Clinical outcomes of low-pressure pneumoperitoneum in minimally invasive urological surgery
Journal of robotic surgery. 2022;:1-10
The adoption of minimally invasive laparoscopic techniques has revolutionised urological practice. This necessitates a pneumoperitoneum (PNP) and the impact the PNP pressure has on post-operative outcomes is uncertain. During the current COVID-19 era guidance has suggested the utilisation of lower PNP pressures to mitigate the risk of intra-operative viral transmission. Review the current literature regarding the impact of pneumoperitoneum pressure, within the field of urology, on post-operative outcomes. A search of the PubMed, Medline and EMBASE databases was undertaken to identify studies that met the inclusion criteria. The Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines were adhered to. Ten studies, that included both randomised controlled trials and retrospective case series reviews, were identified that met the inclusion criteria. The effect of PNP pressure on outcomes following prostatectomy, live donor nephrectomy, partial nephrectomy and a variety of benign upper tract procedures were discussed. Low pressure PNP appears safe when compared to high pressure PNP, potentially reducing post-operative pain and rates of ileus. When compared to general surgery, there is a lack of quality evidence investigating the impact of PNP pressures on outcomes within urology. Low pressure PNP appears non-inferior to high pressure PNP. More research is required to validate this finding, particularly post-cystectomy and nephrectomy.
The role of preoperative dutasteride in reducing bleeding during transurethral resection of the prostate: A systematic review and meta-analysis of randomized controlled trials
Asian journal of urology. 2022;9(1):18-26
OBJECTIVE Bleeding is one of the most common complications of transurethral resection of the prostate (TURP). Several previous studies reported that administering dutasteride before surgery could reduce perioperative bleeding. We aimed to evaluate the efficacy of preoperative dutasteride treatment in benign prostatic hyperplasia patients undergoing TURP by performing a meta-analysis of relevant randomized controlled trials (RCTs). METHODS A comprehensive literature search was performed through the electronic databases including Medline, Cochrane Library, Google Scholar, and ClinicalTrial.gov in October 2020. RCTs evaluating the role of dutasteride for TURP were screened using the eligibility criteria and the quality of RCTs was assessed using the Cochrane Risk of Bias Tool. The heterogeneity was assessed using I (2) statistic. The measured outcomes were hemoglobin (Hb) levels, perioperative blood loss, blood transfusion, microvessel density (MVD), and operation time. Data were pooled as mean difference (MD) and odds ratio (OR). RESULTS A total of 11 RCTs consisting of 627 samples from the treatment group and 615 samples from the placebo group were analyzed. Patients that received dutasteride had less reduction in Hb levels (MD -1.10, 95% confidence interval [CI] -1.39 to -0.81, p<0.00001). Dutasteride also significantly reduced the operation time (MD -1.79, 95% CI -2.97 to -0.61, p=0.003) and transfusion rate after surgery (OR 0.34, 95% CI 0.15 to 0.77, p=0.009) compared to the control group. However, the MVD (MD -3.60, 95% CI -8.04 to 0.84, p=0.11) and perioperative blood loss in dutasteride administration for less than 4 weeks (MD 46.90, 95% CI -144.60 to 238.41, p=0.63) and more than 4 weeks (MD -190.13, 95% CI -378.05 to -2.21, p=0.05) differences were insignificant. CONCLUSION Preoperative administration of dutasteride is able to reduce bleeding during TURP, as indicated by less reduction in Hb level, lower transfusion rate, and less operation time.
