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

A Case of Genital and Extragenital Warts Unresponsive to Immunotherapy Using Measles, Mumps, Rubella Vaccine

Anogenital warts (AGWs) are globally recognized as the most common sexually transmitted infections (STIs) caused by the human papillomavirus (HPV), particularly types 6 and 11. Meanwhile, immunotherapy is one of the treatments of choice for patients with extensive AGWs. Measles, mumps, and rubella (MMR) vaccine induce the production of various T helper 1 cytokines to elicit immune responses, resulting in the clearance of both treated and untreated warts. This study reported a case of extensive genital and extragenital warts in a 53-year-old male which had occurred for five years, with no pseudo-Koebner phenomenon. The history of MMR vaccination was uncertain but the patient received oral antibiotics for one week, one month before seeking consultation. Physical examination showed extensive verrucous and hyperkeratotic papules, plaques, and nodules in the lower abdomen, pubic, inguinal, genital, and gluteal regions. Acetowhite test results were positive, while polymerase chain reaction (PCR) results were positive for HPV types 6 and 11. The patient received an intralesional injection of 0.5 mL MMR vaccine into the largest warts with a 3-week interval. However, during the one-month follow-up after the third injection, no improvement was observed in either the size or number of warts. Based on the results, several factors must be considered to determine the best candidate for immunotherapy, particularly with MMR vaccine, to achieve an optimal outcome. These factors include the active state of diseases, duration of diseases, as well as a history of sensitization, and broad-spectrum antibiotics.

Benign prostatic hyperplasia wound after surgical removal in subjects on anticoagulant or antiplatelet therapy: A meta-analysis

We performed a meta-analysis to evaluate the safety of benign prostatic hyperplasia wound after surgical removal in subjects on anticoagulant or antiplatelet therapy. A systematic literature search up to December 2021 was done and 19 studies included 5715 benign prostatic hyperplasia subjects at the start of the study; 1501 of them were on anticoagulant/antiplatelet therapy, and 4214 were control. We calculated the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) to evaluate the safety of benign prostatic hyperplasia wound after surgical removal in subjects on anticoagulant or antiplatelet therapy by the dichotomous or continuous methods with a random or fixed-influence model. Anticoagulant/antiplatelet therapy had significantly higher bleeding complication (OR, 1.88; 95% CI, 1.36-2.60, P < .001), higher blood transfusion (OR, 2.15; 95% CI, 1.63-2.83, P < .001), lower operation time (MD, -3.53; 95% CI, -6.80-0.27, P = .03), higher catheterization time (MD, 0.30 95% CI, 0.06-0.53, P = .01), longer length of hospital stay (MD, 0.82; 95% CI, 0.37-1.26, P < .001) and higher thromboembolic events (OR, 2.88; 95% CI, 1.26-6.62, P = .01) compared to control in benign prostatic hyperplasia subjects. Anticoagulant/antiplatelet therapy had a significantly higher bleeding complication, higher blood transfusion, lower operation time, higher catheterization time, longer length of hospital stay and higher thromboembolic events compared to control in benign prostatic hyperplasia subjects. Further studies are required.

Meta-analysis of the effect of antithrombotic drugs on perioperative bleeding in BPH surgery

Effects of antithrombotic agents on the bleeding risk after transurethral resection of the prostate (TURP) were assessed in patients with benign prostatic hyperplasia (BPH). Controlled clinical trials on the effects of perioperative anticoagulant therapy on postoperative bleeding in BPH patients published during January 1990 and February 2019 were searched in PubMed, Embase and the Cochrane Library. Two independent reviewers screened the studies according to the inclusion and exclusion criteria, extracted the data, evaluated the quality, and conducted a meta-analysis using the RevMan 5.3 software. A total of 20 studies were included. Analysis of these studies found that compared with interrupted use of antithrombotic agents, continuous use of antithrombotic drugs led to more frequent post-TURP bleeding (OR=4.34, 95% CI=2.29-8.23), and higher transfusion rate (2.96, 1.19-7.36). Compared with patients who never used antithrombotic agents, those who used antithrombotic agents continuously had higher bleeding risk (5.52, 1.64-18.66). Those who continued using antithrombotic agents during laser treatment had higher transfusion rate than those who stopped using them before the operation (5.39, 1.49-19.53), but it had no significant difference in clot retention, blood transfusion rate, intraoperative hemoglobin decrease and postoperative catheter-indwelling time compared with those who never used antithrombotic agents (P>0.05). Those who continued using antithrombotic agents during TURP showed less intraoperative hemoglobin decrease (-0.46, -0.58-0.35) than the patients who underwent low molecular weight heparin substitution. Interruption of antithrombotic agents during TURP can prevent the risk of postoperative bleeding; continuous use of antithrombotic agents is safe and feasible during laser treatment of BPH; whether low molecular weight heparin substitution is necessary during the discontinuation of antithrombotic agents is controversial.

Low-dose aspirin and burr-hole drainage of chronic subdural hematoma: study protocol for a randomized controlled study

BACKGROUND

Low-dose acetylsalicylic acid (ASA) in patients with chronic subdural hematoma (cSDH) represents a significant neurosurgical challenge. While continuation of ASA during the perioperative phase might increase recurrence and bleeding rates, discontinuation increases the risk of thromboembolic events. The aim of this study is to compare the postoperative recurrence and cardiovascular complication rates of patients undergoing burr-hole trepanation for cSDH with and without discontinuation of ASA.

METHODS

In this prospective randomized, placebo-controlled, double-blinded study we include all patients undergoing burr-hole drainage of cSDH who are under ASA treatment. The patients are randomized into two groups, one receiving ASA and the other placebo perioperatively. The study primarily seeks to compare the rate of recurrent events under ASA to that under placebo treatment. Secondary objectives are thromboembolic event rate, perioperative blood loss, postoperative anemia, intra- and postoperative blood transfusion rate, and clinical outcome.

DISCUSSION

To date, there is no evidence-based consensus on how to manage patients undergoing burr-hole drainage for cSDH who are under ASA treatment. Therefore, the decision to maintain or interrupt ASA treatment is based mostly on the surgeons' preference. A randomized placebo-controlled study for this frequent question is urgently needed in order to provide class I evidence for the best possible treatment of this large group of patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03120182 . Initial Release: 19.04.2017.

STUDY PROTOCOL

V2_23.02.2017.

Should aspirin be suspended prior to robot-assisted radical prostatectomy? A systematic review and meta-analysis

Background:

Low-dose aspirin use has been correlated with an increased risk of bleeding and overall complications in surgical and invasive diagnostic procedures. In this review, our aim was to analyze the current literature on whether robot-assisted radical prostatectomy (RARP) is feasible and safe in patients taking low-dose aspirin perioperatively.

