Can high-dose tranexamic acid have a role during transurethral resection of the prostate in large prostates? A randomised controlled trial
Arab journal of urology. 2022;20(1):24-29
OBJECTIVES To assess the efficacy and safety of high-dose tranexamic acid (TXA) during bipolar transurethral resection of the prostate (B-TURP) in patients with large prostates compared to placebo. PATIENTS AND METHODS From February 2018 to May 2020, 204 patients with enlarged prostates of 80-130 g and in need of surgical intervention were randomised into two groups. Patients in Group A underwent B-TURP and received TXA as an intravenous loading dose of 50 mg/kg over 20 min before induction of anaesthesia followed by a maintenance infusion of 5 mg/kg/h until resection was completed. The patients in Group B (placebo) received a saline infusion of a similar volume. RESULTS There was highly significant drop in haemoglobin in the placebo group at 4- and 24-h postoperatively compared with the TXA group (P < 0.001). However, there was no significant difference in the blood transfusion rate between the two groups with five patients (5.5%) in the placebo group and four (4.2%) in the TXA group requiring a transfusion (P = 0.74). The procedural time was significantly less in the TXA group vs the control group, at a mean (SD) of 79.93 (22.18) vs 90.91 (21.4) min (P = 0.001). Also, the intraoperative irrigation fluid volume and postoperative irrigation duration were significantly less in the TXA group vs the control group, at a mean (SD) of 19.21 (3.13) vs 23.05 (3.8) L and 14.75 (5.15) vs 18.33 (5.96) h, respectively (P = 0.001). Catheterisation and hospital stay durations were comparable between both groups (P = 0.384 and P = 0.388, respectively). No complications were recorded with use of high-dose TXA. CONCLUSION High-dose TXA was effective in controlling blood loss during B-TURP in patients with large prostates, with no adverse drug reactions.
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.
Fibrinogen prophylaxis for reducing perioperative bleeding in patients undergoing radical cystectomy: A double-blind placebo-controlled randomized trial
Journal of clinical anesthesia. 2021;73:110373
OBJECTIVE Excessive bleeding is an important complication of radical cystectomy. We aimed to assess whether preoperative administration of fibrinogen decreases perioperative bleeding and improves the outcome of radical cystectomy. DESIGN Double-blinded randomized trial with two parallel arms. SETTING The study was conducted in the department of surgery at a teaching hospital affiliated with a University of Medical Sciences. PATIENTS In total, 70 men undergoing radical cystectomy were randomized to fibrinogen (n = 35) and placebo-control groups. Mean (SD) age was 64.7 (7.4) years. INTERVENTIONS The intervention group received 2 g fibrinogen concentrate diluted in 100 ml distilled water, and the control group received 100 ml normal saline; both intravenously 15 ̶ 30 min before the start of the surgery. OUTCOME MEASURES The primary outcome was the amount of perioperative blood loss. The secondary outcomes were hemodynamic features and vital signs. MAIN RESULTS Fibrinogen significantly decreased the volume of blood loss (p < 0.001) and the total number of transfused packed-cell units per group (38 vs. 115 units); and compensated the decrease of HCO3 (p = 0.030), the mean arterial pressure (p < 0.001), hemoglobin O2 saturation (p = 0.001), heart rate (p < 0.001), and temperature (p < 0.001) throughout the surgery compared with the placebo. Patients in the fibrinogen group had shorter Intensive Care Unit (p = 0.001) and hospital (p < 0.001) stay. We did not find any adverse reaction in our patients receiving fibrinogen concentrate. CONCLUSION Fibrinogen concentrate reduces perioperative bleeding and the need for blood transfusion in radical cystectomy. It improves the outcomes of the surgery and decreases patients' length of stay in the healthcare system following radical cystectomy. REGISTRATION Iranian Registry of Clinical Trials (IRCT) http://www.irct.ir/, reference number: IRCT20191013045091N1. ETHICS CODE Shahid Beheshti University of Medical Sciences, reference number: IR.SBMU.RETECH.REC.1398.033.