Endoscopic Therapy in the Management of Patients With Severe Rectal Bleeding Following Transrectal Ultrasound-Guided Prostate Biopsy: A Case-Based Systematic Review
Journal of investigative medicine high impact case reports. 2021;9:23247096211013206
Rectal bleeding is a known complication of transrectal ultrasound-guided prostate biopsy. It is usually mild and resolves spontaneously. However, massive life-threatening hemorrhage can also rarely occur in this setting, potentially presenting a therapeutic conundrum. We hereby delineate the case of a patient who experienced severe intermittent lower gastrointestinal bleeding following a transrectal ultrasound-guided prostate biopsy. Traditional tamponade methods failed to control the hemorrhage. Subsequently, an urgent flexible sigmoidoscopy revealed an anterior rectal wall prominence with biopsy punctures as the possible source of bleeding. Endoclip was successfully applied at the bleeding site, achieving permanent hemostasis. The patient had an uneventful recovery and was discharged from the hospital. While the use of endoclipping has been widely reported in gastrointestinal endoscopy, its application remains exceedingly rare in this group of patients. To our knowledge, this case represents only the third report of endoclipping alone to treat massive rectal bleeding follwing a prostate biopsy procedure. In addition, we systematically review published medical literature to evaluate endoscopic techniques aimed at managing this important complication. This article illustrates that endoscopic therapy may present an efficient, noninvasive method to deal with severe post-biopsy rectal hemorrhage. Therefore, prompt consultation with the gastroenterology service should be advocated.
Impact of perioperative blood transfusions on oncologic outcomes after radical cystectomy: A systematic review and meta-analysis of comparative studies
Surgical oncology. 2021;38:101592
This study aimed at systematically analyzing and evaluating the impact of perioperative blood transfusions (PBT) on oncologic outcomes of patients undergoing radical cystectomy for bladder cancer. This systematic review follows the recommendations of the Cochrane Handbook for Systematic Reviews and Interventions and was conducted in line with the PRISMA statement and the AMSTAR II criteria. A comprehensive database search was performed based on the PICO criteria. Two independent reviewers performed all screening steps and quality assessment. Risk of bias and certainty in evidence were assessed with the Newcastle Ottawa Scale for non-randomized trials and the GRADE approach. Of 1123 identified studies 20 were eligible for qualitative analysis and 15 for quantitative analysis reporting on 21,915 patients. Receiving a PBT was associated with an increased risk of all-cause mortality (hazard ratio (HR) [95% confidence interval (CI)]: 1.29 [1.18, 1.40]; p < 0.001), cancer-specific mortality (HR [CI]: 1.27 [1.15; 1.41]; p < 0.001) and disease recurrence (HR [CI]: 1.22 [1.12; 1.34]; p < 0.001). Subgroup analysis of transfusion timing revealed a significantly increased risk of mortality with intraoperative or combined intra- and postoperative transfusions compared to postoperative transfusion only for all three outcomes (p < 0.001). Leukocyte-depletion was associated with increased all-cause mortality, but not cancer-specific mortality. The administration of PBT negatively impacts oncological outcomes after radical cystectomy. Therefore, careful treatment indication and strict adherence to transfusion guidelines is encouraged in order to avoid adverse effects during the perioperative course.
Prognostic impact of perioperative blood transfusions on oncological outcomes of patients with bladder cancer undergoing radical cystectomy: A systematic review
Arab journal of urology. 2020;19(1):24-30
Objective: To conduct a systematic review of whether blood transfusions may be associated with worse outcomes for patients with bladder cancer treated with radical cystectomy (RC), as there has been a recent increase in studies addressing this clinically relevant topic. Methods: PubMed, Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), Google Scholar, and the ClinicalTrials.gov databases were searched with pre-specified search terms for studies published between January 2010 and May 2020. The systemic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: A total of 17 studies with 19 627 patients were included after 183 records were screened for eligibility. In all, 10 studies proposed perioperative blood transfusion to be associated with impaired prognosis regarding overall survival, nine studies regarding cancer-specific and four studies regarding recurrence-free survival. The timing of blood transfusion might affect patient outcomes. Notably, several studies did not find a significant correlation between blood transfusions and prognosis. As all studies to date are of retrospective design, the grade of evidence is still limited. Conclusions: Despite the lack of prospective trials, perioperative blood transfusion may lead to worse oncological outcomes. These results, as well as known non-oncological side-effects and associated costs, are important arguments to carefully consider the indication for blood transfusion. Abbreviations BCa: bladder cancer; CSS: cancer-specific survival; HR: hazard ratio; (N)MIBC: (non-) muscle-invasive BCa; OS: overall survival; PBT, perioperative blood transfusion; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RC: radical cystectomy; RFS: recurrence-free survival.
