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Prevention and Management of TURP-Related Hemorrhage

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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Prevention and Management of TURP-Related Hemorrhage

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  1. Dr. Abdullah Ahmad Ghazi (R5) KSMC 8 May 2012 Prevention and Management of TURP-Related Hemorrhage

  2. TURP  gold standard in BPH • Using of A-Cog & A-Plt is increasing. • 4% on A-Cog • 37% on A-plt Introduction

  3. The most common perioperative complication in TURP is hemorrhage. • Blood transfusion 20% (Uchida 1999) • 2.9% (Reich 2008) Introduction

  4. Prolonged operative time. Capsular perforation. Fluid absorption Bleeding Can Lead To

  5. Large prostate. Concurrent UTI. Indwelling urinary catheters. Risk Factors

  6. Warfarin  reversible A-plt  non reversible Warfarin in AF ? Risk Warfarin in cardiac stent ? risk Note

  7. High risk: • Hx intracardiac thrombus. • TIA. • Stroke. • Recent, recurrent UTI • PE • Prosthetic valve • Low risk: • AF • DVT Risk Classification

  8. Warfarine: • Vit-k dependent. • Clotting factor (II, VII, IX, X) • T1/2: 25-60 hr. • Duration of action 2-5 days Anticoagulant

  9. 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

  10. 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

  11. Heparin: • Antithrombin, inactivate II, IX, X, XI, XII. • T1/2 1-6hr • Using of Heparine pre-post TURP not increase risk of bleeding Anticoagulant

  12. 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

  13. 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

  14. 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

  15. Ehrlich et al 2007: • No increase of bleeding if ASA resume at stopping irrigation vs 21 days. Antiplatelet Medication

  16. 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

  17. NSAID can be withheld a week before surgery. Antiplatelet Medication

  18. Thienopyridines: • ADP receptor blocker. • Platelet function return after 7 days. Antiplatelet Medication

  19. Incidence of stent thrombosis: • 31% of clopidogrel stopped • 0% if dual anti-plt Schouten 2007 Antiplatelet Medication

  20. The American College of Chest Physicians: • Clopidogrel should toped 7 days pre-op. • Prostatic surgery should be postpone 12w after coronary stent. Antiplatelet Medication

  21. Treatment of TURP related bleeding

  22. 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

  23. 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

  24. Epinephrine: • Need more studies. Treatment of TURP related bleeding

  25. Loop & Electrode Technology: • Thin-wire loops • Solid electrodes • Thick hybrid loops Minimizing TURP-related Blood Loss

  26. TURP vs TUVP bleeding ( 150ml vs 52.5ml) P<0.0001. Gupta 2006 Minimizing TURP-related Blood Loss

  27. Bipolar Electrical Generators: • Use low voltages. • Less thermal deep tissue injury. • Improve hemostasis (decrease bleeding, no diff in transfusion) Minimizing TURP-related Blood Loss

  28. 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

  29. Minimizing TURP-related Blood Loss

  30. Ruszat et al 2007: • Photovaporization of the prostate is equivalent to TURP in small/medium prostate. Minimizing TURP-related Blood Loss

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