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

2.  TURP  gold standard in BPH  Using of A-Cog & A-Plt is increasing.  4% on A-Cog  37% on A-plt

3.  The most common perioperative complication in TURP is hemorrhage.  Blood transfusion 20% (Uchida 1999)  2.9% (Reich 2008)

4.  Prolonged operative time.  Capsular perforation.  Fluid absorption

5.  Large prostate.  Concurrent UTI.  Indwelling urinary catheters.

6.  Warfarin  reversible  A-plt  non reversible  Warfarin in AF ? Risk  Warfarin in cardiac stent ? risk

8.  High risk:  Hx intracardiac thrombus.  TIA.  Stroke.  Recent, recurrent UTI  PE  Prosthetic valve  Low risk:  AF  DVT

9.  Warfarine:  Vit-k dependent.  Clotting factor (II, VII, IX, X)  T 1/2 : 25-60 hr.  Duration of action 2-5 days

10.  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

11.  Most guidelines recommend:  Stop warfarin 5 days before surgery.  LMWH 4days preop to 1 day preop  INR must be <1.5 day of surgery

12.  Heparin:  Antithrombin, inactivate II, IX, X, XI, XII.  T 1/2 1-6hr  Using of Heparine pre-post TURP not increase risk of bleeding

13.  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

14.  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”.

15.  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.

16.  Ehrlich et al 2007:  No increase of bleeding if ASA resume at stopping irrigation vs 21 days.

17.  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.

18.  NSAID can be withheld a week before surgery.

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

20.  Incidence of stent thrombosis:  31% of clopidogrel stopped  0% if dual anti-plt Schouten 2007

21.  The American College of Chest Physicians:  Clopidogrel should toped 7 days pre-op.  Prostatic surgery should be postpone 12w after coronary stent.

23.  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

24.  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.

25.  Epinephrine:  Need more studies.

26.  Loop & Electrode Technology:  Thin-wire loops  Solid electrodes  Thick hybrid loops

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

28.  Bipolar Electrical Generators:  Use low voltages.  Less thermal deep tissue injury.  Improve hemostasis (decrease bleeding, no diff in transfusion)

29.  Laser Technology:  Ahyai et al 2010:  HoLEP is effective as TURP.  Decrease risk of bleeding.  It is safe in full anticoagulant.

31.  Ruszat et al 2007:  Photovaporization of the prostate is equivalent to TURP in small/medium prostate.