Perioperative major acute cardiovascular events after 180-W GreenLight laser photoselective vaporization of the prostate

Correlation analysis between cerebral microangiopathy and autonomic nervous dysfunction

OBJECTIVE

Our study was conducted aimed at investigating the potential correlation between cerebral microangiopathy and autonomic nervous dysfunction.

METHODS

We initially included 164 hospitalized patients with cerebral microangiopathy at our hospital from November 2019 to January 2021. Based on the inclusion and exclusion criteria, a final total of 162 patients with cerebral microangiopathy were selected. According to the patient's Autonomic Symptom Profile (ASP) score, patients with a score greater than 22 were categorized into a group with concomitant autonomic dysfunction (71 cases, combined group), while those with a score below 22 were categorized into a group of isolated cerebral microangiopathy (83 cases, cerebral microangiopathy group). The general data and laboratory examination results of the two groups were analyzed, and Pearson correlation analysis was performed to evaluate the correlation between cerebral microangiopathy and autonomic dysfunction, as well as the influencing factors of cerebral microangiopathy patients combined with autonomic dysfunction.

RESULTS

There were no significant differences between the two groups in terms of sex, BMI, smoking, drinking, family dementia history, diabetes, hypothyroidism, carotid atherosclerosis, obstructive sleep apnea hypopnea syndrome, hyperuricemia, hyperlipidemia, chronic obstructive pulmonary disease, Hamilton Anxiety Scale score, Hamilton Depression Scale score, 24-h mean systolic blood pressure (SBP), 24-h mean diastolic blood pressure DBP, daytime mean systolic blood pressure (dSBP), daytime mean diastolic blood pressure, nighttime mean systolic blood pressure (nSBP), nighttime mean diastolic blood pressure, 24-h systolic blood pressure standard deviation (SBPSD), 24-h diastolic blood pressure standard deviation, daytime diastolic blood pressure standard deviation, nighttime diastolic blood pressure standard deviation (nDBPSD), nDBPSD (p > .05). However, significant differences were observed between the two groups regarding age, history of coronary heart disease, hypertension, leukoaraiosis, cognitive function, ASP score, SSR, 24-h SBPSD, daytime systolic blood pressure standard deviation (dSBPSD), nighttime systolic blood pressure standard deviation (nSBPSD), standard deviation of RR interval (SDNN), root mean square value of successive RR interval difference (RMSSD), high-frequency component (HF), and low-frequency component (LF) (p < .05). Moreover, the levels of TG, TC, HDL-C, and LDL-C did not show significant differences between the two groups (p > .05), but there were significant differences in blood uric acid and homocysteine (Hcy) levels (p < .05). Age, history of leukoaraiosis, cognitive function assessment, blood uric acid, Hcy levels, 24-h SBPSD, dSBPSD, and nSBPSD showed positive correlations with ASP scores and SSR in patients with cerebral microangiopathy (p < .001). In contrast, hypertension, SDNN, RMSSD, HF, and LF showed negative correlations with ASP scores and SSR (p < .001). Moreover, coronary heart disease was negatively correlated with ASP scores but positively correlated with SSR (p < .001). The independent variables included age, history of leukoaraiosis, cognitive function assessment, ASP score, SSR, blood uric acid, Hcy, bradykinin, coronary heart disease, hypertension, 24-h SBPSD, dSBPSD, nSBPSD, SDNN, RMSSD, HF, and LF, which were indicators with differences in general data and laboratory indicators. The dependent variable was patients with cerebral microangiopathy combined with autonomic nervous dysfunction. The analysis results showed that age, history of leukoaraiosis, ASP score, SSR, 24-h SBPSD, dSBPSD, nSBPSD, SDNN, RMSSD, HF, and LF were the influencing factors of patients with cerebral microangiopathy complicated with autonomic nervous dysfunction.

CONCLUSION

We demonstrates that age, history of leukoaraiosis, cognitive function assessment, blood uric acid, Hcy level, 24-h SBPSD, dSBPSD, nSBPSD, blood pressure, SDNN, RMSSD, HF, LF, and coronary heart disease were highly associated with cerebral microangiopathy with autonomic dysfunction. Furthermore, the influencing factors of cerebral microangiopathy with autonomic dysfunction are age, history of leukoaraiosis, ASP score, SSR, blood pressure variability, and HRV.

Safety and efficacy of GreenLight PVP in octogenarians: evaluation of the Global GreenLight Group database

INTRODUCTION

The present study analyzes the largest international GreenLight database, the Global GreenLight Group (GGG), to evaluate the functional and safety profile of GreenLight photoselective vaporization of the prostate (PVP) in octogenarians.

METHODS

The GGG is a database comprised of patients that underwent GreenLight PVP from 2011 to 2019 performed by 8 experienced urologists at 7 international hospitals. Patients 80 years or older at the time of surgery were categorized as octogenarians. They were compared to a similar group of PVP patients below the age of 80.

