The effect of low-dose acetylsalicylic acid on bleeding after transurethral prostatectomy--a prospective, randomized, double-blind, placebo-controlled study.

OBJECTIVE: An increase in the loss of blood after ingestion of acetylsalicylic acid (ASA) has been reported after several types of surgery, but randomized placebo-controlled studies have exclusively been performed after coronary artery bypass surgery. The reported effects of ASA on bleeding after transurethral prostatectomy (TURP) have been conflicting. We have studied the effect of low doses of ASA (150 mg) on bleeding after TURP in a prospective, randomized, double-blind, placebo-controlled trial. PATIENTS AND METHODS: Patients were randomized to receive either 150 mg ASA (n = 26) or placebo (n = 27) 10 days before surgery. The weight of resected tissue, operation time and blood loss, transfusion requirements and complications were recorded. RESULTS: There was no significant difference in the median operative blood loss between the groups (p = 0.528), but postoperatively the blood loss in the ASA group (median 284; quartiles 196-660 ml) was significantly higher than in the placebo group (median 144; quartiles 75-379 ml), (p = 0.011). No significant difference was observed between the groups regarding the amount of resected tissue (p = 0.209) or the operating time (p = 0.297). In both groups the operative blood loss was significantly related to the amount of resected tissue (p < 0.005) and the operating time (p < 0.005). No significant difference in transfusion requirements (p = 0.280), time to catheter removal (p = 0.455) and hospital stay (p = 0.820) were observed between the groups. CONCLUSION: Long-term low-dose ASA therapy is associated with a significant increase in the postoperative blood loss after TURP, and although no significant difference in transfusion requirements was observed more units of blood were used in the ASA group. We advise that ASA therapy should be withdrawn 10 days before TURP.

Bleeding and activation of coagulation during and after transurethral prostatectomy: importance of the acute-phase response and prostate specific antigen?

OBJECTIVE: To evaluate the importance of coagulation activation in patients with benign prostatic hyperplasia, undergoing transurethral prostatic resection (TURP) and to examine whether changes in activity are related to blood loss, the circulatory entry of prostate specific antigen (PSA), operative trauma (resected tissue weight) and the inflammatory response, as assessed by C-reactive protein (CRP). PATIENTS AND METHODS: TURP was performed in 24 men and the weight of resected tissue and blood loss determined. The activation of coagulation was followed using new sensitive and specific assays, and the changes related to blood loss, the release of PSA, operative trauma and the acute-phase response. The area under the curve (AUC) for the measured quantities was used in correlation analysis. RESULTS: TURP was followed by a marked activation in coagulation. There was no correlation between the markers of coagulation and the operative blood loss, but the latter correlated with the weight of resected tissue (P=0.001). Postoperatively, the blood loss correlated with prothrombin fragment (F1+2; P=0.010), with thrombin-antithrombin complexes (TAT; P=0.024), and with the PSA concentrations (P=0.016) but not with fibrinogen. Serum concentrations of PSA increased significantly and the AUC in the operative period correlated with F1+2 (P=0.003) and TAT (P<0. 005), but postoperatively only with F1+2 (P=0.013). The weight of resected tissue correlated operatively with PSA (P=0.012) but not with the concentrations of F1+2 or TAT. Postoperatively, there was a correlation with the acute-phase proteins, CRP (P=0.005), fibrinogen (P=0.012) and with PSA (P=0.020). CONCLUSION: The operative blood loss is caused by surgical factors and the observed postoperative hypercoagulable state can be explained as a physiological response to bleeding, i.e. to secure haemostasis. The activity of coagulation was unrelated to operative trauma, but the acute-phase proteins were. The release of PSA into the circulation probably has an effect on blood coagulation.

Lack of correlation between blood fibrinolysis and the immediate or post-operative blood loss in transurethral resection of the prostate.

OBJECTIVE: To evaluate whether the activation of the extrinsic tissue-type plasminogen activator-related fibrinolysis is implicated in the blood loss in patients with benign prostatic hyperplasia, undergoing transurethral prostatic resection (TURP). PATIENTS AND METHODS: TURP was performed in 24 men and the operative and post-operative blood loss determined. The activation of the tissue-type plasminogen activator-related fibrinolysis was followed using new sensitive and specific assays, and the changes related to the blood loss. Measurements of the plasma concentrations of free tissue-type plasminogen activator (t-PA) activity, tissue-type plasminogen activator (t-PA) antigen, plasminogen activator inhibitor (PAI) activity, plasminogen activator inhibitor 1 (PAI-1) antigen, plasminogen (Plg) activity, plasminogen (Plg) antigen, alpha 2-antiplasmin (alpha 2-AP), D-dimer and fibrin degradation products (FbDP) were all determined and the area under the curve (AUC) for each of these quantities correlated with the blood loss. RESULTS: TURP was followed by a marked activation of the fibrinolytic system. There was an immediate increase in systemic t-PA activity and t-PA antigen, coinciding with a significant drop in PAI activity. Post-operatively, PAI activity and PAI-1 antigen increased. The formation of plasmin was indicated by a fall in the plasma concentration of Plg activity and Plg-antigen and alpha 2-AP but which increased significantly at the end of the study period. Increased systemic fibrinolytic activity was further confirmed by a marked increase in fibrin D-dimer and FbDP. There was no correlation between the AUC in the operative period of any of the fibrinolytic variables and the measured blood loss. In the post-operative period, t-PA antigen (P = 0.004), PAI activity (P = 0.043), PAI-1 antigen (P = 0.016) and alpha 2-AP (P = 0.047) all correlated with the post-operative blood loss, while there was no correlation between fibrin D-dimer or FbDP and blood loss. CONCLUSION: The fibrinolytic system is activated during and after TURP, but the increased activity is not of pathophysiological importance for the blood loss.