Can tranexamic acid reduce the blood transfusion rate in patients undergoing percutaneous nephrolithotomy? A systematic review and meta-analysis
J Int Med Res. 2020;48(4):300060520917563
OBJECTIVE A systematic review and meta-analysis was conducted to explore the efficacy of tranexamic acid (TXA) in reducing transfusion events in patients undergoing percutaneous nephrolithotomy (PCNL). METHODS PubMed, Web of Science, Embase, EBSCO, and Cochrane library databases from January 1980 to October 2019 were searched for randomized controlled trials (RCTs) that assessed TXA efficacy in reducing transfusion events during PCNL. Intervention treatments include using TXA compared with placebo (or no intervention) for patients who underwent PCNL. The search strategy and study selection process were managed in accordance with the PRISMA statement. RESULTS Six RCTs are included in the meta-analysis. Overall, TXA intervention groups showed a significant reduction in blood transfusion events (RR = 0.34; 95% confidence interval [CI] = 0.19 to 0.62), hemoglobin decrease (MD = -0.80; 95% CI = -1.32 to -0.28), operative time (MD = -12.62; 95% CI = -15.62 to -9.61), and length of hospital stay (MD = -0.73; 95% CI = -1.36 to -0.10) compared with control groups after PCNL. However, TXA had no substantial impact on the rate of stone clearance (RR = 1.10; 95% CI = 1.00 to 1.21). CONCLUSIONS TXA can effectively reduce the transfusion rate and blood loss during PCNL.
Effect of warm bladder irrigation fluid for benign prostatic hyperplasia patients on perioperative hypothermia, blood loss and shiver: A meta-analysis
Asian journal of urology. 2019;6(2):183-191
Objective: To find out whether warm bladder irrigation fluid can decrease the occurrence of perioperative hypothermia, blood loss and shiver in patients treated with benign prostatic hyperplasia (BPH). Method: A comprehensive literature review and meta-analysis that included randomized controlled trials (RCTs) related to temperature of irrigation fluid in the perioperative treatment for BPH was taken by researchers. The relevant literature were searched in Chinese database, such as Retrieval Chinese Journal Full-text Database, VIP Journal Database, Wanfang database, as well as in English search engine and database, including Embase, Cochrane and Medline till January 2018. The study quality was assessed by recommended standards from Cochrane Handbook (version 5.1.0). Results: A total of 28 RCTs and 3858 patients were included. The results showed that the incidences of shiver (risk ratio [RR] = 0.32, 95% confidence interval [CI]: 0.28-0.36, p < 0.001, I (2) = 0%) and hypothermia (RR = 0.36, 95% CI: 0.21-0.59, p < 0.001, I (2) = 67%) in the group of warm irrigation fluid were lower than the group having room-temperature fluid. Room-temperature irrigation fluid group caused a greater drop in body temperature compared to warm irrigation fluid group (p < 0.001, I (2) = 96%). We performed a narrative descriptive statistics only because of substantial heterogeneity. Conclusions: Warm bladder irrigation fluid can decrease the drop of body temperature and the incidence of hypothermia and shiver during and after the operation for BPH. Warm irrigation fluid should be considered as a standard practice in BPH surgeries.
