Do low molecular weight heparin and dextran increase the blood loss in transurethral resection of the prostate?

OBJECTIVE: To evaluate whether the use of dextran or the combination of low molecular weight heparin and dextran increases the blood loss in elective transurethral resection for benign prostatic hyperplasia. PATIENTS AND METHODS: This open randomized controlled study included 198 patients operated under spinal anaesthesia who were allocated to four groups differing in the combination of prophylactic treatment used for thrombosis and for the substitution of blood loss. The prophylactic treatment was either dalteparin sodium, continued each day until mobilization, or 3% Ringer dextran-60 just before operation and continued with 6% dextran-70 for 2 days post-operatively, and the volume substitute was Ringer dextran or Ringer's acetate. Thus, the four treatments (by prophylaxis and volume substitute, respectively) were dalteparin and Ringer's acetate, dalteparin and dextran, dextran and Ringer's acetate, and dextran and dextran. The haemoglobin lost to the irrigation fluid was measured and used to calculate blood loss. RESULTS: Patients receiving dextran had a larger post-operative and total blood loss than those who did not. The need for transfusion did not differ between the treatment groups. CONCLUSION: The combination of dalteparin and dextran was not associated with an increased blood loss above that with dextran alone.

The use of ethanol as a marker to detect and quantify the absorption of irrigation fluid during transurethral resection of the prostate.

During transurethral resection of the prostate (TURP), the irrigation fluid is often absorbed by the circulatory system and/or the region around prostate occasionally resulting in severe signs and symptoms. Instant detection and qualification of absorption of irrigation fluid have not been possible earlier. A method involving tagging of the irrigation fluid with ethanol for detection and quantification of absorbed irrigation fluid by measurement of ethanol in expired breath (EB) has been developed. The validity of measuring EB ethanol to detect and quantify absorption of irrigation fluid was studied in 13 patients undergoing TURP. The EB ethanol was compared with three other methods: I. Isotope tagging of the irrigation fluid and detection of absorbed fluid using a scintillation detector placed over large blood vessels. 2. Measuring changes in serum-sodium every 10 min. 3. Regular interval monitoring (RIM) of the difference between volume used for irrigation and volume recovered from patients every 10 min. The method of measuring EB ethanol was found to be highly valid. The possibility of detecting absorption and the incidence of absorption using EB ethanol in the clinical routine was studied in 192 patients undergoing TURP. Half of them absorbed irrigation fluid, 25% absorbed more than 400 ml. The proportion of patients absorbing irrigation fluid was the same for both experienced and inexperienced resectionists. Clinical assessment of absorption of irrigation fluid was performed by the resectionists and the supervising nurses in 118 patients undergoing TURP. Prerequisites for massive absorption were found by the resectionist in 8/9 patients. The resectionist falsely indicated absorption in 22 patients. The nurses correctly indicated 3/9 patients and falsely indicated 4 patients. To investigate the method measuring EB ethanol to detect absorption of irrigation fluid during general anaesthesia, 20 patients underwent TURP and EB ethanol was compared with the RIM method. There was a good correlation between the methods. Elevated pressure in the bladder and the prostatic fossa is a prerequisite for absorption of irrigation fluid. Detection and quantification of absorbed irrigation fluid by EB ethanol was used for comparing 102 patients operated on with and without a pressure warning device alarming at 1.5 kPa in the bladder. using the device reduced both the volume of absorbed irrigation fluid, and the number of patients absorbing irrigation fluid. Both ethanol per se and haemodilution by absorbed irrigation fluid may have impacts on the coagulation system. To investigate the influence of absorption of ethanol tagged mannitol on bleeding time, measurements were performed before and after TURP in 57 patients. No difference in bleeding time was found among patients who absorbed irrigation fluid as compared with those who did not. In conclusion, measurement of ethanol in EB for detection and quantification of absorbed irrigation fluid is a highly valid method when compared with three other methods. Absorption of irrigation fluid was found in 50% of the patients undergoing TURP. Clinical assessments of absorption of irrigation fluid are unreliable. EB ethanol can be used in patients during general anaesthesia. Using a pressure warning device decreases the volume of absorbed irrigation fluid, as well as the number of patients absorbing it. Absorption of ethanol tagged mannitol as irrigation fluid has no influence on bleeding time.

The use of ethanol-tagged mannitol in transurethral resection of the prostate does not alter the bleeding time in patients who absorb irrigation fluid.

To increase patient safety ethanol tagging of irrigation fluid is practised at several hospitals in Sweden to detect absorption of irrigation fluid during transurethral prostatic resection. Using this method it is found that almost half of the patients undergoing transurethral prostatic resections absorb irrigation fluid to some extent. Patients absorbing irrigation fluid bleed more than others. The phenomenon has been blamed on the open veins and sinusoides. Further, these patients are older, have larger prostates and longer operating times. To exclude an effect of ethanol-tagged irrigation fluid on the skin bleeding time this was measured before and after the operation in 57 patients. In 18 (32%) 160-1760 ml of irrigation fluid was absorbed, and in 9 patients over 480 ml. No difference in skin bleeding time emerged between absorbers and non-absorbers, and absorbers showed no differences in bleeding time between preoperative and postoperative values. There was a slight but insignificant decrease in the skin bleeding time after the operation in both absorbers and non-absorbers.

