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Transurethral Resection of the Prostate in Patients with Hematologic Disease
Vol. 111. Printed in
THE JOURNAL OF UROLOGY
Copyright© 1974 by The Williams & Wilkins Co.
RESECTION OF THE PROSTATE IN PATIENTS WITH HEMATOLOGIC DISEASE JEROME MELCHIOR, WILLIAM L. VALK
AND
WINSTON K. MEBUST
From the Section of Urology, Department of Sur{{ery, University of Kansas Medical Center and Veterans Administration Hospital, Kansas Cit.,·. Kansas
The specter of uncontrollable hemorrhage has always disturbed surgeons but it may be catastrophic to the transurethral resectionist. Even the most bold and competent resectionist, who often resects medically complicated patients, will defer or refer patients with hematologic problems. We herein review our experience with such problems. MATERIALS
A recent review of 7 years of experience in transurethral prostatic resection revealed 19 cases involving patients with significant hematologic disease (table 1). The hospital charts of these patients were reviewed in detail, with special emphasis on the effect of hematologic disease on the transurethral operation. Review was made of the patients' general state of health on admission to the hospital, the procedure itself, size of resection, blood or blood components replaced, number of days hospitalized postoperatively, all complications and length of patient followup (table 2). The hematologic have been thoroughly reviewed and confirmed with appropriate tests as well as one or more bone marrow examinations.
Most of the group :-l leukemics had other medical problems as well as anemia (4 of 6) but combined because of their thrombocytopenia. patients had platelet counts less than 90,000. There were :l complications in this group of patients. Group 4 are non-leukemic with seven-' thrombocytopenia, who presented with much the same problems as group 3 platelet counts were lower. tion in this group. DISCUSSION
Severe prostatism in the with hernato logic disease, with or without urinary retention, is therapeutic dilemma for the urologist. Many of these hematologic diseases accompanied anemia, abnormal mechanisms, deranged immunoglobulins, TABLE
No. Cases Chronic lymphocytic leukemia Subacute lymphocytic leukemia Chronic myelocytic leukemia Idiopathic thrombocytopenic purpura Lymphosarcoma with thrombocytopenia Multiple myeloma Myelofibrosis
RESULTS
The 19 patients listed in table 2 are divided into 4 categories: 1) routine leukemics, 2) leukemics with other serious medical problems, 3) leukemics with thrombocytopenia and 4) non-leukemics with severe thrombocytopenia. The average age of these patients is 71.2 years (range 61 to 89 years). Eighteen of the 19 patients returned for followup for an average time of 21.1 months (range 2 to 73 months). Group 1 involves routine leukemics without other serious problems on admission to the hospital, who have normal hemoglobins and platelet counts and whose leukemia is actually an incidental finding. These patients had normal preoperative and postoperative courses with disposition being made without No bleeding problems were encountered. Group 2 are leukemics with other serious medical problems. Although all have marked medical problems and 3 of 5 were severely anemic and debilitated, all have at least low normal platelet counts. Only 1 patient had a minor complication. Accepted for publication August 31, 1973. Requests for reprints: Section of Urology, University of Kansas Medical Center, Kansas City, Kansas 66103.
1. Hematolo{{ic problem of patients
penia, thrombocytopathia, as well as the induced complications of chemotherapy, 1rn munosuppressives, steroids and ditionally, there are numerous medical resulting simply from the age group involved. Af; the expertise in the use of chemotherapy anci supportive care improves, more and more patients will present with problems in which the risk operation versus the risk of sepsis from a nent indwelling catheter must be Patients from group 1 illustrate that routine leukemics had no unusual problems. All of these patients were diagnosed as leukemics on thi,i hospitalization but none had been treated with either radiation or chemotherapeutic agents. Patients in group 2 require only special care for their medical problems. No unusual for the surgeon resulted from the leukemia. Patients in groups 3 and 4 demonstrate tha1 those with low platelet counts can safely transurethral resection with adequate support. 525
TABLE
Hematologic Disease
Diagnosis Made
Other Problems
01 l,v cr:,
2 Hgb.* (gm.%)
Prostate Resected (gm.)
WBC
Plateletst
(xlO')
(xlO')
13.2 13.4 17.4 16.4
21.2 16.7 150.0 142.0
229 206 269 208
10 37 9 50
16.3 14.2 8.6 9.7
16.3 34.0 17.6 34.0
232 225 296 162
15 27 73 30
Blood Replaced Operating Room
Postop.
