Bilateral Compartment Syndrome Following Prolonged Urological Surgery: A Case Report
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Abstract
Background: Acute compartment syndrome (ACS) is a limb-threatening surgical emergency
characterised by critically elevated intra-compartmental pressures and delta pressure greater
than 30 mmHg, leading to ischaemia and potential tissue necrosis if untreated. A non-traumatic
variant, well-leg compartment syndrome (WLCS), is increasingly recognised in surgical proce-
dures performed in the lithotomy position. Risk factors include prolonged surgery, leg elevation,
intraoperative hypotension, external compression, and morbid obesity.
Case Presentation: A 40-year-old male with a BMI of 50 underwent a prolonged elective ure-
throplasty in lithotomy position. He reported severe bilateral leg pain postoperatively, initially
worse on the right, progressing to bilateral involvement within two hours. Examination revealed
reduced left foot dorsiflexion, severe pain disproportionate to clinical findings, and firm lateral
compartments bilaterally, with preserved pulses, perfusion, and sensation. Clinically, he was
diagnosed with ACS and taken for emergency surgery. Bilateral fasciotomies were performed,
revealing contractile grey and pink muscle and evidence of reperfusion. Incisions were temporarily
closed using the lattice lacing technique.
Outcome: No further complications occurred in hospital. The patient was discharged within
three weeks. Urethroplasty success was confirmed at one-month follow-up. No intervention was
needed after review by plastic surgery for further closure.
Conclusion: WLCS is a rare limb-threatening complication of prolonged lithotomy positioning,
particularly in obese patients. Early recognition and prevention aided by awareness of risk factors
and vigilant postoperative monitoring are critical. Clinicians should limit lithotomy time (< 4 hours),
periodically lower legs, optimise blood pressure, use appropriate leg support, and maintain high
suspicion for prompt diagnosis and intervention.
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References
Torlincasi AM, Lopez RA, Waseem M. Acute compartment syndrome. In: StatPearls. StatPearls
Publishing; 2023. Available from: https://nih.gov.
Simms MS, Terry TR. Well leg compartment syndrome after pelvic and perineal surgery in the
lithotomy position. Postgraduate Medical Journal. 2005 Aug;81(958):534-6.
Nester M, Borrelli J. Well leg compartment syndrome: Pathophysiology, prevention, and
treatment. Journal of Clinical Medicine. 2022 Oct;11(21):6448.
Raza A, Byrne D, Townell N. Lower limb (well leg) compartment syndrome after urological
pelvic surgery. Journal of Urology. 2004 Jan;171(1):5-11.
Mizuno J, Takahashi T. Male sex, height, weight, and body mass index can increase exter-
nal pressure to calf region using knee-crutch-type leg holder system in lithotomy position.
Therapeutics and Clinical Risk Management. 2016 Feb;12:305-12.
Addley S, McMullan J, Scott S, Soleymani Majd H. ‘Well-leg’ compartment syndrome associated
with gynaecological surgery: A perioperative risk-reduction protocol and checklist. BJOG: An
International Journal of Obstetrics & Gynaecology. 2021 June;128(9):1517-25.
Warner MA, Warner DO, Harper CM, Schroeder DR, Maxson PM. Lower Extremity Neu-
ropathies Associated with Lithotomy Positions. Anesthesiology. 2000 Oct;93(4):938-42.
Warner ME, LaMaster LM, Thoeming AK, Shirk Marienau ME, Warner MA. Compartment
syndrome in surgical patients. Anesthesiology. 2001 Apr;94(4):705-8.