A Modified Pressure Dressing to Avoid Severe Bleeding After Circumcision With a Disposable Circumcision Suture Device and a Discussion on the Mechanism of Bleeding With the Disposable Circumcision Suture Device
Sexual medicine. 2021;9(2):100288
INTRODUCTION A novel type of a disposable circumcision suture device (DCSD) has been proved to be effective and safe; however, a few cases of severe bleeding took place after circumcisions. AIM: To evaluate the effectiveness of a modified double-layer pressure dressing to avoid severe bleeding after circumcision with the DCSD, in our department in a prospective randomized controlled study, and discuss the mechanism of bleeding with DCSD. METHODS Patients with redundant foreskin or phimosis were included between September 2018 and November 2019 and divided into 2 groups: In group A, the conventional pressure dressing was performed; in group B, an modified double-layer pressure dressing was performed. MAIN OUTCOME MEASURE The main outcomes and complications (surgical time, incidence of glans ischemia, severe bleeding rate, infection rate, pain level, total cost, and overall satisfaction) were collected and analyzed. RESULTS A total of 624 patients were recruited for this study. There was no difference in the average age and body mass index between 2 groups. No patient suffered obvious glans ischemia. In group B, lower pain level, lower incidences of severe bleeding, and better satisfaction were recorded. CONCLUSION The mechanism of bleeding with the DCSD was discussed in this study, and the modified pressure dressing was proved effective, safe, and easy to perform. W Jiang, J-li Fu, W-l Guo, et al. A Modified Pressure Dressing to Avoid Severe Bleeding After Circumcision With a Disposable Circumcision Suture Device and a Discussion on the Mechanism of Bleeding With the Disposable Circumcision Suture Device. Sex Med 2020;XX:XXX-XXX.
Holmium laser enucleation of the prostate with Virtual Basket mode: faster and better control on bleeding
BMC urology. 2021;21(1):28
BACKGROUND To compare clinical intra and early postoperative outcomes between conventional Holmium laser enucleation of the prostate (HoLEP) and Holmium laser enucleation of the prostate using the Virtual Basket tool (VB-HoLEP) to treat benign prostatic hyperplasia (BPH). METHODS This prospective randomized study enrolled consecutive patients with BPH, who were assigned to undergo either HoLEP (n = 100), or VB-HoLEP (n = 100). All patients were evaluated preoperatively and postoperatively, with particular attention to catheterization time, operative time, blood loss, irrigation volume and hospital stay. We also evaluated the patients at 3 and 6 months after surgery and assessed maximum flow rate (Qmax), postvoid residual urine volume (PVR), the International Prostate Symptom Score (IPSS) and the Quality of Life score (QOLS). RESULTS No significant differences in preoperative parameters between patients in each study arm were found. Compared to HoLEP, VB-HoLEP resulted in less hemoglobin decrease (2.54 vs. 1.12 g/dl, P = 0.03) and reduced operative time (57.33 ± 29.71 vs. 42.99 ± 18.51 min, P = 0.04). HoLEP and VB-HoLEP detrmined similar catheterization time (2.2 vs. 1.9 days, P = 0.45), irrigation volume (33.3 vs. 31.7 l, P = 0.69), and hospital stay (2.8 vs. 2.7 days, P = 0.21). During the 6-month follow-up no significant differences in IPSS, Qmax, PVR, and QOLS were demonstrated. CONCLUSIONS HoLEP and VB-HoLEP are both efficient and safe procedures for relieving lower urinary tract symptoms. VB-HoLEP was statistically superior to HoLEP in blood loss and operative time. However, procedures did not differ significantly in catheterization time, hospital stay, and irrigation volume. No significant differences were demonstrated in QOLS, IPSS, Qmax and PVR throughout the 6-month follow-up. TRIAL REGISTRATION Current Controlled Trials ISRCTN72879639; date of registration: June 25th, 2015. Retrospectively registred.
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.
