Clinical reasoning and decision-making in practice. A patient with oliguria following prostatectomy

Abstract

A 70-year-old man with clinically localised prostate carcinoma underwent extraperitoneal endoscopic radical prostatectomy. His medical history revealed hypertension, renal colic, hypogonadotropic hypogonadism and recurrent deep venous thrombosis in the legs. The operation was uneventful with 500 ml blood loss and no periods of hypotension. The patient developed oliguria within 12 h after surgery. A hypovolemic state was initially suggested to explain the oliguria and increasing amounts of intravenous fluids were administered. The oliguria persisted, however, and the patient did not respond to a diuretic. There was no fluid loss in the drain. Blood pressure, pulse and temperature were normal. Peritonitis and bowel perforation were excluded Ultrasound examination of the bladder and kidneys revealed an empty bladder and no dilatation of the upper urinary tract, which excluded a post-renal obstruction. The clinical situation deteriorated within hours as the patient developed anuria, bowel distension, metabolic acidosis with progressive renal failure and signs of respiratory distress for which mechanical ventilation was needed. A chest X-ray prior to intubation did not show pneumonia or signs indicating pulmonary embolism. CT of the abdomen was performed to evaluate urinary leakage but revealed no fluid collection or urinoma. Thus pre- and post-renal causes of oliguria were excluded. In view of the systemic symptoms, intra-abdominal pressure was measured using a bladder catheter; it varied between 25 and 35 cm water. Together with the clinical situation, a diagnosis of abdominal compartment syndrome was made and coeliotomy was performed immediately. Within 10 min after decompression of the peritoneal cavity, diuresis started spontaneously. Renal function was restored to preoperative levels in 3 weeks. Abdominal compartment syndrome is a potentially life-threatening cause of anuria. The syndrome should be part of the differential diagnosis for patients with postoperative anuria, including those who underwent extraperitoneal minimally invasive procedures.</p