Methods:

A systematic review was performed identifying a total of 767 studies, published between January 2000 and September 2017, with five of these studies meeting the inclusion criteria for the meta-analysis, totalizing 1481 patients underwent RARP. Patients were divided into two groups: taking aspirin (group A) and those not taking aspirin (group B) perioperatively.

Results:

There were no significant differences between groups in the overall [group A 10.7% versus group B 15.7%, risk ratio (RR) 0.83; p = 0.45; I² = 0%] or major complication rates (group A 1% versus group B 3%, RR 0.98; p = 0.98; I² = 0%), rate of cardiovascular events (group A 1.4% and group B 0.5%, RR 2.06; p = 0.24; I² = 9%), blood loss (group A 278 ml versus group B 307 ml, SMD −0.12; p = 0.91; I² = 96%), or hospital length of stay [group A 4 days (3–5) and group B 4 days (3–4), SMD −0.09; p = 0.52; I² = 0%]. There was a slightly higher blood-transfusion rate in group A (2.6%) versus group B (1.6%) (RR, 5.05; p = 0.04; I² = 0%).

Conclusion:

Continued aspirin use in the perioperative period does not correlate with an increase in surgical morbidity, blood loss, or hospital length of stay. There was a slightly higher blood-transfusion rate in patients taking low-dose aspirin (group A) perioperatively.

Continuation versus discontinuation of antiplatelet therapy for bleeding and ischaemic events in adults undergoing non-cardiac surgery

BACKGROUND

Antiplatelet agents are recommended for people with myocardial infarction and acute coronary syndromes, transient ischaemic attack or stroke, and for those in whom coronary stents have been inserted. People who take antiplatelet agents are at increased risk of adverse events when undergoing non-cardiac surgery because of these indications. However, taking antiplatelet therapy also introduces risk to the person undergoing surgery because the likelihood of bleeding is increased. Discontinuing antiplatelet therapy before surgery might reduce this risk but subsequently it might make thrombotic problems, such as myocardial infarction, more likely.

OBJECTIVES

To compare the effects of continuation versus discontinuation for at least five days of antiplatelet therapy on the occurrence of bleeding and ischaemic events in adults undergoing non-cardiac surgery under general, spinal or regional anaesthesia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), MEDLINE (1946 to January 2018), and Embase (1974 to January 2018). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials of adults who were taking single or dual antiplatelet therapy, for at least two weeks, and were scheduled for elective non-cardiac surgery. Included participants had at least one cardiac risk factor. We planned to include quasi-randomized studies.We excluded people scheduled for minor surgeries under local anaesthetic or sedation in which bleeding that required transfusion or additional surgery was unlikely. We included studies which compared perioperative continuation of antiplatelet therapy versus discontinuation of antiplatelet therapy or versus substitution of antiplatelet therapy with a placebo for at least five days before surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias and synthesized findings. Our primary outcomes were: all-cause mortality at longest follow-up (up to six months); all-cause mortality (up to 30 days). Secondary outcomes included: blood loss requiring transfusion of blood products; blood loss requiring further surgical intervention; risk of ischaemic events. We used GRADE to assess the quality of evidence for each outcome MAIN RESULTS: We included five RCTs with 666 randomized adults. We identified three ongoing studies.All study participants were scheduled for elective general surgery (including abdominal, urological, orthopaedic and gynaecological surgery) under general, spinal or regional anaesthesia. Studies compared continuation of single or dual antiplatelet therapy (aspirin or clopidogrel) with discontinuation of therapy for at least five days before surgery.Three studies reported adequate methods of randomization, and two reported methods to conceal allocation. Three studies were placebo-controlled trials and were at low risk of performance bias, and three studies reported adequate methods to blind outcome assessors to group allocation. Attrition was limited in four studies and two studies had reported prospective registration with clinical trial registers and were at low risk of selective outcome reporting bias.We reported mortality at two time points: the longest follow-up reported by study authors up to six months, and time point reported by study authors up to 30 days. Five studies reported mortality up to six months (of which four studies had a longest follow-up at 30 days, and one study at 90 days) and we found that either continuation or discontinuation of antiplatelet therapy may make little or no difference to mortality up to six months (risk ratio (RR) 1.21, 95% confidence interval (CI) 0.34 to 4.27; 659 participants; low-certainty evidence); the absolute effect is three more deaths per 1000 with continuation of antiplatelets (ranging from eight fewer to 40 more). Combining the four studies with a longest follow-up at 30 days alone showed the same effect estimate, and we found that either continuation or discontinuation of antiplatelet therapy may make little or no difference to mortality at 30 days after surgery (RR 1.21, 95% CI 0.34 to 4.27; 616 participants; low-certainty evidence); the absolute effect is three more deaths per 1000 with continuation of antiplatelets (ranging from nine fewer to 42 more).We found that either continuation or discontinuation of antiplatelet therapy probably makes little or no difference in incidences of blood loss requiring transfusion (RR 1.37, 95% CI 0.83 to 2.26; 368 participants; absolute effect of 42 more participants per 1000 requiring transfusion in the continuation group, ranging from 19 fewer to 119 more; four studies; moderate-certainty evidence); and may make little or no difference in incidences of blood loss requiring additional surgery (RR 1.54, 95% CI 0.31 to 7.58; 368 participants; absolute effect of six more participants per 1000 requiring additional surgery in the continuation group, ranging from seven fewer to 71 more; four studies; low-certainty evidence). We found that either continuation or discontinuation of antiplatelet therapy may make little or no difference to incidences of ischaemic events (to include peripheral ischaemia, cerebral infarction, and myocardial infarction) within 30 days of surgery (RR 0.67, 95% CI 0.25 to 1.77; 616 participants; absolute effect of 17 fewer participants per 1000 with an ischaemic event in the continuation group, ranging from 39 fewer to 40 more; four studies; low-certainty evidence).We used the GRADE approach to downgrade evidence for all outcomes owing to limited evidence from few studies. We noted a wide confidence in effect estimates for mortality at the end of follow-up and at 30 days, and for blood loss requiring transfusion which suggested imprecision. We noted visual differences in study results for ischaemic events which suggested inconsistency.

AUTHORS' CONCLUSIONS

We found low-certainty evidence that either continuation or discontinuation of antiplatelet therapy before non-cardiac surgery may make little or no difference to mortality, bleeding requiring surgical intervention, or ischaemic events. We found moderate-certainty evidence that either continuation or discontinuation of antiplatelet therapy before non-cardiac surgery probably makes little or no difference to bleeding requiring transfusion. Evidence was limited to few studies with few participants, and with few events. The three ongoing studies may alter the conclusions of the review once published and assessed.

Does Early Resumption of Low-Dose Aspirin After Evacuation of Chronic Subdural Hematoma With Burr-Hole Drainage Lead to Higher Recurrence Rates?

