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Official Journal of the
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| Case Report « PDF file » |
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Lower Limb Compartment Syndrome following Laparoscopic Radical Prostatectomy
Frederico R. Romero1, Roberto Pilati1, David Kulysz1, Fabrizio A. V. Canali2, Paulo V. Baggio3, Thadeu Brenny Filho1
1 Urology Department; 2 Anesthesiology Department ; 3 Vascular Surgery Department, São Vicente Hospital, Curitiba, PR-Brazil.
ABSTRACT
Objective - Compartment syndrome (CS) is rare after laparoscopic radical prostatectomy
(LRP). We report a recently diagnosed case in our institution with the objective of discussing the pathophysiology of this serious
complication, highlighting possible preventive measures.
Case report - A 68-year-old man diagnosed with clinical stage T2a
prostate adenocarcinoma underwent extraperitoneal LRP with bilateral preservation of neurovascular bundles.
Postoperatively, he developed CS of the right leg, requiring decompressive fasciotomy. Six months after LRP, the patient recovered
well, thus walking without supervision. Discussion - There are several circumstantial risk factors associated with LRP
that when combined, may potentially predispose to the development of CS, including obesity, evidence of peripheral
vascular disease (increasing age, hypertension, hyperlipidemia, and diabetes mellitus), thromboembolism prophylaxis
with compressive leg wraps together with intermittent pneumatic device, combined general and spinal anesthesia,
prolonged operative time in Trendelemburg position, and systemic hypotension due to intraoperative bleeding. Recognizing
these factors preoperatively may identify patients at high risk of CS after LRP, allowing the application of preventive
measures to avoid this important cause of postoperative morbidity.
Key words: Compartment Syndrome; Risk Factors; Prostatectomy; Laparoscopy; Complication.
Bras. J. Video-Sur, 2008, v. 1, n. 1: 037-039
| Accepted after revision: January, 17, 2008. |
INTRODUCTION
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ompartment Syndrome (CS) is frequently
associated to limbs injury; however it may occur as a complication after prolonged
pelvic surgeries. High suspicious of this condition
is necessary for an early diagnosis. Frequently,
CS is misdiagnosis as deep venous thrombosis or neuropraxia, mainly when disease signs
are discreet and unilateral. A delayed and
erroneous diagnosis could have devastating
consequences for the patient such as loss of limb or even death.
CS is rare after laparoscopic radical prostatectomy (LRP), despite
erroneous diagnosis and medical-legal implications
possible accountability for its low incidence. There
are several circumstantial risk factors associated with LRP that may result in CS.
CASE REPORT
A 68 year-old man, with a PSA of 3.8ng/mL, was diagnosed with clinical stage T2a
prostate cancer during a screening exam. He had
significant comorbidities such as hypertension,
diabetes, hiperlipidemia, myocardiopathy, obesity (31.2
kg/m2 of body mass index) and hepatic cirrhosis.
Before the surgery, the legs of the patient were wrapped together with an
intermittent pneumatic device to avoid DVT. Under
combined general and spinal anesthesia the patient
was placed in Trendelemburg position and
underwent extraperitoneal LRP with bilateral sparing of
the neurovascular bundles. At the moment of the anesthesic induction his blood pressure
was150/80 mmHg, and was maintained in a lower
level during the entire surgery. Operative time was
360 minutes and intraoperative bleeding was 1000 mL. The bleeding mainly occurred
while controlling prostate lateral pedicle and
dissecting the neurovascular bundles. Pathologic
analysis revealed a Gleason 6 adenocarcinoma in a
55 grams prostate with negative surgical margins.
On the first postoperative day, the right calf was enlarged and painful during palpation
and paresthesia and pain were the patient's chief complaint. Dorsalis
pedis pulse in bilateral lower extremities was palpable. In order to
investigate diagnosis of DVT, Doppler ultrasound
was requested and depicted patency of the deep venous system. Serum creatinine
values increases to 3.2 mg/dL and phosphokinase creatinine reached 23.000 U/L. In spite of
Doppler study normal results, DVT diagnosis
associated with secondary rhabdomyolysis and renal insufficiency for myoglobinuria was based
on clinical and laboratories findings, thus
appropriate treatment was initiated with a high dose of heparin.
On the following postoperative period, although dorsalis pedis pulse was palpable
and serum and phosphokinase creatinine levels improved, patient's intermittent episodes of pain
in the right lower limb persisted. Another Doppler ultrasound evaluation definitely excluded
DVT diagnosis and depicted high resistance of the
right tibial arteries. Then the patient was submitted
to decompressive fasciotomy of the four compartments of the right leg on the
12th postoperative day. Muscles bulged after
superjacent fascia incision was performed and revealed
focal necrotic areas which were debrided.