0 0 0 0
0 0 0 0
0 0 0 2 units
0 0 1 unit 0
0 0 4 units 1 unit
0 0 0 0
Preop.
Group 1 Chronic lymphocytic leukemia Chronic lymphocytic leukemia Chronic lymphocytic leukemia Chronic lymphocytic leukemia
Admit. Admit. Admit. Admit.
Chronic lymphocytic leukemia Chronic lymphocytic leukemia Chronic lymphocytic leukemia Chronic lymphocytic leukemia
Admit. Admit. 2yrs. 13 yrs.
Chronic lymphocytic leukemia Chronic lymphocytic leukemia Chronic lymphocytic leukemia Chronic lymphocytic leukemia
Chronic lymphocytic leukemia Subacute lymphocytic leukemia
4yrs. lOyrs. 4yrs. 14 yrs.
2mos. 1 yr.
Chronic myelocytic leukemia
Admit.
Idiopathic thrombocytopenic purpura Lymphosarcoma
7yrs. 1 yr.
Multiple myeloma
1 yr.
Group2 Congestive heart failure, severe angina Ca prostate, extensive osteoblastic lesions Retention, Foley drainage 4 mos. Retention, azotemic, congestive heart failure, Klebsiella pneumonia, on chlorambucil Retention, diabetes Group3 Retention, diabetes On prednisone Septic, congestive heart failure
Prior radiation, retention, 57% blast cells on peripheral smear Retention, marked azotemia, diabetes
10.0
25.0
174
40
0 0 0 5 units
10.7 14.0 7.5
33.0 4.3 0.85
135 57 51
3(VNC):f: 53 10
16.7 6.8
17.0 36.8
110 49
10 8
0 7 units 15 platelet packs 2 units
8.9
7.2
87
12.2
9.5
18.0
15
0
Extensive radiation, pleural effusion, retention, on prednisone and alkeran
9.5
5.7
75.0
32
3 units
Ca colon, severe hypoimmunoglobulinemic, retention, azotemic, on alkeran
8.9
4.0
38
22
14.8
9.4
80.0
100
1 unit 0 4 units 1 unit 10 platelet packs 0 0
0 0 0 4 platelet packs 0 0
2 units 6 platelet packs
0
8 platelet packs 8 platelet packs
5 units
6 platelet packs 2 units 6 platelet packs 0
0
0
Group4
Myelofibrosis * Admission values. t Last preoperative determination. :f: Vesical neck contracture.
22 yrs.
Massive splenomegaly, bladder calculi
4(VNC):f:
5 units 12 platelet packs 0
~ l"l
t"" 0
:t
0
JI
~
:,::
~ ~
Erl c::: w >-3
PROSTATIC RESECTION IN PATIENTS WITH HEMATOLOGIC DISEASE TABLE
8. Pathology of prostatic tissue re moued No. Cases with marked
11 4
adenocarcinoma (stage ll)
Well differentiated adenocarcinoma (focal. stage I) Poorly differentiated adenocarcinoma (stage IV)
TABLE
--~----··-
4. Complications
·-----------------
Mortality
No. Cases -------------0
(mean 70,000). Half of these counts less than 60,000. Platelet 6 of these of time patients had major confirm the belief of most that such increased risk. The examination of resected in table 3. This series reveals 22 to have carcinoma of the percentage to have marked leukemic infiltration. This Px,w•c1Pn of leukemic infiltration will be the of another The 1 focal adenocarcinoma vesical neck contracture years after a 40 gm. resection Review of these no area o,f Lumor. Table 4 lists the C
postop.) .lower extremity (7 days postop.)
Perineal urethrostomy open 4 mos. postop.
count less than but are uncommon if platelet count exceeds 70,()00. 1 hemoris often seen when counts are less than 30,000. f.HW.c,c~~U the distinchemostasis-the maintenance of hemostasis until healing is hemostasis is to the transurethral resectionist whi.Ie the sected fossa Low adhesiveness. The remain more and friable and dot retraction is absent if count is less than 70,000. 1 care of these with the use of is a well established method of exact life span of the 1s >h,-.rnTh< tween 8 and 11 The life span of transfused is unknown but believed to be considervariable" 3 • ' 4 illustrate 10 patients with from 135,000 to 18,000
prone of numerous variables that bine to make him more vuinerable. ,n,CTC,,VH
SUMMARY AND CONCLUSIONS
infiltrations of the prostate in our series. 5 , 6
Dr. Frank A. Mantz, Jr. reviewed the slides. P.: Infiltration
cI. Uroi
A.: Suhactrce of
THE JOURNAL OF UROLOGY
Copyright© 1974 by The Williams & Wilkins Co.