BACKGROUND

Antiplatelet therapy in patients with chronic subdural hematoma (cSDH) presents significant neurosurgical challenges. Given the lack of guidelines regarding perioperative management with antiplatelet therapy, it is difficult to balance the patient's increased cardiovascular risk and prevalence of cSDH.

OBJECTIVE

To better understand the risk and recurrence rates related to resuming low-dose acetylsalicylic acid (ASA) by evaluating our patients' resumption of low-dose ASA at various times after burr-hole drainage of the hematoma.

METHODS

In our retrospective study, 140 consecutive patients taking low-dose ASA undergoing surgical evacuation of cSDH were included. Data included baseline characteristics and rates of recurrence, morbidity, and mortality. A multivariate logistic regression model analyzed the association between ASA resumption time and recurrence rates.

RESULTS

No statistically significant association was observed between early postoperative resumption of low-dose ASA and recurrence of cSDH (odds ratio, 1.01; 95% confidence interval, 1.001-1.022; P = .06). Corresponding odds ratios and risk differences for restarting ASA treatment on postoperative days 1, 7, 14, 21, 28, 35, or 42 were estimated at 1.53 and 5.9%, 1.42 and 5.1%, 1.33 and 4.1%, 1.23 and 3.2%, 1.15 and 2.2%, 1.07 and 1.1%, and 1.01 and 0.2%, respectively (P > .05). Cardiovascular event rates, surgical morbidity, and mortality did not significantly differ between patients with or without ASA therapy.

CONCLUSION

Given the few published studies regarding ASA use in cranial neurosurgery, our findings elucidate one issue, showing comparable recurrence rates with early or late resumption of low-dose ASA after burr-hole evacuation of cSDH.

ABBREVIATIONS

ASA, acetylsalicylic acidCAD, coronary artery diseaseCI, confidence intervalcSDH, chronic subdural hematomaGCS, Glasgow Coma ScalemRS, modified Rankin ScaleOR, odds ratioRD, risk difference.

CSN1 Somatic Mutations in Penile Squamous Cell Carcinoma

Other than an association with HPV infection, little is known about the genetic alterations determining the development of penile cancer. Although penile cancer is rare in the developed world, it presents a significant burden in developing countries. Here, we report the findings of whole-exome sequencing (WES) to determine the somatic mutational landscape of penile cancer. WES was performed on penile cancer and matched germline DNA from 27 patients undergoing surgical resection. Targeted resequencing of candidate genes was performed in an independent 70 patient cohort. Mutation data were also integrated with DNA methylation and copy-number information from the same patients. We identified an HPV-associated APOBEC mutation signature and an NpCpG signature in HPV-negative disease. We also identified recurrent mutations in the novel penile cancer tumor suppressor genes CSN1(GPS1) and FAT1 Expression of CSN1 mutants in cells resulted in colocalization with AGO2 in cytoplasmic P-bodies, ultimately leading to the loss of miRNA-mediated gene silencing, which may contribute to disease etiology. Our findings represent the first comprehensive analysis of somatic alterations in penile cancer, highlighting the complex landscape of alterations in this malignancy. Cancer Res; 76(16); 4720-7. ©2016 AACR.

Epithelial Lesions Associated with Invasive Penile Squamous Cell Carcinoma: A Pathologic Study of 288 Cases

A heterogeneous spectrum of epithelial alterations and atypical lesions affect the squamous epithelium of penile mucosal anatomical compartments. Analogous to other genital sites, the terminology utilized to define the lesions is variable. The few pathologic studies of penile precancerous lesions are mostly related to carcinoma in situ and human papilloma virus (HPV), and the information on low-grade atypical lesions is limited. The objective of this study was to comprehensively describe the morphologic features of all epithelial alterations, benign and atypical, low grade and high grade, associated with invasive squamous cell carcinoma of the penis and to investigate their relation with each other and with subtypes of invasive carcinoma. We also propose herein a simple and reproducible nomenclature for penile precancerous abnormalities until more biological, molecular, or epidemiologic information on the lesions is available. Two hundred and eighty-eight penectomy and circumcision specimens with invasive squamous cell carcinoma were pathologically evaluated. Carcinomas were classified as usual, verrucous, papillary not otherwise specified, warty (condylomatous), basaloid, and mixed. Associated lesions were classified as squamous hyperplasia and squamous intraepithelial lesions of low and high grade (LGSIL and HGSIL). In LGSIL, atypia was confined to the lower third, and in HGSIL, atypical cells affected at least two thirds of the squamous epithelium. Subtypes of SIL were squamous, warty, basaloid, warty-basaloid, and papillary. Squamous hyperplasia, the most common lesion, was found in 83% of the cases, followed by LGSIL (59%) and HGSIL (44%). In 62% of the cases more than 1 associated lesion was present per specimen. A sequence from squamous hyperplasia to low-grade to high-grade SIL was seen frequently. Squamous hyperplasia was more commonly associated with usual squamous, papillary, and verrucous than with warty and basaloid invasive carcinomas. LGSIL was associated with all types of squamous cell carcinoma but was rarely present adjacent to basaloid or verrucous tumors. HGSIL was present in two thirds of invasive warty, basaloid, and mixed warty-basaloid tumors, in about half of usual squamous cell carcinomas, and was absent in papillary and verrucous carcinomas. Correlation of special types of invasive carcinomas with subtypes of SIL revealed morphologic correspondence of invasive tumor and the associated intraepithelial lesion. Squamous LGSIL was preferentially associated with verrucous, papillary, and usual squamous cell carcinomas; warty LGSIL, with invasive warty and mixed wartybasaloid carcinomas. High-grade SIL of the squamous type was frequently found in squamous cell carcinoma of usual type but was rarely present with warty or basaloid carcinomas. Basaloid HGSIL was associated with basaloid carcinoma, and HGSIL of warty type, with either warty or mixed warty-basaloid carcinomas. The high frequency of squamous hyperplasia and LGSIL and preferential association with usual, verrucous, and papillary carcinomas plus the subtle morphologic differences of the 2 lesions suggest that, despite its benign appearance, squamous hyperplasia is a precursor of the aforementioned carcinomas. The association and histologic similarities between high-grade SIL of the basaloid, warty, or mixed forms with their invasive counterparts indicate these lesions are their likely precursors.

Perioperative Management of Antiplatelets and Anticoagulants Among Patients Undergoing Elective Transurethral Resection of the Prostate--A Single Institution Experience

PURPOSE

To evaluate current practice in the perioperative management of antiplatelets (AP) and anticoagulants (AC) among men undergoing elective transurethral resection of the prostate (TURP), as well as the associated perioperative bleeding and thromboembolic complications.

