An old male patient was admitted in our hospital for BPH (benign prostate hyperplasia).
We planned for the operation and he underwent prostatectomy which did not pose any special problem in theater. The procedure was smooth and the bleeding minimum.
The following day the patient suddenly complained of palpitations and arrhythmia, and an ECG diagnosed an acute episode of Atrial Fibrillation which was not there during the operation. We treated him with digoxin and the fibrillation disappeared within 24 hours.
Creatinine levels were normal and HB was 13 g/dl.
The continuous wash out was doing well and there were no clots, even though we started noticing that the suvrapubic drainage was draining some fluids.
On day 3 post-op the patient developed acute psychosis which at the beginning we considered due to spinal anaestesia.
On day 5 post-op the patient was still restless and unconscious; the creatinine levels went up to 3 g/dl and liver function tests were elevated at GOT 350, GPT 365.
We noticed some hematoma on the skin of the patient in hypostatic areas, and the HB went down to 5 g/dl even without any hematuria in the post op.
Patient has been transfused 3 pints of blood and enoxiparine (which we normally use in the post-operative period at the dose of 4000 I.U. sc OD for prevention of DVT) was stopped.
The electrolyte levels showed to us an important hyponatremia, and, while the patient was still restless and semiconscious, we tried to correct the sodium balance, thinking that the unconsciousness and restlessness may be due to electrolyte imbalance and possible cerebral oedema.
In fact when sodium went back to normal the conditions of the patient have improved. GOT and GPT went back to range, while creatinine has been at around 2 g/dl and it has never gone back to normal levels.
The surgical wound has been doing well and we have removed the stitches after 10 days without any problem.
We have removed the catheter on day 10 post op. The patient was passing urine well and therefore we have removed also the suvrapubic drainage
On day 13 post op we have realized that some fluid was coming out of
the drainage site and we have reinserted the catheter. It had happened other times and normally the urinary fistula closed when the catheter was draining well.
Meanwhile the general conditions have really improved and the patient has been mobile and feeding well. He was still anemic but the HB has been increasing reaching 7 g/dl.
From time to time there was fever.
The patient has been on antibiotics from the day of the operation up to now and, at the moment he is on cephalexin 500 mg QID (he has also been on penicillines and quinolones).
During the time of admission he has also been found positive for malaria twice and he has been treated with quinine once and with artenam i.m the second time.
The main problem has been the urinary fistula.
I have realized that the urinary fistula was not improving because the catheter was actually not going to the urine bladder but to some space between the bladder and the rectum.
I have seen it clearly through U/S which has shown the balloon of the foley catheter to be too deep to be actually in the bladder.
This was the main cause of the catheter not draining and the urine just following the way of the fistula.
I have called for help from another surgeon who has decided to reopen the bladder under general anaesthesia and to reposition the catheter in the bladder under direct vision. The opening of the bladder has allowed also a surgical toilet of the prostatic lodge which was full
of pus and debris (this was probably the main cause of the fever).
The patient is now doing very well and the fistula is closing even though the wound is still a bit septic: therefore he is still on catheter and he will remain hospitalized for a while, in order to allow the infection to be completely controlled and the fistula completely closed.
My personal meditation in a nutshell leads me to the following simple points:
1) Prostatectomy is not a very difficult operation to perform, but the post-op period is the most difficult and challenging for us in Chaaria. Complications can arise at any time, from the first day after the operation up to weeks afterwards.
2) The most common complication is certainly bleeding, but also urinary fistula is not uncommon and it is generally very difficult to manage.
3) Because the patients are elderly and frail we can expect even medical complications which are not strictly surgical and are caused by the already impaired metabolism of the client.
4) Therefore the decision on doing a prostatectomy is always a difficult one and must take into consideration the gains in the living standards of the patient and the possible problems which can arise from the surgery itself.
For the patient I have presented today, I am now a bit relieved because finally things seem to go in the right direction, and he will be well again: I thank God and also the surgeon who has come to my help.
Dr Bro Giuseppe Gaido
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