Reliability of clinical assessment of fluid absorption in transurethral prostatic resection.

We evaluated 5 frequently used clinical methods of assessing absorption of irrigation fluid during 118 transurethral prostatic resections. The use of an irrigating solution containing glycine 1.5% and ethanol 1% and subsequent analysis of the alcohol concentration in the exhaled breath (ethanol monitoring) served as control method. Most cases of fluid absorption in excess of 1,000 ml could be indicated from a combination of clinical observations made by the surgeon and the anaesthetic nurse, and by measuring the serum sodium concentration. 'False alarms' were common, however. The volumetric fluid balance did not accurately reflect absorption. We conclude that none of the routine methods alone was specific enough to suffice for detection of irrigation fluid.

[A study on prostatic cancer. The patient can decide himself: medical or surgical treatment]. / Studie om prostatacancer. Patienten kan få bestämma själv: medicinsk eller kirurgisk behandling.

In a multicentre study, 101 consecutive patients with advanced prostate cancer were offered the choice of orchiectomy or treatment with an LHRH analogue. Together with the cancer diagnosis the patients were given verbal information about the treatment alternatives, and detailed written information to peruse at home. One week later the patients informed the attending physicians of their choice. Information as to the reasons for the patients' choice, and their views on their choice after the start of treatment were elicited by questionnaire. Of the 101 patients, 48 chose orchiectomy, and 48 treatment with an LHRH analogue, five patients being excluded owing to their inability to decide. Mean age was about 73 years in both treatment groups, and about two thirds of each group lived with a partner. The level of education was higher among those who chose medical treatment. The predominant reasons for the choice of treatment were as follows: Orchiectomy, simpler (31 per cent), troublesome having to have monthly injections (19 per cent), simple to perform (15 per cent); medical treatment, possibility of change in treatment (27 per cent), simpler (17 per cent), fear of surgery (15 per cent). Most patients in both groups had no difficulty deciding, chose quickly, felt sure about their choice, appreciated the opportunity of choosing, and had discussed their choice with their partners or intimates. Three months after the start of treatment, almost all patients were still satisfied with their choice, and had no wish to change their choice even if that were possible.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of a bladder pressure warning device during transurethral prostatic resection decreases absorption of irrigation fluid.

During a period of 4 weeks 102 patients underwent transurethral prostatic resection (TURP). Of these, 50 were randomly allocated to the use of an intravesical pressure device which warned the surgeon at a pressure elevation of 1.5 kPa. Ethanol (1%) was used as a marker in the irrigation fluid (glycine 2.2%), and absorption of ethanol-tagged irrigation fluid was detected by measurements in the expired air. In 28 patients absorption took place (in 8 of the 50 patients equipped with the warning device and in 20 of the 52 without the device). The greatest absorption was seen in the group without the device. No differences were found between the groups with regard to age, resected mass, resection time, resection speed, or haemorrhage. Patients who absorbed irrigation fluid were slightly older and bled more, and the resected mass was larger. The use of a pressure warning device reduces the amount of irrigation fluid absorbed and the number of patients who absorb irrigation fluid, and minimises the risk of the TUR syndrome.

Absorption of irrigating fluid during transurethral prostatic resection as measured by ethanol, radioisotopes, and regular-interval monitoring.

Ethanol monitoring is a novel noninvasive method for immediate detection of absorption of irrigating fluid during transurethral prostatic resection. Its accuracy was evaluated during thirteen resections using 5% mannitol +2% ethanol as the irrigating fluid. The ethanol concentration in the expired breath correlated strongly with the degree of absorption of intravascular irrigating fluid as determined by a radioisotope technique, and fluid volume measurements, and with the changes in the serum sodium concentration. Extravascular absorption of the irrigating fluid resulted in prolonged elevation of the ethanol concentration and gave smaller changes in the serum sodium concentration.

Use of ethanol as marker substance to increase patient safety during transurethral prostatic resection. Screening investigation of irrigating fluid absorption in four hospitals and comparison of experienced and inexperienced urologists.

Of 472 patients at four different hospitals electively undergoing transurethral resection of the prostate (TURP), 192 received Sorbitur as an irrigating fluid with 2% ethanol (w/v) as a marker. Using a breath analyzer (Alcol-meter), the amount of ethanol in expired air was measured regularly during the operation to detect the absorption of irrigating fluid. The ethanol concentration in expired air was plotted against time. The time-ethanol concentration product was used as a measurement of absorbed ethanol marked irrigating fluid. A unit of more than 2.5 was considered to be a major absorption with possible clinical significance. This criterion was fulfilled in 24 percent of the patients. Postoperative serum sodium was shown to decrease more in patients with major absorption than in patients with minor absorption in comparison to preoperative values. The weight of resected tissue and the bleeding per resected gram of tissue was higher in the patients with major absorption, but the resected tissue per operating time was the same in both groups. The experienced urologists had as many patients with absorption as did the inexperienced ones. Ethanol-marked irrigating fluid is a simple, safe, noninvasive, rapid, and cheap method of detecting absorption of irrigating fluid thus increasing patient safety during TURP. This method indicates absorption before clinical signs and symptoms of the TUR syndrome occur. It also provides an easy method for estimating the frequency of absorption of irrigating fluid routinely in clinical work.