PATIENTS AND METHODS

Retrospective review of consecutive elective TURP patients in a single tertiary institution from January 2011 to December 2013 (n = 293). Data on the regular use of AP/AC and the perioperative management approach were collected from patients' electronic medical records. Bleeding and thromboembolic complications were assessed up to 30 days postoperative. Association between AP/AC use and perioperative complications was assessed using the Kruskall-Wallis test (continuous variables) and the Fisher exact test (categoric variables).

RESULTS

There were 107/293 (37%) patients receiving long-term AP while there were 25/293 (9%) patients receiving long-term AC. A total of 72/107 (67%) patients ceased AP on an average of 7.6 days preoperatively, while 35/107 (33%) continued receiving AP. Patients with coronary stents (62%) and coronary bypass graft (67%) were significantly more likely to continued receiving AP (P < 0.001). AC was ceased in all patients preoperatively, with 16/25 (64%) receiving enoxaparin bridging. Overall, there were 31 (10%) incidents of bleeding complications and 5 (2%) thromboembolic events. AC users who had enoxaparin bridging had significantly higher risk of bleeding complications (44%), compared with non-AP/AC users (8%), AP users who ceased AP (4%), AP users who continued receiving AP (17%), and AC users who did not receive enoxaparin bridging (0%) (P < 0.001). AC users who received enoxaparin bridging also reported significantly higher thromboembolic complications (17%; P < 0.001) and prolonged hospital stay (mean 5.4 days) (P = 0.002), compared with other patients.

CONCLUSION

Perioperative management of AP/AC should be based on the indications and the American College of Chest Physicians thromboembolic risk stratification. Regular AC users who had enoxaparin bridging are at increased risk of both perioperative bleeding and thromboembolic complications.

Open and robot-assisted radical retropubic prostatectomy in men receiving ongoing low-dose aspirin medication: revisiting an old paradigm?

OBJECTIVE

To assess blood loss, transfusion rates and 90-day complication rates in patients receiving ongoing 100 mg/day aspirin medication and undergoing open radical prostatectomy (RP) or robot-assisted RP (RARP).

PATIENTS AND METHODS

Between February 2010 and August 2011, 2061 open RPs and 400 RARPs were performed. All patients received low-molecular-weight heparin for thrombembolism prophylaxis. Aspirin intake during surgery was recorded in 137 patients (5.5%). Descriptive statistics and multivariable analyses after propensity-score matching for balancing potential differences in patients with and without aspirin medication were used to assess the risk of blood loss above the median in patients undergoing open RP or RARP.

RESULTS

The median blood loss in the open RP cohort with and without aspirin medication was 750 and 700 mL, respectively, and in the RARP cohort it was 200 and 150 mL, respectively. Within the same cohorts, transfusions were administered in 21 and 8% and 0 and 1% of patients, respectively. The 90-day complication rates in patients with ongoing aspirin medication were 5.8, 4.4, 7.3 and 0% for Clavien grades I, II, III and IV complications, respectively. In multivariable analyses and after propensity-score matching, prostate volume (odds ratio 1.03; 95% CI 1.02-1.04; P < 0.01) but not ongoing aspirin medication achieved independent predictor status for the risk of blood loss above the median.

CONCLUSIONS

Major surgery such as open RP and RARP can be safely performed in patients with ongoing aspirin medication without greater blood loss. Higher 90-day complication rates were not detected in such patients. Differences in transfusion rates between the groups receiving and not receiving ongoing aspirin medication may be explained by a higher proportion of patients with coronary artery disease in the group receiving ongoing aspirin medication. This comorbidity may result in a higher peri-operative threshold for allogenic blood transfusion.

[ASA and clopidogrel for urological operations. Perioperative management]

In a systematic overview and meta-analysis among more than 50,000 patients at risk for coronary artery disease, not adhering to or discontinuing aspirin (acetylsalicylic acid, ASA) was associated with a significantly increased risk of non-fatal myocardial infarction or death. Withdrawal of low dose aspirin was correlated with a threefold increase in the risk of adverse cardiovascular events. This risk is present irrespective of the length of time patients had been taking low dose aspirin. Therefore, in patients on chronic low dose aspirin for secondary prevention of cardiovascular disease, aspirin should never be discontinued. In the few available studies in urological surgery the increase in bleeding does not translate into a significant increase in specific morbidity. This seems to be also true for the additional administration of clopidogrel to aspirin. Nevertheless, in patients with drug-eluting stents and dual antiplatelet therapy, urologists should ensure a multidisciplinary management of the perioperative course.

Recovery time of platelet function after aspirin withdrawal

Introduction

Inappropriate antiplatelet therapy discontinuation increases the risk of thrombotic complications and bleeding after dental procedures. To determine the platelet reactivity recovery time after aspirin withdrawal in vivo, our study was conducted in patients with low-risk cardiovascular disease who can stop aspirin administration following the guidelines stipulated by the American College of Chest Physicians. The time it takes for platelet activity to normalize and the diagnostic accuracy of testing methods were assessed for a residual antiplatelet activity with multiple electrode aggregometry. Our study included patients with clinically indicated hypertension preparing for a dental extraction procedure.

Materials and methods

A total of 212 patients not taking aspirin (control group) and 248 patients with hypertension receiving long-time aspirin treatment at a 100-mg daily dose were prospectively included in the study, which involved stopping aspirin intake before dental extraction. The residual platelet activity and dental bleeding in patients who stopped aspirin intake were analyzed and compared with those of the control group. In addition, platelet reactivity recovery time and bleeding risk in patients who stopped taking aspirin every 24 hours for 0 to 5 days (0–143 hours) before dental extraction was also assessed.

Results

Platelet reactivity normalized 96 hours after aspirin withdrawal. The cut-off value of 49 arbitrary units in the arachidonic acid platelet aggregation test excluded the effect of aspirin with 91% sensitivity and 66% specificity. AUC showed 0.86 (P < 0.001) diagnostic accuracy. The immediate bleeding complications in all treatment groups were similar to those seen in the control group and were successfully managed with local hemostatic measures.

Conclusions

The antiplatelet effects of aspirin disappeared 96 hours after aspirin withdrawal in our study, and dental extractions may be safely performed in this period when appropriate local hemostatic measures are taken. Based on these results, a shorter aspirin intake cessation period may be allowable in complex dental procedures and surgery for which a longer aspirin intake cessation period (7–10 days) is recommended based on the American College of Chest Physicians guidelines.