RESECTION OF THE PROSTATE IN PATIENTS WITH HEMATOLOGIC DISEASE JEROME MELCHIOR, WILLIAM L. VALK
AND
WINSTON K. MEBUST
From the Section of Urology, Department of Sur{{ery, University of Kansas Medical Center and Veterans Administration Hospital, Kansas Cit.,·. Kansas
The specter of uncontrollable hemorrhage has always disturbed surgeons but it may be catastrophic to the transurethral resectionist. Even the most bold and competent resectionist, who often resects medically complicated patients, will defer or refer patients with hematologic problems. We herein review our experience with such problems. MATERIALS
A recent review of 7 years of experience in transurethral prostatic resection revealed 19 cases involving patients with significant hematologic disease (table 1). The hospital charts of these patients were reviewed in detail, with special emphasis on the effect of hematologic disease on the transurethral operation. Review was made of the patients' general state of health on admission to the hospital, the procedure itself, size of resection, blood or blood components replaced, number of days hospitalized postoperatively, all complications and length of patient followup (table 2). The hematologic have been thoroughly reviewed and confirmed with appropriate tests as well as one or more bone marrow examinations.
Most of the group :-l leukemics had other medical problems as well as anemia (4 of 6) but combined because of their thrombocytopenia. patients had platelet counts less than 90,000. There were :l complications in this group of patients. Group 4 are non-leukemic with seven-' thrombocytopenia, who presented with much the same problems as group 3 platelet counts were lower. tion in this group. DISCUSSION
Severe prostatism in the with hernato logic disease, with or without urinary retention, is therapeutic dilemma for the urologist. Many of these hematologic diseases accompanied anemia, abnormal mechanisms, deranged immunoglobulins, TABLE
No. Cases Chronic lymphocytic leukemia Subacute lymphocytic leukemia Chronic myelocytic leukemia Idiopathic thrombocytopenic purpura Lymphosarcoma with thrombocytopenia Multiple myeloma Myelofibrosis
RESULTS
The 19 patients listed in table 2 are divided into 4 categories: 1) routine leukemics, 2) leukemics with other serious medical problems, 3) leukemics with thrombocytopenia and 4) non-leukemics with severe thrombocytopenia. The average age of these patients is 71.2 years (range 61 to 89 years). Eighteen of the 19 patients returned for followup for an average time of 21.1 months (range 2 to 73 months). Group 1 involves routine leukemics without other serious problems on admission to the hospital, who have normal hemoglobins and platelet counts and whose leukemia is actually an incidental finding. These patients had normal preoperative and postoperative courses with disposition being made without No bleeding problems were encountered. Group 2 are leukemics with other serious medical problems. Although all have marked medical problems and 3 of 5 were severely anemic and debilitated, all have at least low normal platelet counts. Only 1 patient had a minor complication. Accepted for publication August 31, 1973. Requests for reprints: Section of Urology, University of Kansas Medical Center, Kansas City, Kansas 66103.
1. Hematolo{{ic problem of patients
penia, thrombocytopathia, as well as the induced complications of chemotherapy, 1rn munosuppressives, steroids and ditionally, there are numerous medical resulting simply from the age group involved. Af; the expertise in the use of chemotherapy anci supportive care improves, more and more patients will present with problems in which the risk operation versus the risk of sepsis from a nent indwelling catheter must be Patients from group 1 illustrate that routine leukemics had no unusual problems. All of these patients were diagnosed as leukemics on thi,i hospitalization but none had been treated with either radiation or chemotherapeutic agents. Patients in group 2 require only special care for their medical problems. No unusual for the surgeon resulted from the leukemia. Patients in groups 3 and 4 demonstrate tha1 those with low platelet counts can safely transurethral resection with adequate support. 525
TABLE
Hematologic Disease
Diagnosis Made
Other Problems
01 l,v cr:,
2 Hgb.* (gm.%)
Prostate Resected (gm.)
WBC
Plateletst
(xlO')
(xlO')
13.2 13.4 17.4 16.4
21.2 16.7 150.0 142.0
229 206 269 208
10 37 9 50
16.3 14.2 8.6 9.7
16.3 34.0 17.6 34.0
232 225 296 162
15 27 73 30
Blood Replaced Operating Room
Postop.
0 0 0 0
0 0 0 0
0 0 0 2 units
0 0 1 unit 0
0 0 4 units 1 unit
0 0 0 0
Preop.