Post-operative blood loss after transurethral prostatectomy is dependent on in situ fibrinolysis.

OBJECTIVE: To evaluate whether post-operative blood loss in patients with benign prostatic hyperplasia, undergoing transurethral resection of the prostate (TURP), depends on in situ fibrinolysis in urine, and to determine the relative contributions of the urokinase and tissue-type plasminogen activator systems. PATIENTS AND METHODS: TURP was performed in 24 men (median age 68.5 years, range 52-78) and the weight of resected tissue, the operative and post-operative blood loss determined. The concentrations of the urokinase- (u-PA) and tissue-type plasminogen activator (t-PA)-related fibrinolysis in their urine was followed using sensitive and specific assays, and the changes related to post-operative blood loss. Measurements of the urinary concentrations of free t-PA activity, t-PA antigen, free u-PA activity, u-PA antigen and fibrin degradation products (FbDP) were determined and the area under the curve for each of these quantities correlated with the post-operative blood loss. RESULTS: The post-operative blood loss correlated significantly with the per-operative loss (P = 0.047) and the weight of resected tissue (P = 0.029). There was a highly significant correlation between the area under the curve of FbDP in the urine and the post-operative blood loss (P < 0.005), while there was no significant positive correlation between the PA concentration or activity in the urine and post-operative blood loss. There was a significant correlation between the urinary t-PA activity and the amount of FbDP in the urine (P = 0.047), and a significant correlation between the weight of resected tissue and the amount of FbDP in the urine (P = 0.014). CONCLUSION: The post-operative blood loss after TURP is significantly related to an increase of the urinary fibrinolytic activity and the enhanced fibrinolytic activity is probably caused by t-PA.

Laparoscopic lymphadenectomy. Preliminary experience.

Pelvic lymphadenectomy is a well established method for staging carcinoma of the bladder and prostate. Usually it is done by open surgery, but we now report preliminary experience with the laparoscopic approach. The technique is described in detail, and the results seem to indicate that the procedure is safe, has few complications and gives less pain than open surgery, with rapid recovery and early postoperative discharge from hospital.

Transurethral ultrasound scanning in the evaluation of invasive bladder cancer.

One hundred and sixty-six patients suspected of having bladder tumours underwent transurethral ultrasound scanning before cystoscopy. Forty-nine patients had no tumour either at cystoscopy or on ultrasonography. Nine of the remaining 117 patients (8%) had false positive results and in a further 8 (7%) the ultrasound failed to show the tumour. The diagnostic accuracy for superficial tumours was 73%, whereas the accuracy in assessing muscle infiltrating and more advanced tumours was almost identical, 58-59%. It is concluded that transurethral ultrasound scanning does not add to the information obtained from cystoscopy and bimanual palpation in patients with bladder tumours.

Inverted papilloma of upper urinary tract.

Two new cases of inverted urothelial papilloma in the upper urinary tract are described and added to the 22 cases previously reported in the literature. In both cases inverted papilloma was localized beneath macroscopic normal surface, and in one of the cases the changes were found scattered widely in the upper urinary tract. The possible etiology and the symptomatology are discussed, and the need for follow-up of these patients is emphasized.

Direct vision internal urethrotomy. A critical review of 365 operations.

Internal urethrotomy under direct vision for urethral strictures in the male was employed on 369 occasions in 225 patients during a 4-year period. A retrospective review of results showed an overall cure rate of 77% but the cure rate after each individual operation was less than 50%. Operations for recurrence carried a significantly lower cure rate than initial operations but even after several recurrences there were reasonably good results considering the relatively minor procedure. An active post-operative follow-up employing routine urethroscopy showed significantly better results than mictiographic follow-up. The post-operative period of catheterisation and positive urine culture at the time of follow-up had no significant influence on the results.

The prognostic value of probe renography in ureteric stone obstruction.

During a 4-year period 143 ureteric stone patients were monitored with probe renography during and after obstruction. Cases with obstruction of short duration (less than 2 weeks) all did well. In cases with longer duration the renographic function values could be used to predict irreversible kidney damage. Stone size showed no correlation with functional impairment. Infection proximal to ureteric stones accelerated kidney damage. Recommendations for the control of ureteric stone patients are given.