Efficacy of tranexamic acid in decreasing primary hemorrhage in transurethral resection of the prostate: A novel combination of intravenous and topical approach
Urology annals. 2021;13(3):238-242
BACKGROUND Transurethral resection of the prostate (TURP) is the gold standard for benign prostatic enlargement; however, hemorrhage still remains one of the major complications. OBJECTIVE The primary aim of this study was to evaluate the effect of tranexamic acid (TXA) in reducing intraoperative blood loss and need for blood transfusion. Secondary parameters compared were operating time, volume of irrigation fluid used, and reduction in hemoglobin concentration. SUBJECTS AND METHODS A total of 70 eligible patients undergoing TURP were randomized based on computer generated table into two groups. The study group (1) received IV TXA 500 mg after induction of anesthesia and 500 mg in each irrigation fluid bottle (dual mode) and the control group (2) received none. RESULTS The mean age (68.20 vs. 66.5 years), prostate size (57 vs. 51 g), and preoperative hemoglobin (13.3 vs. 13.5 g/dl) were similar between the groups. Intraoperative blood loss in the TXA group was found to be significantly reduced (174.60 ± 125.38 ml vs. 232.47 ± 116.8; P = 0.04). Blood transfusion was required in 2.8% of cases as compared to 14.2% in controls. Operating time, volume of irrigation fluid, and postoperative reduction of hemoglobin were not significant between the groups. No complications were observed in both groups. CONCLUSION In this study, we observed that TXA, when used as a combination of Intravenous and topical route, effectively reduced intra-operative blood loss and the need for transfusion.
Effect of preoperative finasteride on perioperative blood loss during transurethral resection of the prostate and on microvessel density in patients with benign prostatic hyperplasia: An open label randomized controlled trial
Urology annals. 2021;13(3):199-204
OBJECTIVE Transurethral resection of the prostate (TURP) is a common procedure for the treatment of benign prostatic hyperplasia (BPH). Previous studies on the effect of 5-alpha reductase inhibitors on perioperative blood loss in TURP and microvessel density (MVD) in the prostate are equivocal. We evaluated whether pretreatment with finasteride for 2 weeks before surgery can reduce perioperative blood loss in TURP and MVD in the prostate. MATERIALS AND METHODS Sixty-eight patients of BPH planned for TURP were randomized into two groups. The study group comprising 34 patients was treated with finasteride (5 mg/day) for 2 weeks and the placebo group comprising 34 patients received placebo for 2 weeks, before TURP. Blood loss was measured in terms of a reduction in the blood hemoglobin (Hb) and hematocrit (HCT) levels between preoperative values and 24 h after surgery. MVD was measured in the resected prostate tissue stained with anti-CD31 monoclonal antibody. RESULTS The reduction of Hb and HCT in the finasteride group was significantly lower than the reduction in the placebo group (P < 0.05). The artery (P = 0.005), vein (P = 0.05), and gland (P = 0.008) densities were significantly less in the finasteride group than in the placebo group. There was no significant correlation between blood loss and MVD. CONCLUSIONS Our study suggests a clear advantage of the preoperative use of finasteride for 2 weeks by reducing the perioperative blood loss in TURP in patients with BPH. While there is a significant reduction in MVD in the prostate on treatment with finasteride, it is not clear that this is the mechanism of reduction in blood loss in TURP.
Autologous platelet gel improves outcomes in tubularized incised plate repair of hypospadias
Journal of pediatric surgery. 2021
BACKGROUND hypospadias is one of the most widespread male congenital anomalies, occurring in 1:250 to 1:300 live births. Several repair techniques have been developing to improve the outcomes. PURPOSE a randomized prospective controlled study was adopted to evaluate effectiveness of autologous platelet gel in healing promotion and improving the outcomes of hypospadias repair. METHODS thirty children who aged between 6 months and 12 years were recruited and subdivided into two groups; group A had tubularized incised plate (TIP) repair with autologous platelet gel application and group B had TIP repair without autologous platelet gel. RESULTS there was no significant difference in duration of operation between both groups. All patients in groups A and B had slit-like meatus shape in the distal glans. While all those of group A had one urine stream, yet only 11 of group B had one. There were complications that happened exclusively in group B such as spray stream (27%) and fistula (20%). Whereas other complications occurred insignificantly more in group B than in A including meatal stenosis (53 versus 27%), glans dehiscence, (20 versus 7%), bleeding (33 versus 13%), infection (33 versus 27%), edema (27% versus13), respectively. The incidence of skin necrosis was equal in both groups. CONCLUSION autologous platelet gel usage in TIP hypospadias repair can be a reliable technique to promote wound healing, and to limit of postoperative surgical complications.