Coronary stent management in elective genitourinary surgery

What's known on the subject? and What does the study add? Withdrawal of dual antiplatelet therapy before the recommended, 12 months for drug-eluting stents and 1 month for bare-metal stents increases the rate of major adverse coronary events and mortality. However, in those undergoing surgery the risk of bleeding is increased substantially for those on antiplatelet agents. Successful management in patients with coronary stents who must undergo elective or non-elective urological surgery should be a multidisciplinary decision. This article reviews the literature and recommends a protocol for clinical management of patients undergoing urological procedures after coronary stent placement. To review the literature on coronary stents and genitourinary surgery and provide a protocol for perioperative. The keywords, 'elective surgery', 'aspirin', 'clopidogrel', 'guidelines for percutaneous coronary intervention', and 'antiplatelet therapy after coronary stent placement' were used to search PubMed for any relevant articles relating to coronary stents. Recommendations were made based on the whether the procedures patients were exposed to placed them at low-, moderate- or high-bleeding risk based on the extent of the procedure. All elective procedures should be delayed for 1 month after bare-metal stent placement and 1 year after drug-eluting stent placement. In patients classified as low risk (endoscopy and laser prostatectomy), aspirin should be continued throughout the perioperative period and dual antiplatelet therapy should continue 24-48 h postoperatively, if there is no concern for active bleeding. In those classified as moderate risk (scrotal procedures, transurethral resection of bladder tumours, transurethral resection of the prostate, urinary sphincter placement) dual antiplatelet therapy should be discontinued 5-7 days before the procedure and continued within 7 days after procedure, if there is no concern for active bleeding, in consultation with cardiology. In high-risk procedures (cystectomy, nephrectomy, prostatectomy, penile prosthesis placement) dual antiplatelet therapy should be discontinued 10 days before the procedure and continued postoperatively within 7-10 days of the procedure, when there is no longer a concern for active bleeding with the assistance of a cardiologist. Coronary artery disease is becoming more prominent in our society, increasing the use of coronary stents and antiplatelet agents. With the proposed protocol, it is safe to proceed with surgical intervention in those that have adequate stent endothelialisation.

Human papillomavirus vaccination uptake and factors related to uptake in a traditional desert city in the United Arab Emirates

It is important to assess uptake of a new vaccine. The present survey estimated the uptake of the recently introduced human papillomavirus vaccine (HPVV) in the emirate of Abu Dhabi and also explored barriers to uptake. A questionnaire survey was conducted in secondary schools, enrolling 334 girls. The uptake percentage was estimated and factors associated with uptake were assessed with multilevel logistic regression. Crude vaccination uptake was 53%. Factors positively associated with uptake were, among others, having knowledge on human papillomavirus (vaccine) and having United Arab Emirates (UAE) nationality. The HPVV uptake of just over 50% could probably be improved by educating the target group and their parents before offering the HPVV and by making it free of costs for everyone.

Antiplatelet drugs and the perioperative period: What every urologist needs to know

Antiplatelet agents like aspirin and clopidogrel are widely used for indications ranging from primary and secondary prevention of myocardial infarction or stroke to prevention of coronary stent thrombosis after percutaneous coronary interventions. When patients receiving antiplatelet drugs are scheduled for surgery, urologists commonly advise routine periprocedural withdrawal of these drugs to decrease the hemorrhagic risks that may be associated if such therapy is continued in the perioperative period. This approach may be inappropriate as stopping antiplatelet drugs often exposes the patient to a more serious risk, i.e. the risk of developing an arterial thrombosis with its potentially fatal consequences. Moreover, it has been seen that the increase in perioperative bleeding if such drugs are continued is usually of a quantitative nature and does not shift the bleeding complication to a higher risk quality. We, in this mini review, look at the physiological role and pathological implications of platelets, commonly used antiplatelet therapy and how continuation or discontinuation of such therapy in the perioperative period affects the hemorrhagic and thrombotic risks, respectively. Literature on the subject between 1985 and 2008 is reviewed. The consensus that seems to have emerged is that the policy of routine discontinuation of antiplatelet drugs in the perioperative period must be discouraged and risk stratification must be employed while making decisions regarding continuation or temporary discontinuation of antiplatelet therapy. Although antiplatelet drugs may be discontinued in patients at a low risk for an arterial thrombotic event, they must be continued in patients where the risks of bleeding and complications related to excessive bleeding are less than the risks of developing arterial thrombosis.

Postoperative haemorrhage following transurethral resection of the prostate (TURP) and photoselective vaporisation of the prostate (PVP)

INTRODUCTION

Intractable haemorrhage after endoscopic surgery, including transurethral resection of the prostate (TURP) and photoselective vaporisation of the prostate (PVP), is uncommon but a significant and life-threatening problem. The knowledge and technical experience to deal with this complication may not be wide-spread among urologists and trainees. We describe our series of TURPs and PVPs and the incidence of postoperative bleeding requiring intervention.

PATIENTS AND METHODS

We retrospectively reviewed 437 TURPs and 590 PVPs over 3 years in our institution. We describe the conservative, endoscopic and open prostatic packing techniques used for patients who experienced postoperative bleeding.

RESULTS

Of 437 TURPs, 19 required endoscopic intervention for postoperative bleeding. Of 590 PVPs, two patients were successfully managed endoscopically for delayed haemorrhage at 7 and 13 days post-surgery, respectively. In one TURP and one PVP patient, endoscopic management was insufficient to control postoperative haemorrhage and open exploration and packing of the prostatic cavity was performed.

CONCLUSIONS

Significant bleeding after endoscopic prostatic surgery is still a potentially life-threatening complication. Prophylactic measures have been employed to reduce peri-operative bleeding but persistent bleeding post-endoscopic prostatic surgery should be treated promptly to prevent the risk of rapid deterioration. We demonstrated that the technique of open prostate packing may be life-saving.

Postoperative haemorrhage following transurethral resection of the prostate (TURP) and photoselective vaporisation of the prostate (PVP)

INTRODUCTION

Intractable haemorrhage after endoscopic surgery, including transurethral resection of the prostate (TURP) and photoselective vaporisation of the prostate (PVP), is uncommon but a significant and life-threatening problem. The knowledge and technical experience to deal with this complication may not be wide-spread among urologists and trainees. We describe our series of TURPs and PVPs and the incidence of postoperative bleeding requiring intervention.

PATIENTS AND METHODS

We retrospectively reviewed 437 TURPs and 590 PVPs over 3 years in our institution. We describe the conservative, endoscopic and open prostatic packing techniques used for patients who experienced postoperative bleeding.

RESULTS

Of 437 TURPs, 19 required endoscopic intervention for postoperative bleeding. Of 590 PVPs, two patients were successfully managed endoscopically for delayed haemorrhage at 7 and 13 days post-surgery, respectively. In one TURP and one PVP patient, endoscopic management was insufficient to control postoperative haemorrhage and open exploration and packing of the prostatic cavity was performed.

CONCLUSIONS

Significant bleeding after endoscopic prostatic surgery is still a potentially life-threatening complication. Prophylactic measures have been employed to reduce peri-operative bleeding but persistent bleeding post-endoscopic prostatic surgery should be treated promptly to prevent the risk of rapid deterioration. We demonstrated that the technique of open prostate packing may be life-saving.

