Perioperative platelet inhibition in transurethral interventions: TURP/TURB

[Complication management for TUR of the bladder]

Transurethral resection of bladder cancer is a standard procedure in urology which requires complete resection. Knowledge of the possible complications and their management is essential for practicing urologists. The most common complications are catheter related bladder symptoms, bleeding, infections and perforation of the bladder. Resection of the orifice and positional damage are seldom but severe complications which need immediate treatment. In this review, we summarise the above mentioned complications as well as their management.

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.

[Optimizing the management of bladder cancer in older patients]

AIM

To define and present potential improvements for the management of bladder cancer in older patients.

METHOD

Bibliographical search was performed from the Medline bibliographic database (NLM Pubmed tool) and Embase focused on: bladder cancer, treatment, BCG, chemotherapy, cystectomy, and elderly.

RESULTS

The oncological principles of medico-surgical management of bladder cancer do not differ according to age. On the other hand, the patient comorbidities have been likely to alter the tolerance of these treatments. At the NMIBC stages, no adaptation of the standard treatment has demonstrated any interest. At the MIBC stages, the prognosis was improved by geriatric multidisciplinary perioperative management.

CONCLUSION

The indications and principles of surgical treatments must be identical regardless of the patient age. At the NMIBC stages, adjuvant therapy, including BCG therapy, should not be questioned because of the age of the patient. On the other hand, at the localized MIBC stages, neoadjuvant and adjuvant chemotherapy should not be considered as a standard and their indications assessed individually after geriatric assessment.

Safety and Effectiveness of Bipolar Transurethral Resection of the Prostate in Patients Under Ongoing Oral Anticoagulation with Coumarins or Antiplatelet Drug Therapy Compared to Patients Without Anticoagulation/Antiplatelet Therapy

Objective: To determine whether transurethral resection of the prostate (TURP) is safe and effective in patients under ongoing therapeutic oral anticoagulation (OAC) or antiplatelet drug (APD) therapy. Patients and Methods: We analyzed data on 276 consecutive TURP patients under ongoing APD therapy with acetylsalicylic acid (n = 130) or clopidogrel (n = 16) or ongoing OAC with phenprocoumon (n = 57), without stopping or bridging the medication, compared to 73 TURP patients without APD/OAC. Results: Outcomes of patients under acetylsalicylic acid were comparable to the controls. Under ongoing OAC therapy TURP patients tended to need slightly longer bladder irrigation (median 24 hours vs 22 hours, p = 0.06), needed longer transurethral catheterization (median 42 hours vs 24 hours, p = 0.031), were threefold more likely to have postoperative urinary retention (18% vs 6%, p = 0.04), had slightly longer hospital stays (median 4 days vs 3 days, p = 0.008), and tended to need more blood transfusions (9% vs 1%, p = 0.09), compared to controls. TURP patients under ongoing APD therapy with clopidogrel needed slightly longer bladder irrigation (median 24 hours vs 22 hours, p = 0.006), received more blood transfusions (19% vs 1%, p = 0.017), and had more rehospitalizations (19% vs 3%, p = 0.039). The significant functional improvement 1, 3, and 12 months after TURP was similar in all groups. Conclusions: Ongoing APD therapy with acetylsalicylic acid does not significantly impact TURP outcomes in terms of bleeding complications. Patients under ongoing therapeutic OAC with phenprocoumon or APD with clopidogrel can safely undergo TURP with an increased risk of bleeding complications, blood transfusions, and longer hospitalization.

Outcome of Transurethral Resection of Bladder Tumor: Does Antiplatelet Therapy Really Matter? Analysis of a Retrospective Series

INTRODUCTION

Transurethral resection of bladder tumor (TURBT) is considered to be at a moderate or high risk of bleeding during surgical procedure. The number of patients on antiplatelet (AP) drugs has been increasing; we wanted to assess their impact on the outcome of patients undergoing scheduled TURBT.

MATERIALS AND METHODS

A retrospective assessment of noninferiority of 450 consecutive procedures performed between April 2013 and June 2015 was conducted. Patients were divided in two groups: naive or AP drug users. The primary endpoint was the average length of stay (ALOS). Noninferiority was set at 1 day. A subgroup analysis comparing the acetylsalicylic acid (ASA) group and clopidogrel group to the naive group was performed. Multivariate analysis was performed to find the determinants of a longer ALOS. Chi-square or Fisher tests were used to analyze categorical variables, and Student's or Mann-Whitney tests were used to analyze quantitative variables.

RESULTS

We included 325 patients who underwent TURBT: 117 received AP drugs (ASA, 85; clopidogrel, 32) and 208 were naive to AP drugs (of whom 117 were consecutively analyzed). The ALOSs were 2.5 days (naive group) and 2.9 days (AP group). The subgroup analysis showed ALOSs of 2.6 days (ASA group) and 3.7 days (clopidogrel group). Clopidogrel therapy (odds ratio = 4.1 [1.7-9.6]) and the duration and depth of resection emerged as determinants of a longer ALOS in multivariate analysis. Perioperative management of AP therapies was achieved according to recommended practices.

CONCLUSIONS

The ALOS of patients receiving AP drugs was not clinically different from naive patients. This result was identical for patients receiving ASA. However, clopidogrel increased the length of stay, making us question its use in perioperative management.