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)
T
1/2
: 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.
T
1/2
1-6hr
Using of Heparine pre-post TURP not increase risk of bleeding
ANTICOAGULANT
LMWH:
Inhibit factor X.
T
1/2
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.