Impact of perioperative blood transfusions on clinical outcomes in patients undergoing surgery for major urologic malignancies
Therapeutic advances in urology. 2019;11:1756287219868054
The association between allogeneic perioperative blood transfusion (PBT) and decreased survival among patients undergoing various oncological surgeries has been established in various malignant diseases, including colorectal, thoracic and hepatocellular cancer. However, when focusing on urologic tumors, the significance of PBT and its adverse effect remains debatable, mainly due to inconsistency between studies. Nevertheless, the rate of PBT remains high and may reach up to 62% in patients undergoing major urologic surgeries. Hence, the relatively high rate of PBT among related operations, along with the increasing prevalence of several urologic tumors, give this topic great significance in clinical practice. Indeed, recent retrospective studies, followed by systematic reviews in both prostate and bladder cancer surgery have supported the association that has been demonstrated in several malignancies, while other major urologic malignancies, including renal cell carcinoma and upper tract urothelial carcinoma, have also been addressed retrospectively. It is only a matter of time before the data will be sufficient for qualitative systematic review/qualitative evidence synthesis. In the current study, we performed a literature review to define the association between PBT and the oncological outcomes in patients who undergo surgery for major urologic malignancies. We believe that the current review of the literature will increase awareness of the importance and relevance of this issue, as well as highlight the need for evidence-based standards for blood transfusion as well as more controlled transfusion thresholds.
Selective embolisation for intractable bladder haemorrhages: A systematic review of the literature
Arab Journal of Urology. 2018;16((2)):197-205.
Objective: To establish the current evidence and assess the effectiveness and safety of selective transarterial embolisation (STE) to control intractable bladder haemorrhage (IBH). Materials and methods: With a rise in the use of STE for the treatment of IBH, a systematic review was performed according to the Cochrane reviews guidelines and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Results: The literature search yielded 38 studies, of which 11 were excluded because of irrelevance of data. All included studies were observational cohort studies, with no randomisation or control groups apart from in relation to the materials used for embolisation. The studies were published between 1978 and 2016. There were 295 patients with an age range between 51 and 95years. The success rate ranged from 43% up to 100%. The most reported complication was post-embolisation syndrome, although other complications were described such as mild transient gluteal claudication, nausea, and vomiting. Conclusion: STE of the internal iliac artery is a safe and effective alternative technique to control severe IBH, and has been successfully applied over many years to treat bladder haemorrhage associated with terminal pelvic malignancy.
The impact of perioperative blood transfusion on survival and recurrence after radical prostatectomy for prostate cancer: A systematic review and meta-analysis
Journal of Cancer Research & Therapeutics. 2018;14((Supplement)):S701-S707.
Objective: Conflicting data have been reported regarding the association between perioperative blood transfusion (PBT) and clinical outcomes for prostate cancer patients. We conducted a systematic review and meta-analysis to evaluate the impact of PBT on cancer survival and recurrence for patients who underwent radical prostatectomy (RP). Methods: A systematic review of PubMed, EMBASE, and Cochrane libraries was performed to identify all eligible studies that evaluate the association between PBT and clinical outcomes for prostate cancer patients undergoing RP. The analyzed outcomes were overall survival (OS) and recurrence-free survival (RFS) at 3, 5, and 10 years. Results: A total of eight articles met our criteria. Meta-analysis indicated that prostate cancer patients with PBT had decreased OS (hazard ratio [HR] =1.51, 95% confidence interval [CI], 1.22-1.85, P < 0.01; HR = 1.57, 95% CI, 1.33-1.85, P < 0.01; HR = 1.55, 95% CI, 1.03-2.33, P = 0.04) and RFS (HR = 1.67, 95% CI, 1.37-2.04, P < 0.01; HR = 1.42, 95% CI, 1.23-1.63, P < 0.01; HR = 1.37, 95% CI, 1.03-1.83, P = 0.03) at 3, 5, and 10 years after surgery compared with those without PBT. Conclusions: The findings from the current meta-analysis demonstrate that PBT was associated with adverse survival and recurrence outcomes for prostate cancer patients undergoing RP.