Acute Renal Failure with Paralytic Ileus and Polyserositis after Open Suprapubic Radical Prostatectomy: A Case Report.

M.Sučić, ¹ S.Ovčariček,¹ H.Budinčević,² B.Mažuran¹

¹ University Hospital “ Sveti Duh”, Zagreb, Depatment of Urology
² University Hospital “ Sveti Duh”, Zagreb, Depatment of Neurology

Introduction: Prostate cancer is the second leading cause of cancer related death in men in the Western world. In more than 90% of cases the cancer is localized, and radical prostatectomy represent one of the main treatment options. The aim of this case report is to present possible complication of radical prostatectomy.

Case Presentation: A 62-year-old man presented to our Department with pain during urination with elevated prostate specific antigen (21,71 ng/mL). His previous medical history included transrectal prostate puncture due to inflammation in 1986. Five years ago, the PSA was 14.9 ng / mL , periodically taking tamsulosin , and was not regularly controlled . He does not take other medications.

Suspicion of prostate neoplasm on digital rectal examination was confirmed by transrectal biopsy. Transrectal biopsy demonstrated prostate adenocarcinoma of right lobe gland (GS 7 of 3/10 needle cores). Skeletal scintigraphy was unremarkable, without signs of metastases.

Open retropubic radical prostatectomy was performed with routine perioperative antibiotic prophylaxis with 400mg of intravenous ciprofloxacin.

Surgery lasted for two hours without intraoperative complications. Blood loss during surgery was 680 ml, without marked drop in red blood cells count (RBC: Er 4.2 Hb 121 , Hct 0.35). During first postoperative day patient’s diuresis was 1200 ml with serum creatinine levels of 212 mmol/L. On second postoperative day decrease of diuresis was noted (800ml) with slight elevation of serum creatinine levels (296 mmol/L), but later during the same day patient became anuric despite the continued stimulation of furosemide, hypotensive, subfebrile (37.3°C) with elevation of inflammatory markers levels (CRP 312.6 mg/L and leukocytes 14.23×109/L) and serum creatinine levels (450mm/L). Further, patient developed paralytic ileus with abdominal distension, edemas of scrotum and legs and became dyspneic with tachycardia. The antibiotic therapy with meropenem and hemodialysis were started with other supportive procedures. The computed tomography of abdomen and chest showed bilateral pleural, intraperitoneal and retroperitoneal effusions. The urine cultures and hemocultures were negative. After the second hemodialysis on third postoperative day the patient began to urinate. During next few days patient showed the gradual clinical improvement with decrease of inflammatory markers.

The surgery wound healed primarily, the catheter was removed on 13th day of hospitalization. Pathogistological examination of surgically removed prostate revealed adenocarcinoma of the prostate (GS 7 , pT3N0Mx) with chronic prostatitis and focal comedonecrosis.

Discussion: Our case demonstrates very rare but possible complication of radical prostatectomy. Sepsis with acute renal failure with paralytic ileus and polyserositis probably was caused by dissemination of infective agent (bacteria) resistant to ciprofloxacine during bladder neck dissection.