Group 1 Chronic lymphocytic leukemia Chronic lymphocytic leukemia Chronic lymphocytic leukemia Chronic lymphocytic leukemia
Admit. Admit. Admit. Admit.
Chronic lymphocytic leukemia Chronic lymphocytic leukemia Chronic lymphocytic leukemia Chronic lymphocytic leukemia
Admit. Admit. 2yrs. 13 yrs.
Chronic lymphocytic leukemia Chronic lymphocytic leukemia Chronic lymphocytic leukemia Chronic lymphocytic leukemia
Chronic lymphocytic leukemia Subacute lymphocytic leukemia
4yrs. lOyrs. 4yrs. 14 yrs.
2mos. 1 yr.
Chronic myelocytic leukemia
Admit.
Idiopathic thrombocytopenic purpura Lymphosarcoma
7yrs. 1 yr.
Multiple myeloma
1 yr.
Group2 Congestive heart failure, severe angina Ca prostate, extensive osteoblastic lesions Retention, Foley drainage 4 mos. Retention, azotemic, congestive heart failure, Klebsiella pneumonia, on chlorambucil Retention, diabetes Group3 Retention, diabetes On prednisone Septic, congestive heart failure
Prior radiation, retention, 57% blast cells on peripheral smear Retention, marked azotemia, diabetes
10.0
25.0
174
40
0 0 0 5 units
10.7 14.0 7.5
33.0 4.3 0.85
135 57 51
3(VNC):f: 53 10
16.7 6.8
17.0 36.8
110 49
10 8
0 7 units 15 platelet packs 2 units
8.9
7.2
87
12.2
9.5
18.0
15
0
Extensive radiation, pleural effusion, retention, on prednisone and alkeran
9.5
5.7
75.0
32
3 units
Ca colon, severe hypoimmunoglobulinemic, retention, azotemic, on alkeran
8.9
4.0
38
22
14.8
9.4
80.0
100
1 unit 0 4 units 1 unit 10 platelet packs 0 0
0 0 0 4 platelet packs 0 0
2 units 6 platelet packs
0
8 platelet packs 8 platelet packs
5 units
6 platelet packs 2 units 6 platelet packs 0
0
0
Group4
Myelofibrosis * Admission values. t Last preoperative determination. :f: Vesical neck contracture.
22 yrs.
Massive splenomegaly, bladder calculi
4(VNC):f:
5 units 12 platelet packs 0
~ l"l
t"" 0
:t
0
JI
~
:,::
~ ~
Erl c::: w >-3
PROSTATIC RESECTION IN PATIENTS WITH HEMATOLOGIC DISEASE TABLE
8. Pathology of prostatic tissue re moued No. Cases with marked
11 4
adenocarcinoma (stage ll)
Well differentiated adenocarcinoma (focal. stage I) Poorly differentiated adenocarcinoma (stage IV)
TABLE
--~----··-
4. Complications
·-----------------
Mortality
No. Cases -------------0
(mean 70,000). Half of these counts less than 60,000. Platelet 6 of these of time patients had major confirm the belief of most that such increased risk. The examination of resected in table 3. This series reveals 22 to have carcinoma of the percentage to have marked leukemic infiltration. This Px,w•c1Pn of leukemic infiltration will be the of another The 1 focal adenocarcinoma vesical neck contracture years after a 40 gm. resection Review of these no area o,f Lumor. Table 4 lists the C
postop.) .lower extremity (7 days postop.)
Perineal urethrostomy open 4 mos. postop.
count less than but are uncommon if platelet count exceeds 70,()00. 1 hemoris often seen when counts are less than 30,000. f.HW.c,c~~U the distinchemostasis-the maintenance of hemostasis until healing is hemostasis is to the transurethral resectionist whi.Ie the sected fossa Low adhesiveness. The remain more and friable and dot retraction is absent if count is less than 70,000. 1 care of these with the use of is a well established method of exact life span of the 1s >h,-.rnTh< tween 8 and 11 The life span of transfused is unknown but believed to be considervariable" 3 • ' 4 illustrate 10 patients with from 135,000 to 18,000
prone of numerous variables that bine to make him more vuinerable. ,n,CTC,,VH
SUMMARY AND CONCLUSIONS
infiltrations of the prostate in our series. 5 , 6
Dr. Frank A. Mantz, Jr. reviewed the slides. P.: Infiltration
cI. Uroi
A.: Suhactrce of