RESULTS

Among 3,648 patients, 586 men were above the age of 80. Compared to patients under the age of 80, octogenarians had larger prostates (76.0 vs 71.9 ml, p = 0.02) and a lower BMI (25.6 vs 26.7, p = 0.045). Operative time was not significantly longer in octogenarians. The improvement in functional outcomes between 80-year-old patients and control patients was not significantly different at one-year follow-up, with the exception of maximum urinary flow (Q_max) that favoured younger patients (10.3 vs 12.6 ml/s, p = 0.02). The odds of transfusion were greater for older patients [OR 8.2 (95% CI 3.6-18.9, p < 0.01)], but they were not at increased risk of hematuria. Octogenarians had higher readmission rates (23.0 vs 11.9%, p < 0.01).

CONCLUSIONS

GreenLight PVP is a safe option in well-selected octogenarians in a cohort of patients treated by surgeons experienced with the technology. The odds of transfusion were higher in patients over 80, but the absolute risk remains low. The 30-day hospital readmission rate was higher in octogenarians.

Safety of not withholding clopidogrel therapy during the immediate several days pre- and post-trans-urethral resection of prostate (TURP): a retrospective cohort study

BACKGROUND AND AIM

Benign prostatic hypertrophy or hyperplasia (BPH) is a frequent urological complain particularly in old-aged individuals. Those patients usually have other risk factors (such as ischemic cardiovascular diseases) for which they might be treated with anti-thrombotic agents chronically. These medicines may induce blood thinning and raise the incidence of hemorrhage. Thus, if those patients needed operative treatment for BPH, they may be at high risk of hemorrhage or its related adverse effects with the usage of anti-thrombotic drugs during the peri-operative time. On the other hand, dis-continuation of these agents can lead to ischemic events in susceptible individuals. Therefore, this research aims to assess the safety of the continuation of using anti-thrombotic agents throughout the peri-operative duration in patients with prostate surgery in form of Transurethral Resection of Prostate (TURP) only for Benign Prostatic Hypertrophy (BPH).

METHODS

Patients' notes were reviewed retrospectively. The entire participants were categorized into two categories. First category was on clopidogrel therapy (CTC) for prolong time and the usage of these agents was carried on throughout the peri-operative period. The second category was not on clopidogrel therapy at all (NCTC). Both of these categories had Transurethral Resection of Prostate (TURP) for Benign Prostatic Hypertrophy (BPH). A comparison had been conducted between the two categories with regards to: (i) the amount of blood lost intra-operatively (ii) the duration of operation (iii) hematocrit concentration per-operatively (iv) transfused packed red blood cells (PRBC) if needed (v) clearance of hematuria postoperatively (vi) secondary hemorrhage and clot retention after discharge. Pearson Chi-square test, Independent sample t test and test for numeric variables were used as appropriate.

RESULTS

The study identified 329 patients. One hundred and sixty five participants in the CTC (clopidogrel therapy category) and 164 in the NCTC (non-clopidogrel therapy category). It had been revealed that there was no statistically significant difference between the CTC and NCTC regarding: (i) the amount of blood lost intra-operatively (ii) the duration of operation (iii) hematocrit concentration per-operatively (iv) transfused packed red blood cells (packed RBC) if needed (v) clearance of hematuria postoperatively (vi) secondary hemorrhage and clot retention after discharge (P > 0.65).

CONCLUSION

The continuation of usage of anti-thrombotic therapy (clopidogrel) during peri-operative period in patients with TURP for BPH is a safe practice. It is not associated with high probability of hemorrhage or PRBC transfusion or other adverse effects.

Multicenter experience with photoselective vaporization of the prostate on men taking novel oral anticoagulants

Objective

Photoselective vaporization of the prostate (PVP) is a widely performed surgical procedure for benign prostatic obstruction. This approach has become particular favoured for men on anti-platelet and anticoagulation agents such as clopidogrel and warfarin but there is minimal published experience in the setting of novel oral anticoagulants (NOACs). This study was to examine the perioperative outcomes in men on NOACs undergoing PVP, with particular reference to perioperative morbidity.

Methods

A retrospective analysis of PVP datasets was undertaken from three centres in Sydney (Australia), Toulouse (France) and Boston (USA). Subjects who had been treated whilst on NOACs without discontinuation or bridging were identified. Perioperative outcomes and treatment parameters were examined and morbidity recorded according to Clavien-Dindo (CD) classification.

Results

There were a total of 20 subjects who had undergone PVP whilst NOACs had been continued during the perioperative period. The mean age was 77±6.5 years. The mean prostate volume, energy utilization and vaporisation time was 94±56 mL, 301±211 kJ, and 35±21 min respectively. The mean postoperative duration of catheterization and duration of hospitalization was 2.2±2.4 days and 2.4±2.4 days respectively. There was a single episode of urinary tract infection and four subjects required re-catheterisation for non-hematuric retentions.

Conclusions

This study supports the safety of men on NOACs undergoing PVP. Whilst this study represents the largest experience of PVP in these men, larger studies are necessary to confirm the safety of PVP in this group of men undergoing BPH-related surgery.

