Dr. Abdullah Ahmad Ghazi (R5)KSMC 8 May 2012

TURP gold standard in BPH

Using of A-Cog & A-Plt is increasing. 4% on A-Cog 37% on A-plt

The most common perioperative complication in TURP is hemorrhage. Blood transfusion 20% (Uchida 1999)

2.9% (Reich 2008)

Prolonged operative time.

Capsular perforation.

Fluid absorption

Large prostate.

Concurrent UTI.

Indwelling urinary catheters.

Warfarin reversible A-plt non reversible

Warfarin in AF ? Risk Warfarin in cardiac stent ? risk

High risk: Hx intracardiac thrombus. TIA. Stroke. Recent, recurrent UTI PE Prosthetic valve

Low risk: AF DVT

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

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

Most guidelines recommend:

Stop warfarin 5 days before surgery. LMWH 4days preop to 1 day preop INR must be <1.5 day of surgery

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

increase risk of bleeding

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

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”.

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.

Ehrlich et al 2007: No increase of bleeding if ASA resume at

stopping irrigation vs 21 days.

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.

NSAID can be withheld a week before surgery.

Thienopyridines: ADP receptor blocker. Platelet function return after 7 days.

Incidence of stent thrombosis:

31% of clopidogrel stopped 0% if dual anti-plt

Schouten 2007

The American College of Chest Physicians:

Clopidogrel should toped 7 days pre-op. Prostatic surgery should be postpone 12w

after coronary stent.

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

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.

Epinephrine: Need more studies.

Loop & Electrode Technology: Thin-wire loops Solid electrodes Thick hybrid loops

TURP vs TUVP bleeding ( 150ml vs 52.5ml) P<0.0001. Gupta 2006

Bipolar Electrical Generators: Use low voltages. Less thermal deep tissue injury. Improve hemostasis (decrease bleeding,

no diff in transfusion)

Laser Technology: Ahyai et al 2010:

HoLEP is effective as TURP. Decrease risk of bleeding. It is safe in full anticoagulant.

Ruszat et al 2007: Photovaporization of the prostate is

equivalent to TURP in small/medium prostate.