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Dr. Abdullah Ahmad Ghazi (R5) KSMC 8 May 2012. Prevention and Management of TURP-Related Hemorrhage. TURP gold standard in BPH Using of A-Cog & A-Plt is increasing. 4% on A-Cog 37% on A-plt. Introduction. The most common perioperative complication in TURP is hemorrhage.
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Dr. Abdullah Ahmad Ghazi (R5) KSMC 8 May 2012 Prevention and Management of TURP-Related Hemorrhage
TURP gold standard in BPH • Using of A-Cog & A-Plt is increasing. • 4% on A-Cog • 37% on A-plt Introduction
The most common perioperative complication in TURP is hemorrhage. • Blood transfusion 20% (Uchida 1999) • 2.9% (Reich 2008) Introduction
Prolonged operative time. Capsular perforation. Fluid absorption Bleeding Can Lead To
Large prostate. Concurrent UTI. Indwelling urinary catheters. Risk Factors
Warfarin reversible A-plt non reversible Warfarin in AF ? Risk Warfarin in cardiac stent ? risk Note
High risk: • Hx intracardiac thrombus. • TIA. • Stroke. • Recent, recurrent UTI • PE • Prosthetic valve • Low risk: • AF • DVT Risk Classification
Warfarine: • Vit-k dependent. • Clotting factor (II, VII, IX, X) • T1/2: 25-60 hr. • Duration of action 2-5 days Anticoagulant
Katholi et al • TURP done for 12 pt on warfarin (INR 2.3) • 33% need transfusion. • Mulcahy et al • Recommend start warfarin once hematuria resolved = 48hrs. • High risk should received LMWH w/o risk of bleeding Anticoagulant
Most guidelines recommend: • Stop warfarin 5 days before surgery. • LMWH 4days preop to 1 day preop • INR must be <1.5 day of surgery Anticoagulant
Heparin: • Antithrombin, inactivate II, IX, X, XI, XII. • T1/2 1-6hr • Using of Heparine pre-post TURP not increase risk of bleeding Anticoagulant
LMWH: • Inhibit factor X. • T1/2 8-10h • ½ dose if cre clea < 30ml/min • High risk should received LMWH preop and resume it within 48hrs. • No increase risk of bleeding. • Increase hospitalization and catheterization Anticoagulant
Aspirin & NSAID: • Inhibit TXA2 • Stop ASA BT return tnormal in 48hrs. Sonksen 1999 • Common prectice is to stop ASA 7-10D. Enver 2006. “no evidence, & harm to high risk”. Antiplatelet Medication
20% of pt for TURP have IHD or CVA. Gyomber 2006. • Nielsen et al 2000: • Randomize trial. • TURP (continue vs holding ASA for 10d) • No significant intra-op bleeding loss. • Postoperative higher blood loss (284ml vs 44ml) • No difference in transfusion or cauterization. Antiplatelet Medication
Ehrlich et al 2007: • No increase of bleeding if ASA resume at stopping irrigation vs 21 days. Antiplatelet Medication
The American College of Chest Physicians: Suggest to continued ASA perioperatively in high-risk pt undergo noncardiac surgery, but stop ASA in low risk and resume it within 24hrs post-op. Antiplatelet Medication
NSAID can be withheld a week before surgery. Antiplatelet Medication
Thienopyridines: • ADP receptor blocker. • Platelet function return after 7 days. Antiplatelet Medication
Incidence of stent thrombosis: • 31% of clopidogrel stopped • 0% if dual anti-plt Schouten 2007 Antiplatelet Medication
The American College of Chest Physicians: • Clopidogrel should toped 7 days pre-op. • Prostatic surgery should be postpone 12w after coronary stent. Antiplatelet Medication
Finastride stop 98% of idiopathic prostate bleeding. Donohue 2004 • Bleeding is • 7.6ml/gm (Fins) • 14mlml/gm (control). Ozdal 2005 • Dutasteride study no difference. • Increase the cost Treatment of TURP related bleeding
Antifibrinolytics “Tranexamic acid” • Dose 1gm Q6hr (IV, intravesical). • It decrease the amount of bleeding & irrigated fluid used. • Can be used in high risk pt for bleeding. Treatment of TURP related bleeding
Epinephrine: • Need more studies. Treatment of TURP related bleeding
Loop & Electrode Technology: • Thin-wire loops • Solid electrodes • Thick hybrid loops Minimizing TURP-related Blood Loss
TURP vs TUVP bleeding ( 150ml vs 52.5ml) P<0.0001. Gupta 2006 Minimizing TURP-related Blood Loss
Bipolar Electrical Generators: • Use low voltages. • Less thermal deep tissue injury. • Improve hemostasis (decrease bleeding, no diff in transfusion) Minimizing TURP-related Blood Loss
Laser Technology: • Ahyai et al 2010: • HoLEP is effective as TURP. • Decrease risk of bleeding. • It is safe in full anticoagulant. Minimizing TURP-related Blood Loss
Ruszat et al 2007: • Photovaporization of the prostate is equivalent to TURP in small/medium prostate. Minimizing TURP-related Blood Loss