1 coverings of the prostate and seminal vesicles. Also, the Iymphatics and the uretera wall course in a Iongitudinal direction and anastomose distally with the Iymphatics of the prostate and seminal vesicles. There is invariabIy some degree of infection in the ureteral wall at the site where a caIcuIus has been lodged. Incision of the ureter to extract the stone may aIlow infecting organisms to invade the periuretera1 sheath and extend down to the prostate, thus initiating Iow grade prostatitis. Trauma to the
December,
1953
UreteroIithotomy
719
uretera Iymphatics during surgery may aIso be a factor in the spread of the infection in a distal direction to invoIve the prostate. The occurrence of prostatitis foIIowing high ureteroIithotomy would seem to suggest the spread of infection by the previousIy described pathways rather than direct extension to a contiguous structure as would follow a low ureterolithotomy. SUMMARY I. The occurrence of low grade prostatitis as a Iate complication foIIowing ureteroIithotomy is described. In a series of forty-one consecutive male patients upon whom ureteroIithotomy was performed this complication occurred in eight patients, an incidence of 19.5 per cent. 2. In these eight patients four high and four low ureteroIithotomies were performed. 3. The cIinica1 picture in each patient was characteristic. TypicaI symptoms of prostatitis appeared during the convaIescent period, between three and eight weeks postoperatively. Objective findings consisted of pyuria, a boggy prostate and numerous pus ceIIs in the massaged prostatic secretion. 4. Pathogenesis of the prostatitis is believed to be extension of infecting organisms from the site of the ureteroIithotomy through the periureteral sheath and//or ureteral Iymphatics downward to the prostate. 5. It is fuIIy realized that any conclusions drawn from a smaI1 series of cases may be questionable. However, the characteristic pattern of the cIinica1 picture in these patients is highIy suggestive of a definite causa1 relationship. It is hoped that further observations on this subject wiI1 be made by others so that a more objective evaIuation may be made.
FOLLOWING
URETEROLITHOTOMY*
DAVID PRESMAN, M.D. Chicago, Illinois ECENTLY we have observed a Iate compIication folIowing ureteroIithotomy in two patients which has apparentIy not been heretofore described. This consists of Iow grade prostatitis which occurs severa weeks after surgery on the ureter for remova of a
R
TABLE SUMMARY
OF PATIENTS FOLLOWING
I
DEVELOPED
I of
SYmPLevel of tomSPoSt Ureteroperaotomy tively
Pyuria
(wk.1
PUS in Prostatic SeCr‘Ztion
Marked Marked
3
Gross Microscopic GTOSS Gross
Marked
R. P., 40 L. K., 5z
High High
6
J. G., 51
High
A. R.,
PROSTATIS
URETEROLITHOTOMY
Onset Name and Age
I
IN WHOM
5
Marked
44
LOW
5
A. L., 53
LOW
4
Marked
M. M.. 54 A. L., 63 J. N., 65
High LOW LOW
8 7 3
Marked Marked Marked
Preoperative Cystoscopy
days preoperatively 2 days preoperatively z days preoperatively NOIX NolIe 7 days preoperativety 2
caIcuIus. In order to determine the significance of this observation the records on a series of private aduIt maIe patients upon whom ureteroIithotomy was performed in the past few years have been reviewed. Of a total of fortyone consecutive patients this compIication deveIoped in eight, an incidence of 19.5 per cent. Since this figure is statisticaIIy significant, the records of these eight patients were studied in detai1 in an attempt to anaIyze the cIinica1 picture. The saIient features in each case are summarized in TabIe I. The age group ranged between forty and sixty-five years. The IeveI of the ureterotomy is apparentIy unimportant since there were four high and four Iow ureterotomies. The onset of symptoms was characteristicaIIy Iate in appearance, deveIoping as a ruIe after the patient was home and fairIy we11 through the convaIescent period. The earIiest * From the Department
occurred three weeks postoperativeIy and the Iatest eight weeks postoperativeIy. In each instance the patient compIained of typica symptoms of prostatitis such as sIowing of the stream, sIight frequency, dysuria and perinea1 discomfort. In none of these patients was there any previous history suggestive of prostatitis. Routine urologic studies performed when the patients were originaIIy seen incIuded recta1 and microscopic examinations of the massaged prostatic secretion. Both were norma in a11 cases. In five cases, after the onset of prostatic symptoms a grossIy cIoudy urine deveIoped which showed numerous pus ceIIs on microscopic examination. The urine had been grossIy cIear in a11these patients prior to onset of these symptoms. The diagnosis of prostatitis was made on each patient by the finding of a boggy prostate on recta1 examination which on massage yieIded prostatic secretion Ioaded with pus. Treatment of the prostatitis consisted of the usua1 measures of periodic prostatic massage and the administration of gantrisin.@ The symptoms subsided in a11patients and the prostatitis was cIeared up within four to six weeks. The question naturaIIy arises as to whether urethral instrumentation couId have been a factor in the etioIogy of the prostatitis. AIthough this is possibIe, it does not seem very IikeIy inasmuch as four of the eight patients had no instrumentation of any kind either before or after surgery. AIso, it has been our experience that as a ruIe prostatic reactions to cystoscopy occur within a few days and deveIop as acute, severe prostatitis with chiIIs, fever and very marked IocaI symptoms. In none of the four patients who were cystoscoped preoperativeIy did this acute compIication arise. In the four patients who were cystoscoped the symptoms of Iow grade prostatitis deveIoped from three to five weeks postoperativeIy. The fact that four patients had no instrumentation at any time wouId seem to minimize the importance of cytoscopy as a predisposing cause of the prostatitis.