Immediately afterwards postoperative phase, it was possible
to observe patient's pain relief and ability to walk
under supervision. Fourteen days after fasciotomy
the wounds were surgically closed.
Six months after LRP his PSA is undetectable, and he needs daily protection
for mild urinary incontinence and is still
recovering sexual function.
DISCUSSION
There are several risk factors during Laparoscopic Radical Prostatectomy that
could reduce blood flow to lower extremities or
increase blood flow resistance due to external compression, however they are usually
not enough to cause CS. On the other hand, if
these factors were associated to intracompartment high pressure, it is possible to add
reduced perfusion pressure or other factors that
may contribute to the development of CS.
Patient Positioning: CS was already reported after procedures in
lithotony/hemilithotomy position especially when combined
with Trendelemburg position. During LRP,
Tredelemburg position helps deviating intestinal loops from
pelvic operative field. Reduction of arterial
perfusion pressure of lower limbs when ankle height is
above heart level allows CS to develop even with
slight elevation of intracompartmental pressure of
the lower limbs. Reducing elevation of legs may maintain the blood flow to the muscle of the
legs above ischemic level. This could be easier
during extraperitoneal LRP, since the peritoneum acts
as a natural retractor to intestinal loops. If
accentuated elevation of the legs is essential as it happens
in Transperitoneal Laparoscopic Radical Prostactetomies, Trendelemburg position should
be reverted every 2 hours for a short period of
time allowing an adequate perfusion of the lower limbs.
Anesthesia: a combination of general and regional anesthesia during LRP may
reduce significantly intraoperative bleeding,
postoperative pain and thromboembolism risk.
Nevertheless, hypotension induced by vasodilation as a
result of regional anesthesia may cause
hypoperfusion of the lower extremities.
However, benefits of general and regional anesthesia are greater than risks,
especially when considering higher incidence of deep
vein thrombosis comparing to CS. Lower risk of bleeding and reduced operative time
associated with regional anesthesia are protectors
factors against CS. The main discussion towards
regional anesthesia and CS is the delayed
diagnosis and treatment of CS in several patients
submitted to spinal or peridural anesthesia.
DVT Prophilaxy: compression bandages or stockings and intermittent pneumatic device in
DVT prophylaxis may reduce compartments compliance and compress internal musculature which
will decrease perfusion pressure of the lower extremities. Despite the fact that all
compression applied is not transmitted to muscle
compartments, this effect can represent an additional risk factor
to local blood flow implications.
Tension applied to compressive bandages should not be excessive to avoid
a tourniquet effect. There is a high risk of CS
when compressive bandage or stockings are associated to intermittent
pneumatic compression devices. Recognizing these
factors preoperatively may identify patients at high
risk to CS, allowing the application of
appropriate prophylaxis to prevent DVT.
Prolonged operative time: CS has been associated with prolonged surgery
in Trendelemburg position as well as in dorsal decubitus position where local blood flow
is affected with the weight of the legs.
Laparoscopic radical prostatectomy operative time is
longer than open radical retropubic prostatectomy
(less than 4 hours). However, operative time is
longer in obese and enlarged prostate patients.
Intraoperative bleeding: systemic hypotension decreases compartments blood
flow which may cause perfusion failure mainly in patients with arteriosclerosis and
controlled hypertension, in whom sclerotic vessels
high chronic pressure levels are common. During
LRP intraoperative bleeding is lesser than open
radical prostatectomy. However, bleeding is
considerably greater in patients with obesity and
enlarged prostate. In case of intraoperative
bleeding, volemic replacement should be appropriate
to maintain the normal blood pressure of the patient.
Pheripheral Vascular Disease: moderate blood pressure fall in lower limbs is greater
with evidence of PVD, reducing possible
development of CS. Suspicion of PVD should be
considered during anamnesis in patients with increased
age, smoking history, hypertension,
hyperlipidemia, diabetes and intermittent claudication; as well
as during physical examination through palpation
of lower limbs pulse. In case of PVD suspicion an evaluation of a vascular surgeon is
necessary before planning a major pelvic surgery.
Obesity: obesity is associated with elevated compartment pressure and
reduced blood pressure of the ankle. During LRP,
obesity may also worsen perfusion failure as
operative time and intraoperative bleeding risk are greater.
CONCLUSION
Knowledge of the factors associated to CS physiopathology during LRP preoperative may identify patients at high risk. Preventive measures may avoid this important cause of postoperative morbimortality.
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Correspondence address:
Frederico R. Romero
Departamento de Urologia
Hospital São Vicente
Av. Vicente Machado, 467 - Sétimo andar
Curitiba, PR 80420-010
Brazil
Tel: 41-3322-0877
Fax: 41-3322-0377
E-mail: frederico.romero@gmail.com