Stuttering priapism after laparoscopic radical prostatectomy: A case report

Abstract

Introduction Prostate cancer is the most common cancer in men. 1 Laparoscopic radical prostatectomy is a recommended treatment for localised prostate cancer. Recognised complications of this procedure include erectile dysfunction (25–50%) and urethral/bladder neck stricturing (2–5%). 2 We present a rare case of intermittent priapism following this procedure. Case report A 66-year-old man presented with voiding symptoms, a serum prostate-specific antigen (PSA) of 7.24 ng/ml, a benign-feeling prostate and normal erections. His medical history included chronic obstructive pulmonary disease (COPD). Trans-rectal ultrasound-guided biopsy revealed Gleason 4+3 prostate adenocarcinoma. Staging magnetic resonance imaging (MRI) scan illustrated bilateral disease, T2c pN0 M0 (Figure 1). He underwent a laparoscopic radical prostatectomy two months later with a trans-peritoneal approach and bilateral nerve spare. Histology revealed pT3a Gleason 4+3 disease with negative margins. At 14 days he presented with spontaneous moderately painful erections every two hours without sexual stimulation along with urinary tract infection. Examination was normal. Urine microscopy and culture revealed an extended spectrum beta lactamase (ESBL)-producing E. coli organism, and antibiotic treatment was commenced. By day 28, his erections occurred mainly in association with voiding and straining. A computed tomography (CT) scan identified an organised haematoma in the prostatic bed (Figure 2), and a flexible cystoscopy revealed complete closure of the proximal urethra so a suprapubic catheter was inserted. His stuttering erections fully resolved and the haematoma was managed conservatively. He underwent a delayed optical urethrotomy. At six months, his PSA level was un-recordable. He reported improved continence and partial return of sexual function.

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Journal of Clinical Urology
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Urological Surgeons 2015
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DOI: 10.1177/2051415815572724
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Introduction
Prostate cancer is the most common cancer in men.1
Laparoscopic radical prostatectomy is a recommended
treatment for localised prostate cancer. Recognised com-
plications of this procedure include erectile dysfunction
(25–50%) and urethral/bladder neck stricturing (2–5%).2
We present a rare case of intermittent priapism following
this procedure.
Case report
A 66-year-old man presented with voiding symptoms, a
serum prostate-specific antigen (PSA) of 7.24 ng/ml, a
benign-feeling prostate and normal erections. His medical
history included chronic obstructive pulmonary disease
(COPD). Trans-rectal ultrasound-guided biopsy revealed
Gleason 4+3 prostate adenocarcinoma. Staging magnetic
resonance imaging (MRI) scan illustrated bilateral disease,
T2c pN0 M0 (Figure 1).
He underwent a laparoscopic radical prostatectomy two
months later with a trans-peritoneal approach and bilateral
nerve spare. Histology revealed pT3a Gleason 4+3 disease
with negative margins.
At 14 days he presented with spontaneous moder-
ately painful erections every two hours without sexual
stimulation along with urinary tract infection. Exam-
ination was normal. Urine microscopy and culture
revealed an extended spectrum beta lactamase (ESBL)-
producing E. coli organism, and antibiotic treatment
was commenced.
By day 28, his erections occurred mainly in association
with voiding and straining. A computed tomography (CT)
scan identified an organised haematoma in the prostatic bed
(Figure 2), and a flexible cystoscopy revealed complete
closure of the proximal urethra so a suprapubic catheter
was inserted. His stuttering erections fully resolved and the
haematoma was managed conservatively.
He underwent a delayed optical urethrotomy. At six
months, his PSA level was un-recordable. He reported
improved continence and partial return of sexual function.
Stuttering priapism after laparoscopic
radical prostatectomy: A case report
Paul Cleaveland1, Craig Jones1, Morkos Iskander2
and Jeremy Oates1,2
1Stepping Hill Hospital, Stockport NHS Foundation Trust, UK
2Mid-Cheshire Hospitals NHS Foundation Trust, UK
Corresponding author:
Paul Cleaveland, Urology Department, Stockport NHS Foundation
Trust, Poplar grove, Stockport, SK2 7JE, UK.
Email: paulcleaveland@doctors.org.uk
572724URO0010.1177/2051415815572724Journal of Clinical UrologyCleaveland et al.
research-article2015
Case Report
Figure 1. Magnetic resonance scan of prostate showing
cancer staging.
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2 Journal of Clinical Urology
Discussion
Priapism is not a well-documented complication of radical
prostatectomy. Priapism is a pathological disorder of
penile erection that lasts more than four hours and is unre-
lated to stimulation or sexual interest. It is classified as
low-flow, high-flow or stuttering priapism.
There is only one reported case of spontaneous self-
limiting priapism following open radical retropubic pros-
tatectomy.3 It was caused by position-dependent venous
drainage occlusion due to local haematoma.
Priapism has been described following radiotherapy for
prostate cancer.4 Malignant priapism has also been reported
in metastatic prostate cancer.5
We hypothesise that the haematoma at the prostatic
bed caused veno-occlusion of the penile venous drain-
age. Venous engorgement would have occurred during
the increased intra-abdominal pressure associated with
straining to micturate, which was exacerbated by his
bladder neck stenosis. This would account for the occur-
rence of erections in association with micturition and for
the improvement following insertion of supra-pubic
catheter. The rapid onset of the bladder neck stenosis
may have been associated with the ESBL urinary tract
infection.
In summary, we present a rare case of spontane-
ous stuttering priapism following laparoscopic radical
prostatectomy, due to bladder neck stenosis and prostatic
bed haematoma. We encourage assessment for both atypi-
cal urinary tract organisms and for bladder outflow
obstruction in patients with early and unusual symptoms
following radical prostatectomy.
Acknowledgements
Informed consent was obtained from the patient and his identity
remained concealed.
Conflicting interests
The Authors declare that there is no conflict of interest.
Funding
None declared.
Ethical approval
Not Applicable.
Guarantor
PC.
Contributorship
PC and CJ contributed to reviewing case notes, obtaining images
and writing the manuscript. MI and JO contributed to correcting
and revising the manuscript for submission.
Acknowledgements
None.
References
1. National Institute for Health and Care Excellence. Prostate
cancer: Diagnosis and treatment. NICE clinical guideline
175, guidance.nice.org.uk/cg175 (January 2014, accessed
17 October 2014).
2. European Association of Urology. Guidelines on Prostate
Cancer 2014. Prostate Cancer Update 2014. http://www.
uroweb.org/gls/pdf/1607%20Prostate%20Cancer_LRV3.
pdf. (Accessed 17 October 2014).
3. Böhlen D, Eberle J and Schmid HP. Spontaneous priapism
after radical retropubic prostatectomy. Urol Int 2006; 77:
182–183.
4. Lomaga MA and Hayter C. Priapism as a possible acute
side effect of radical radiotherapy for prostate cancer. Can J
Urol 2004; 11: 2205–2206.
5. Schroeder-Printzen I, Vosshenrich R, Weidner W, et al.
Malignant priapism in a patient with metastatic prostate
adenocarcinoma. Urol Int 1994; 52: 52–54.
Figure 2. Computed tomography scan showing prostatic bed
haematoma.
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