Dr. Abdullah Ahmad Ghazi (R5) KSMC 8 May 2012. TURP gold standard in BPH Using of A-Cog & A-Plt...
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Transcript of Dr. Abdullah Ahmad Ghazi (R5) KSMC 8 May 2012. TURP gold standard in BPH Using of A-Cog & A-Plt...
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.