Human papillomavirus prevalence and type distribution in penile carcinoma

BACKGROUND

Penile carcinoma is an uncommon and potentially mutilating disease with a heterogeneous aetiology. Several risk factors have been established for its development. Human papillomavirus (HPV) infection seems to play an important role in the development of a subset of these carcinomas and its presence is thought to be related to the histological type. HPV prevalence in penile tumours is reported to be associated to a variety of morphological changes. Its determination will provide a better estimate for HPV related cancer burden and its preventable fraction.

METHODS

A systematic and comprehensive literature review of the major penile cancer studies published from 1986 until June 2008 evaluating the HPV prevalence among the different histological types was carried out.

RESULTS

31 studies including 1466 penile carcinomas were reviewed. Global HPV prevalence was 46.9%. Relative contribution was: HPV-16 (60.23%), HPV-18 (13.35%), HPV-6/11 (8.13%), HPV-31 (1.16%), HPV-45 (1.16%), HPV-33 (0.97%), HPV-52 (0.58%), other types (2.47%). Assessment of multiple infections contribution is limited due to study design. Basaloid and warty squamous cell carcinomas were the most frequent HPV-related histological types, but keratinising and non-keratinising subtypes also showed prevalence rates of around 50%.

CONCLUSIONS

About half of the penile tumours were associated with HPV 16-18 with little presence of other genotypes. Research on the mechanisms behind penile carcinogenesis is warranted. Available HPV vaccines are likely to be effective in penile tumours.

Comparison of Subtypes of Penile Squamous Cell Carcinoma From High and Low Incidence Geographical Regions

There is a worldwide geographical variation in the incidence of penile squamous cell carcinoma (PSCC); some subtypes are HPV-related (warty, basaloid) while others (keratinizing variants) are not. The aims of this study were to compare the distribution of different histological subtypes of PSCC from regions of low (Paraguay, 144 cases) and high (USA, 157 cases) incidence and to identify and compare tumors with and without warty and/or basaloid morphology. The distribution of subtypes in the Paraguayan and the American series was: usual, 49.3 and 46.5%; verrucous, 8.3 and 7.6%; papillary NOS, 7.6 and 5.7%; warty, 6.9 and 8.3%; basaloid, 4.2 and 7.0%; sarcomatoid, 0.7 and 0.6%; adenosquamous, 3.5 and 0.6%; and mixed, 19.4 and 23.6%, respectively. The distribution of mixed PSCC was: warty-basaloid, 50.0 and 59.5%; usual-verrucous, 21.4 and 21.6%; usual-warty, 14.3 and 8.1%; usual-basaloid, 7.1 and 0.0%; usual-papillary, 3.6 and 5.4%; and others, 3.6 and 5.4%, respectively. In conclusion, we found no geographical difference in the incidence of histological subtypes ( p = 0.6501), mixed PSCC ( p = 0.5937) or HPV-related tumors ( p = 0.2505). Geographical variation may be the result of staging variation at clinical presentation or of pathological diagnosis. The identification of similar histological subtypes in both series validates this classification approach for penile cancer. The tendency for typical SCC to mix with verrucous and papillary carcinomas and of the basaloid to preferentially mix with benign condyloma and condylomatous (warty) carcinomas would support the hypothesis of the existence of an etiologically different dual population of penile tumors.

Histological characteristics of human papilloma-virus-positive and -negative invasive and in situ squamous cell tumours of the penis

A high prevalence of cervical cancer associated high-risk types of human papillomavirus (hrHPV) has been demonstrated in premalignant and invasive squamous cell lesions of the penis, but large studies correlating histological characteristics with HPV status are few in number. Tumour tissues from 145 patients with invasive (n = 116) or in situ (n = 29) penile squamous cell carcinoma were subjected to systematic histological evaluation and were PCR-tested for 14 hrHPV types and 23 low-risk HPV types. Around half (52%) of invasive and nine-tenths (90%) of in situ lesions were positive for an hrHPV type, of which HPV 16 was by far the predominant type (91% of hrHPV-positive lesions). In relation to histological characteristics, hrHPV positivity was statistically significantly more common in high-grade tumours, lesions dominated by small tumour cells, lesions with a high number of multinucleated cells and mitoses, and lesions with a small amount of parakeratosis. In conclusion, about half of invasive penile squamous carcinomas in this study were hrHPV-positive, most notably to HPV 16, and probably arose through in situ lesions whereas the other half of invasive penile lesions appeared to be unrelated to hrHPV. A number of histological characteristics differed significantly between hrHPV-positive and -negative invasive penile carcinomas.

The effects of nonsteroidal anti-inflammatory drugs on platelet function and severity of upper gastrointestinal haemorrhage

Nonsteroidal anti-inflammatory drugs (NSAIDs) cause gastrointestinal (GI) damage primarily due to the inhibition of prostaglandin synthesis in gastric mucosa, which is an important factor in mucosa protection. Platelets are a cardinal feature of vascular repair. A variety of angiogenic stimulators are stored in platelets and are released during clotting at the wound. When there is a defect in any of these functions and/or platelet number, haemostasis is usually impaired and there may be an associated increased risk and severity of bleeding. While the mechanism of mucosal injury and bleeding are well documented with the use of NSAIDs, very little is known about the platelet function abnormalities and their effects on severity of upper GI bleedings. We performed a prospective analysis of 49 patients who had a history of NSAIDs use to investigate the association between the platelet function impairment associated with NSAIDs and severity of upper GI haemorrhages. Thirty-six of 49 patients (73.5%) had deteriorated platelet function. Mean severity score of patients with deteriorated platelet functions was 3.39, and that of patients with normal platelet functions was 2.46. Mean severity score was statistically significantly higher in patients with deteriorated platelet functions. In conclusion, impaired platelet functions associated with NSAIDs may cause more severe upper GI bleeding. Clinicians should be alert for GI complications especially in older patients and in those with a history of ulcer bleeding.

Early Initiation of Aspirin After Prostate and Transurethral Bladder Surgeries is Not Associated With Increased Incidence of Postoperative Bleeding: A Prospective, Randomized Trial

PURPOSE

Lower urinary tract operations are being increasingly performed in elderly patients, in whom aspirin intake is common for preventing cardiovascular disease. We determined the safety of early aspirin re-initiation after lower urinary tract surgeries.

MATERIALS AND METHODS

A randomized, open label clinical trial was done. The study cohort included patients referred for transurethral prostatectomy, open prostatectomy and transurethral resection of bladder tumor while receiving aspirin prophylaxis. After controlling for surgical modality patients were randomized into 2 arms, including aspirin treatment initiation 24 hours after discontinuing of bladder irrigation (early treatment group) and aspirin treatment initiation 3 weeks after surgery (late treatment group). Primary end points were pre-discharge hematuria necessitating the restoration of bladder irrigation or the cessation of aspirin treatment and late hematuria treated in an urgent care setting, requiring hospital admission or compelling the cessation of aspirin treatment.

