Transcript Prevention and Management of TURP-Related Hemorrhage

PREVENTION AND MANAGEMENT OF
TURP-RELATED HEMORRHAGE
Dr. Abdullah Ahmad Ghazi (R5)
KSMC 8 May 2012
INTRODUCTION

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%
2.9%
(Uchida 1999)
(Reich 2008)
BLEEDING CAN LEAD TO

Prolonged operative time.

Capsular perforation.

Fluid absorption
RISK FACTORS

Large prostate.

Concurrent UTI.

Indwelling urinary catheters.
NOTE
Warfarin  reversible
 A-plt  non reversible

Warfarin in AF ? Risk
 Warfarin in cardiac stent ? risk

RISK CLASSIFICATION

High risk:







Hx intracardiac thrombus.
TIA.
Stroke.
Recent, recurrent UTI
PE
Prosthetic valve
Low risk:


AF
DVT
ANTICOAGULANT

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



Mulcahy et al


TURP done for 12 pt on warfarin (INR 2.3)
33% need transfusion.
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,
 T1/2
inactivate II, IX, X, XI, XII.
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
ANTIPLATELET MEDICATION

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 highrisk 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.
TREATMENT OF TURP RELATED BLEEDING
TREATMENT OF TURP RELATED BLEEDING

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.
MINIMIZING TURP-RELATED BLOOD LOSS

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
MINIMIZING TURP-RELATED BLOOD LOSS

Ruszat et al 2007:
 Photovaporization
of the prostate is equivalent to
TURP in small/medium prostate.