Monitoring of irrigating fluid absorption during transurethral prostatectomy. A study in anaesthetised patients using a 1% ethanol tag solution.

A simple, reliable method to detect absorption of irrigating fluid during transurethral prostatectomy is to tag irrigating fluids with 1% ethanol and monitor expired breath ethanol concentrations. This method correlated well (n = 0.79) with other existing methods of absorption monitoring in 20 anaesthetised patients. Ethanol (1%) tagging does not alter the optical quality of the irrigating fluid and is harmless to the patient. The technique is non-invasive, repeatable, cheap and gives instant results. It can be used in anaesthetised or awake patients and can detect absorption of as little as 100-150 ml in any 10-minute period.

Physiological variations in blood ethanol measurements during the post-absorptive state.

Specimens of arterial plasma and venous whole blood were obtained at 3-10 min intervals during the post-peak phase of ethanol metabolism in healthy volunteers. The concentrations of ethanol in blood and plasma were determined by headspace gas chromatography. This method had a standard deviation of 0.28 mg/dl for whole blood and 0.26 mg/dl for plasma and the coefficients of variation were 0.43% and 0.79% respectively. The physiological variation from time-to-time, expressed as the residual standard deviation after fitting the ethanol concentration-time regression relationships, ranged from 0.43-3.7 mg/dl (0.65-16%). The time-to-time variations in concentrations of ethanol were maximum when there were problems in getting an unimpeded flow of blood through the indwelling catheters. The results do not support the existence of sporadic fluctuations or spiking in the blood alcohol concentration-time profile during the post-absorptive state. Instead, this study underscores the need to control carefully the method of sampling blood and in this way keep pre-analytical sources of variation to a minimum.

The cost of prostatic cancer in a defined population.

Health-service costs for prostatic adenocarcinoma were calculated on the basis of 101 patients resident in the Linköping area throughout their illness and who died in 1984-1985. At the time of diagnosis 54 tumours were advanced and 47 were localized. Primary treatment was expectant or surgical in 77 and oestrogen therapy in 17 cases. The average number of life-years lost was 4.3 in the total series and 10.7 in the men younger than 70. The median cost per case, SEK 50,000 (US dollars 7,900), was significantly lower than the average cost, SEK 79,000 (US dollars 12,400), due to a few high-cost patients. Approximately 50% of the total treatment cost was incurred during the year before death. The total number of hospitalizations for prostatic cancer in Sweden during 1984 was 11,800. The total estimated cost of this disease for the Swedish Health Services in 1985 was around 300 million SEK (47 million US dollars).

Treatment of prostatic cancer by monthly injections of an LHRH-analogue depot.

Thirty-six patients with advanced prostatic cancer were treated by monthly depot injections of a luteinizing-hormone releasing hormone analogue (LHRH-a). Five of these patients were also pretreated for 14 days with cyproterone acetate (CPA) in order to counteract initial increase in testosterone concentration. Two weeks after the initial depot injection the serum testosterone had been reduced to and was maintained at castrate level. Luteinizing hormone and follicle stimulating hormone were also significantly reduced. Of the 31 patients 23 showed objective regression at 3 months, 9 had stable disease and none showed progression. At 3 months 22 patients reported subjective improvement. At 12 months 18 showed objective regression, 7 had withdrawn from therapy and 6 showed progression. Side effects were acceptable and comparable to those following surgical castration. It is shown that CPA counteracts the initial increase in testosterone concentration at initiation of LHRH-a treatment. We conclude that depot preparations of LHRH-analogues, both with and without pretreatment with CPA, are useful in the treatment of patients with advanced prostatic cancer.

Influence of continuous luteinizing hormone-releasing hormone agonist treatment on steroidogenic enzymes in the human testis.

Nine elderly men with prostatic carcinoma underwent treatment with a LHRH-agonist (Zoladex, ICI) for 3-6 months. At the end of the treatment period the patients underwent subcapsular orchidectomy. Testicular tissue was incubated with different tritiated testosterone precursors. Conversion mediated by several testicular steroidogenic enzymes was compared between Zoladex-treated patients and nineteen non-treated patients who underwent orchidectomy because of prostatic carcinoma. Serum concentrations of LH, FSH and testosterone were determined before and during treatment in the treated patients. The LHRH agonist treatment induced significantly decreased conversion mediated by the enzymes 3 beta-hydroxysteroid dehydrogenase, 17 alpha-hydroxylase and C17-20 lyase. Conversion mediated by 17 beta-ketosteroid reductase was also decreased although not as dramatically as the other enzymes, while conversion mediated by 20 alpha-dehydrogenase was increased. Serum concentrations of testosterone decreased to castration levels. Serum gonadotrophins decreased but remained within normal levels suggesting that "desensitization" at the pituitary level was not the only mechanism of action of the LHRH-agonist.