Usefulness of non-invasive cardiac output monitoring in elderly patients undergoing monopolar transurethral resection of the prostate: a pilot study

Objective

To assess the impact of irrigating fluid on hemodynamic profiles using real-time non-invasive cardiac output monitoring (NICOM) in elderly patients undergoing monopolar transurethral resection of the prostate (TURP).

Methods

Twenty patients between 65 and 80 years of age who were scheduled for monopolar TURP and received spinal anesthesia up to T10 were enrolled. Irrigating fluid (2.7% sorbitol with 0.5% mannitol solution) was used. Hemodynamic profiles including cardiac index, and stroke volume variation (SVV) using NICOM were obtained. Estimated irrigating fluid absorption was indirectly calculated.

Results

The median amount of irrigating fluid used was 6000 mL. The median SVV was 11%, which increased to 12% at 10 minutes after initiating surgery. No significant changes in the cardiac index were observed. The estimated absorption of irrigating fluid was almost zero.

Conclusions

Although the estimated amount of irrigating fluid that was absorbed was negligible, the increase in SVV may indicate intravascular volume depletion with diuresis resulting from mannitol in the irrigating fluid early during irrigation. Therefore, even during short irrigating times, intensive hemodynamic monitoring should be performed to monitor the possibility of intravascular volume depletion as well as volume overload, especially immediately after large amounts of irrigating fluid are used.

Perioperative Safety and Efficacy of Holmium Laser Enucleation of the Prostate in Patients Receiving Antithrombotic Therapy: A Prospective Cohort Study

We investigated the efficacy of and risk from holmium laser enucleation of the prostate (HoLEP) due to discontinuation of antithrombotics in patients with benign prostatic hyperplasia (BPH). Patients in the prospective SNUH-BPH Database Registry who underwent HoLEP between December 2010 and December 2017 were enrolled. Preoperative evaluation included symptom score questionnaires, laboratory tests, urine tests, prostate-specific antigens, urodynamic study, and transrectal ultrasonography. Postoperative evaluation was performed at 2 weeks, 3 months, and 6 months. Information regarding the types of antithrombotics and their use, underlying disease, and antithrombotic management during surgery was collected. The study included 55 patients. The mean age and preoperative prostate volume were 68.7 ± 6.4 years and 70.3 ± 32.2 mL, respectively. The mean preoperative hemoglobin level was 13.5 ± 2.6 g/dL in the patients receiving antithrombotics. Of the patients, 71% were taking aspirin. Seventy-five (66.5%) and 70 patients (28.2%) discontinued the antithrombotic therapy 5–7 days and <1 week preoperatively, respectively. Three patients (1.21%) were switched to low-molecular-weight heparin therapy, and 10 (4.03%) continued antithrombotic therapy. No significant differences were found in the incidence rates of postoperative transfusion (p = 0.894) or complications from antithrombotic use, thrombosis (p = 0.946), haemorrhage requiring bladder irrigation (p = 0.959), transurethral coagulation (p = 0.894), cardiovascular events (p = 0.845), and cerebrovascular events (p = 0.848). Efficacy and complications related to the short-term antithrombotic withdrawal before and after HoLEP also showed no significant differences. HoLEP may be a beneficial surgical technique for patients with BPH who are receiving antithrombotics.

Major Acute Cardiovascular Events After Transurethral Prostate Surgery: A Population-based Analysis

OBJECTIVE

To test the prevalence and predictors of major acute cardiovascular events (MACE) after transurethral prostate surgery (TPS).

MATERIAL AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program database (2011-2016) was queried for patients who underwent transurethral resection of the prostate, photoselective vaporization, or laser enucleation. MACE included: cerebrovascular events, cardiac arrest, myocardial infarction, deep venous thrombosis requiring therapy, and pulmonary embolism episodes occurred up to 30 days after discharge. Univariable and multivariable logistic regression models tested MACE predictors and effect of MACE on perioperative mortality. Within covariates significant at univariable analyses a stepwise selection, based on Akaike Information Criterion values, was performed to fit the most appropriate multivariable model.

RESULTS

Overall 44,939 patients were included in our analyses. Of these 365 (0.8%) had MACE within 30 days after surgery. The strongest MACE predictors were recent congestive heart failure (odds ratio [OR]: 2.1, 95% confidence interval [CI]: 1.2-3.7, P = .007), transfusions (OR: 2.5, 95% CI: 1.5-4.1, P <.001) and preoperative Systemic Inflammatory Response Syndrome or sepsis (OR: 2.6, 95% CI: 1.6-4.2, P <.001). Similarly, inpatient (OR: 2.0, 95% CI: 1.6-2.5, P <.001) and nonelective (OR: 1.5, 95% CI: 1.1-2.1, P = .012) patients experienced higher MACE rates. Perioperative mortality rates were statistical significantly higher in MACE patients (OR: 13.1, 95% CI: 8.2-21.0, P <.001).

CONCLUSION

Up to 1% of patients undergoing transurethral prostate surgery experience MACE. MACE are burdened by high mortality rates (up to 14% in MACE patients). Proper patient selection and postoperative monitoring are necessary to reduce MACE incidence and mortality rates.