達文西機械手臂輔助腹腔鏡攝護腺全切除術後肺栓塞及急性腎功能損傷之個案報告及文獻回顧

洪健哲 謝德生

國泰綜合醫院 外科部 泌尿科

Post robotic-assisted laparoscopic radical prostatectomy pulmonary embolism and acute renal failure: Case report and review of the literature

Chien-Che Hung, Teh-Sheng Hsieh

Division of Urology, Department of Surgery, Cathay General Hospital, Taipei, Taiwan

Venous thromboembolism (VTE) is a condition where blood clots form in the veins, usually in the legs or pelvis, and can break off and travel to other parts of the body, such as the lungs. Pulmonary embolism (PE) which is a blood clot blocking one of the pulmonary arteries in the lungs, can lead to shortness of breath, chest pain, or even life-threatening. Factors that can increase the risk of VTE include surgery, immobilization, cancer, obesity, and a personal or family history of blood clots.

We present a case of a 71-year-old male with the medical history of hypertension, dyslipidemia, and coronary artery disease status post drug-eluting stent inserted at the left anterior descending branch before. He initially came to our urological department for prostate enlargement with severe lower urinary tract symptoms. Transurethral vaporization of the prostate with diode laser was performed in 2010, and he regularly followed up at our outpatient department afterwards. Nonetheless, abnormal PSA levels were noted for a period. Transrectal ultrasound-guided prostatic needle biopsy was performed twice separately in 2017 and 2021. The pathological reports both demonstrated benign prostate hyperplasia. Owing to the persistent elevated PSA level of 10.31ng/mL, contrast-enhanced pelvic MRI was further arranged and revealed suspicious lesions at the bilateral anterior transition zone and anterior peripheral zone over the apex of the prostate. Therefore, robotic-assisted MR/US transperineal fusion-guided prostatic needle biopsy was scheduled performed. The pathological report indicated an acinar adenocarcinoma of the prostatic target zone with a Gleason score of 3+4 = 7, involving two cores (40% and <5%, separately). The whole body bone scan demonstrated no definite bony metastasis. After discussing with the patient and his family, robotics-assisted laparoscopic radical prostatectomy was arranged. There was no extracapsular extension of prostatic cancer grossly nor obvious bilateral lymph node enlargement. Despite the operation being quite smooth, he still suffered from an acute episode of shortness of breath with desaturation two days after the operation. Arterial blood gas analysis showed poor PaO2 down to 67.6 mmHg without acidosis. Lab data also revealed elevated D-dimer up to 20.276, which strongly suspected pulmonary embolism-induced V-Q mismatch. Contrast-enhanced chest CT was further arranged, and bilateral pulmonary arterial thromboembolism was proven, including main pulmonary arteries and the following branches. Heparin pump was immediately prescribed for anticoagulation. Bilateral lower limbs doppler was further examined, demonstrating total occlusion of the right superficial saphenous vein. Furthermore, paralytic ileus, acute kidney injury with anuria, and high creatinine levels were noted afterward. Abdominal and pelvic contrast-enhanced CT was done and no sign of SMV or portal vein thrombosis was mentioned. Intermittent hemodialysis with full dosage of furosemide was prescribed subsequently. After anticoagulation treatment, O2 saturation was corrected, and renal function was gradually improved, with normal urine output noted. Despite the complicated post-operative situation, the patient recovered smoothly. He is now regularly following up at our outpatient department without specific discomfort.

During robotic-assisted surgery, patients may be at increased risk of developing VTE due to several factors, including prolonged immobilization periods, veins manipulation, and underlying medical conditions. To reduce the risk of VTE, surgeons may take several measures, including using mechanical thromboprophylaxis such as compression stockings, administering prophylactic anticoagulants, and encouraging early postoperative mobilization after surgery. Therefore, we hereby present this case to share our experience of postoperative VTE management.