RESULTS

A total of 120 patients were enrolled, including 60 per treatment group. There were no significant differences between the groups in surgery related factors that could have affected postoperative bleeding. Primary end points were attained by 16 of the 120 patients (13.6%), including 10 of the 60 (16.7%) in the early treatment group and 6 (10%) in the late treatment group (p = 0.28). Time to catheter removal and persistent hematuria duration were similar in the 2 groups. Cardiovascular morbidity was noted in 3 of 120 patients, of whom all were assigned to the early treatment group.

CONCLUSIONS

Early aspirin initiation after lower urinary tract surgeries does not appear to carry an increased risk of postoperative bleeding. Thus, it may be considered in patients at high risk for cardiovascular morbidity.

MVA E2 recombinant vaccine in the treatment of human papillomavirus infection in men presenting intraurethral flat condyloma: a phase I/II study

BACKGROUND

Human papillomavirus (HPV) is the etiologic agent for warts and cervical cancer. In Mexico, the death rate from cervical cancer is extremely high, and statistical data show that since 1990 the number of deaths is increasing. Condylomas and cancer of the penis are the most common lesions presented in men; bladder and prostate cancer in men are also associated with the presence of HPV. Since HPV is transmitted by sexual intercourse, treating both partners is necessary in order to eliminate the virus in the population. Approaches to this include preventative vaccines such as Gardasil, and therapeutic vaccines to treat established infections in both men and women. This will be the only way to decrease the numbers of deaths due to this malignancy.

PATIENTS AND METHODS

We conducted a phase I/II clinical trial to evaluate the potential use of the recombinant vaccinia viral vaccine MVA E2 (composed of modified vaccinia virus Ankara [MVA] expressing the E2 gene of bovine papillomavirus) to treat flat condyloma lesions associated with oncogenic HPV in men. Fifty male patients with flat condyloma lesions were treated with either MVA E2 therapeutic vaccine or fluorouracil (5-fluorouracil). Thirty men received the therapeutic vaccine, at a total of 10(6) virus particles per dose, administered directly into the urethra once every week over a 4-week period. Twenty control patients were treated with 5% fluorouracil 1mL twice weekly over a 4-week period directly into the urethra. Reduction of lesions or absence of papillomavirus infection was monitored by colposcopy and histologic analysis. The immune response after MVA E2 treatment was determined by measuring the antibodies against the MVA E2 virus and by analyzing the lymphocyte cytotoxic activity against cancer cells bearing oncogenic papillomavirus. Presence of papillomavirus was determined by the Hybrid Capture method.

RESULTS

Twenty-eight of 30 patients showed no lesion or presence of papillomavirus as diagnosed by colposcopy and brush histologic examination after 4 weeks of MVA E2 treatment. These patients showed complete elimination of flat condyloma in the urethra and no acetowhite spots were detected over the prepuce. In two other patients the acetowhite spots and flat condyloma did not diminish. All patients developed antibodies against the MVA E2 vaccine and E2 protein, and generated a specific cytotoxic response against papilloma-transformed cells. Viral DNA was not detected in MVA E2-treated patients. In the control group, 13 of 20 patients were free of lesions. Three of these patients had recurrence of lesions after 3 months of treatment and none of the patients developed specific antibodies against cancer cells. In contrast, patients treated with MVA E2 did not show any recurrence of lesions after 1 year of treatment. In addition, none of the patients had local or systemic adverse effects according to the WHO classification 1-4.

CONCLUSIONS

Therapeutic vaccination with MVA E2 proved to be very effective in stimulating the immune system against papillomavirus, and in generating regression of flat condyloma lesions in men.

Update on the role of non-opioids for postoperative pain treatment

Non-opioids play an ever increasing role in the treatment of postoperative pain; either on their own for mild to moderate pain or in combination with other analgesic approaches, in particular opioids, as a component of multimodal analgesia. The analgesics paracetamol (acetaminophen) and dipyrone (metamizole) as well as compounds with an additional anti-inflammatory effect (non-selective non-steroidal anti-inflammatory drugs and selective cyclo-oxygenase-2 inhibitors) are used widely in the perioperative period. Paracetamol is gaining renewed interest in this setting due to its minimal adverse effects and recent availability in a parenteral preparation, but its benefits are insufficiently studied. Dipyrone continues to be used in many countries despite the ongoing debate on the incidence and relevance of its ability to cause agranulocytosis. Among the anti-inflammatory drugs, selective cyclo-oxygenase-2 inhibitors have the most supportive data for their beneficial effects as a component of multimodal analgesia and offer benefits with regard to their adverse effect profile.

Optionen der palliativen Therapie des Peniskarzinoms

Penile cancer, with an incidence of 0.1-0.9/100,000 males/year, is one of the least common malignant tumors. Most patients are over 50 years old and the tumor is slow growing. Therapeutic success is highly dependent on lymph node status. Cancer related death is usually due to local complications such as arrosion bleeding caused by the tumor or infected inguinal metastases. The therapy for advanced penile cancer and its complications represents a challenge. Taking into consideration quality of life, the therapeutic strategy should be based on the patient's age, his sexual function, motivation and psychological condition, as well as previous illnesses and tumor biology. Palliative therapy requires good interdisciplinary work between oncologists, radiologists, plastic surgeons, physiotherapists and psychologists.

Discontinuation of perioperative antiplatelet and anticoagulant therapy in stroke patients

Growing evidence suggests that perioperative withdrawal of ASA for secondary stroke prevention increases thromboembolic risk without the associated benefit of decreased bleeding complications. ASA maintenance is acceptable in many procedures, including invasive ones. Many procedures, in particular ophthalmologic, dermatologic, and dental surgeries, also are safe while continuing oral AC. Warfarin has been continued successfully even in some surgeries that have high bleeding risk. When the risk is too high, temporary bridging therapy with LWMH is safe in many populations. Although the exact thromboembolic risks associated with temporary cessation of AP and AC are unknown and likely low, morbidity and mortality associated with thromboembolism are high. Further studies investigating the risks and benefits of maintaining AP and AC during procedures, particularly invasive ones, are needed. Meanwhile, it is critical that physicians understand the risks and benefits of perioperative AP and AC and the variety of procedures in which these agents can be safely continued.

Low-dose aspirin before intracranial surgery--results of a survey among neurosurgeons in Germany

BACKGROUND

Increasing numbers of patients presenting for intracranial surgery are receiving concurrent medication with low-dose aspirin, leading to dysfunctional circulating platelets, which might increase the peri-operative risk of bleeding.