of Urology, Chicago MedicaI SchooI, MichaeI Reese and Mt. Sinai Hospitals, Chicago,
718
American
Journal
III.
of Surgery
Presman-Prostatitis
Following
COMMENTS
The thesis that prostatitis may occur as a direct resutt of uretera surgery is admittedIy specmative and difficuIt to prove. It would seem, however, that certain facts tend to substantiate this supposition. The reIatively high incidence of this complication (19.5 per cent) in a consecutive series of forty-one patients is very suggestive of a causal relationship. The characteristic clinical picture in a11 of the eight patients in whom prostatitis deveIoped is very simiIar in severa respects. Symptoms did not appear unti1 several weeks following surgery, the Iongest period being eight weeks. In most cases the urine was grossly pyuric and in each instance the massaged prostatic secretion was loaded with pus. There was no correIation with the IeveI at which the ureteroIithotomy was performed since the upper and lower portions of the ureter were involved in an equal number of cases. When a11 these facts are considered, it appears that there may be a definite correIation between ureteroIithotomy and appearance of postoperative prostatitis. The exact pathogenesis of the prostatitis is conjectura1 but certain anatomic factors may be considered. The periureteral sheath extends down to and is continuous with the fascia1 coverings of the prostate and seminal vesicles. Also, the Iymphatics and the uretera wall course in a Iongitudinal direction and anastomose distally with the Iymphatics of the prostate and seminal vesicles. There is invariabIy some degree of infection in the ureteral wall at the site where a caIcuIus has been lodged. Incision of the ureter to extract the stone may aIlow infecting organisms to invade the periuretera1 sheath and extend down to the prostate, thus initiating Iow grade prostatitis. Trauma to the
December,
1953
UreteroIithotomy
719
uretera Iymphatics during surgery may aIso be a factor in the spread of the infection in a distal direction to invoIve the prostate. The occurrence of prostatitis foIIowing high ureteroIithotomy would seem to suggest the spread of infection by the previousIy described pathways rather than direct extension to a contiguous structure as would follow a low ureterolithotomy. SUMMARY I. The occurrence of low grade prostatitis as a Iate complication foIIowing ureteroIithotomy is described. In a series of forty-one consecutive male patients upon whom ureteroIithotomy was performed this complication occurred in eight patients, an incidence of 19.5 per cent. 2. In these eight patients four high and four low ureteroIithotomies were performed. 3. The cIinica1 picture in each patient was characteristic. TypicaI symptoms of prostatitis appeared during the convaIescent period, between three and eight weeks postoperatively. Objective findings consisted of pyuria, a boggy prostate and numerous pus ceIIs in the massaged prostatic secretion. 4. Pathogenesis of the prostatitis is believed to be extension of infecting organisms from the site of the ureteroIithotomy through the periureteral sheath and//or ureteral Iymphatics downward to the prostate. 5. It is fuIIy realized that any conclusions drawn from a smaI1 series of cases may be questionable. However, the characteristic pattern of the cIinica1 picture in these patients is highIy suggestive of a definite causa1 relationship. It is hoped that further observations on this subject wiI1 be made by others so that a more objective evaIuation may be made.