TESTICULAR ISCHEMIA FOLLOWING OPEN PROSTATECTOMY

Testicular ischemia is a known complication of inguinal herniorrhaphy and varicocelectomy. We report a case of acute testicular ischemia following simple retropubic prostatectomy. CASE REPORT A 49-year-old male underwent open retropubic prostatectomy for benign prostatic hyperplasia (BPH) and urinary retention, without complications. A 22Fr Foley catheter was placed intraoperatively. The patient had painless scrotal edema on postoperative day 1 and was treated with a scrotal support. On postoperative day 4 he complained of sudden onset left testicular pain. On physical examination the left hemiscrotum was erythematous with an enlarged and tender left testicle and thickening of the ipsilateral spermatic cord to the level of the external inguinal ring. Cremasteric reflexes were absent bilaterally. Laboratory evaluation showed leukocytosis and no evidence of bacteriuria. Color Doppler ultrasound demonstrated a heterogeneous left testicle devoid of flow to the left epididymis and testicle. Emergency scrotal exploration revealed an enlarged swollen left testicle and thickened spermatic cord. On opening the tunica vaginalis the testis appeared cyanotic and mottled with an indurated epididymis (see figure). The testicle and epididymis were in the normal axis without evidence of testicular torsion. Immediately after the tunica vaginalis was opened the testicle and epididymis became pink, suggesting reperfusion. Intraoperative Doppler showed a strong signal in the left distal spermatic cord. Brisk bleeding was identified following a small incision through the tunica albuginea, confirming good blood flow to the testis. The scrotum was closed in the standard fashion with a Penrose drain left indwelling. DISCUSSION Simple retropubic prostatectomy for BPH offers advantages over the less invasive modalities, including a lower re-treatment rate and more complete removal of the prostatic adenoma under direct visualization. Complications include bleeding requiring a blood transfusion, sepsis, urinary incontinence and retrograde ejaculation, with cardiovascular complications such as pulmonary emboli, myocardial infarctions, cerebrovascular accidents and deep vein thrombi occurring less than 1% of the time. 1 Iatrogenic testicular ischemia and infarction have been reported after inguinal herniorrhaphies and varicocelectomies. 2 Although scrotal edema and ecchymosis may be common after retropubic prostatectomy, acute scrotal pain secondary to ischemia is unusual. Doppler ultrasound is an effective noninvasive test with a sensitivity and specificity of 100% and 97%, respectively, in diagnosing testicular ischemia. 3 Testicular torsion and torsion-detorsion are the most likely culprits leading to an ischemic testis. However, this clinical scenario does not meet the usual presentation. The brisk restoration of pink color along with the presence of a strong Doppler signal after opening the tunica vaginalis in the absence of a twisted cord and in the setting of an already edematous scrotum makes a compelling argument for a scrotal compartmental syndrome. Scrotal compartmental syndrome causing testicular ischemia has yet to be reported in the literature as a complication of this procedure. Although compression and vasospasm of the testicular artery may occur intraoperatively from retraction, such findings would be an unusual presentation 4 days postoperatively. We report a unique phenomenon of resolution of testicular ischemia after opening the tunica vaginalis, suggestive of a scrotal compartmental syndrome presenting with negative flow to the unilateral testis and temporary ischemia following open prostatectomy for BPH.