OBJECTIVE

To survey the opinions and working practices of neurosurgical facilities in Germany regarding patients who present with low-dose aspirin medication before elective intracranial surgery. Methods. Questionnaires were sent to 210 neurosurgical facilities asking five main questions: (1) the adherence of any policy of stopping aspirin pre-operatively, (2) the personal risk assessment for patients with brain surgery under low-dose aspirin medication, (3) the preferred method of treatment for excessive bleeding in this context, (4) personal knowledge of haemorrhagic complications in this group of patients, and (5) the characteristics of the neurosurgical units concerned.

RESULTS

There were 138 (65.7%) valid responses. Of the respondents, 111 (80.4%) had a departmental policy for the discontinuation of pre-operative aspirin treatment. The mean time for discontinuation of aspirin pre-operatively was 7.3 days (range: 0-21 days). 107 respondents (77.5%) considered that patients taking low-dose aspirin were at increased risk for excessive peri-operative haemorrhage, and 80 (58%) reported having personal experience of such problems. Ninety-seven respondents (70.3%) would use special medical therapy, preferably desmopressin, if haemorrhagic complications developed intra-operatively. The mean amount of intracranial operations per year in each neurosurgical facility was 494 (range: 50-1700).

CONCLUSIONS

The majority of neurosurgical facilities in Germany have distinct departmental policies concerning the discontinuation of low-dose aspirin pre-operatively, with an average of 7.3 days. Three-quarter of the respondents felt that aspirin was a risk factor for haemorrhagic complications associated with intracranial procedures, and more than half of the interviewees reported having personal experience of such problems. Various medicamentous methods of counteracting aspirin-induced platelet dysfunction and excessive bleeding in this context are discussed and evaluated.

Low-dose aspirin before spinal surgery: results of a survey among neurosurgeons in Germany

The main problem faced by the increasing numbers of patients presenting for spinal surgery are receiving concurrent medication with low-dose aspirin, leading to dysfunctional circulating platelets. The contribution of low-dose aspirin to increased peri-operative risk of bleeding and blood loss is a contentious issue with conflicting published results from different surgical groups. Data from neurosurgical spine patients is sparse, but aspirin has been identified as an important risk factor in the development of post-operative hematoma following intracranial surgery. We surveyed the opinions and working practices of the neurosurgical facilities performing spinal operations in Germany regarding patients who present for elective spinal surgery. Identical questionnaires were sent to 210 neurosurgical facilities and proffered five main questions: (1) the adherence of any policy of stopping aspirin pre-operatively, (2) the personal risk assessment for patients with spinal surgery under low-dose aspirin medication, (3) the preferred method of treatment for excessive bleeding in this context, (4) personal knowledge of hemorrhagic complications in this group of patients, and (5) the characteristics of the neurosurgical units concerned. There were 145 (69.1%) responses of which 142 (67.6%) were valid. Of the respondents, 114 (80.3%) had a (written) departmental policy for the discontinuation of pre-operative aspirin treatment, 28 (19.7%) were unaware of such a policy. The mean time suggested for discontinuation of aspirin pre-operatively was 6.9 days (range: 0-21 days), with seven respondents who perform the operations despite the ongoing aspirin medication. Ninety-four respondents (66.2%) considered that patients taking low-dose aspirin were at increased risk for excessive peri-operative hemorrhage or were indetermined (8.6%), and 73 (51.4%) reported having personal experience of such problems. Ninety-two respondents (65.5%) would use special medical therapy, preferably Desmopressin alone or in combination with other blood products or prohemostatic agents (46.1%), if hemorrhagic complications developed intra- or post-operatively. The average number of spinal operations per year in each service was 607.9 (range: 40-1,500). Despite the existence of distinct departmental policies concerning the discontinuation of low-dose aspirin pre-operatively in the majority of neurosurgical facilities performing spinal operations, there is a wide range of the moment of this interruption with an average of 7 days. Two-thirds of the respondents felt that aspirin was a risk factor for hemorrhagic complications associated with spinal procedures, and more than half of the interviewees reported having personal experience of such problems. Finally, various medicamentous methods of counteracting aspirin-induced platelet dysfunction and excessive bleeding in this context are elicited, discussed and evaluated.

Endoscopic dacryocystorhinostomy in patients taking aspirin perioperatively

PURPOSE

The aim of this study is to report the results of endoscopic dacryocystorhinotomy (EDCR) in patients who did not interrupt their low-dose (75-150 mg daily) aspirin regimen for the procedure.

MATERIALS AND METHODS

A case note review was made of all 40 patients taking aspirin who had EDCR at Ipswich Hospital from May 1998 to October 2003. Age, gender, indications for surgery, complications, and outcome were analyzed and the bleeding rate compared to that in patients who were not on aspirin or warfarin who had an EDCR.

RESULTS

Of the 51 EDCRs performed in the 40 patients, 47 had complete relief of epiphora. Two of the patients with a persistent watering eye are to have revision surgery, 1 patient was observed (75% improvement), and 1 patient has since died. A total of 33 patients had no postoperative complications; 5 had epistaxis but only 1 of these required a nasal pack; 1 each had minor periorbital bruising, confusion, and facial pain, none of which delayed discharge. None required readmission. Of 257 EDCRs in patients not on aspirin or warfarin, 1.3% had epistaxis resulting in delayed discharged or readmission.

CONCLUSIONS

EDCR is a safe and efficacious treatment in patients with distal nasolacrimal obstruction in patients taking aspirin and does not require stopping the aspirin perioperatively.

The management of aspirin in transurethral prostatectomy: current practice in the UK

INTRODUCTION

Stopping aspirin prior to transurethral prostatectomy (TURP) may minimise peri-operative blood loss, but it may also increase the risk of a significant cardiovascular event. There are no guidelines on the management of aspirin in TURP. This study sought to determine the variation in the peri-operative management of transurethral prostatectomy (TURP) patients that are taking aspirin.

MATERIALS AND METHODS

A questionnaire was sent to 444 consultant urologists in the UK from a list obtained from the British Association of Urologists. This resulted in 290 anonymous replies (65%), of which 287 were suitable for analysis.

RESULTS

Of these 287 urologists, 178 (62%) ask patients to stop aspirin prior to TURP. Aspirin is stopped 9.8 days (median, 10 days; range, 2-30 days) prior to surgery, and recommenced 8.8 days (median, 7 days; range, 1-42 days) after surgery. In those that stop aspirin, 62% will stop aspirin in all patients, regardless of the indication, and 40% will cancel a TURP if aspirin use has inadvertently continued. Of the 287 urologists, 109 (38%) do not stop aspirin.

CONCLUSIONS

There is a wide variation in the management of aspirin in TURP patients in the UK. Aspirin is being stopped in patients at high risk of serious cardiovascular disease, often for longer than necessary. There is a need for multidisciplinary guidelines to reduce variation in practice.