Fibrinolysis and Thromboplastic Activity in Relation to Hemorrage in Transvesical Prostatectomy

Coagulation tests in predicting haemorrhage after prostatic resection

It is known that disseminated intravascular coagulation (DIC) can contribute towards blood loss after transurethral resection of the prostate because of the absorption of various prostatic substances. The aim of the present study was to establish whether simple coagulation tests (prothrombin time/activated partial thromboplastin time) carried out immediately after surgery would be useful in predicting those patients who bleed excessively after prostatic resection due to DIC. Criteria to determine significant post-operative haemorrhage were defined. Of 110 patients entered into the study, 34.5% had significant post-operative bleeding and 74% of these had an abnormal prothrombin time (> or = 15 s) immediately after surgery. An abnormal prothrombin time was associated with the resection of large prostates but could also predict the risk of bleeding independent of the resected weight; 18% of patients with an abnormal prothrombin time were also found to have an abnormal activated partial thromboplastin time and all of these had significant blood loss. A group of patients with an abnormal prothrombin time and a resected dry weight > or = 35 g was identified as a high risk group.

[Favorable outcome of neoplastic disseminated intravascular coagulation treated with ketoconazole and estrogen derivative]

A prostate biopsy was carried out in a 53-year-old male outpatient with disseminated prostatic carcinoma. Two days later, he was admitted with severe acute anaemia (haemoglobin: 48 g.l-1) and macroscopic haematuria. Biological investigations revealed a disseminated intravascular coagulation (DIC). Symptomatic treatment was undertaken (transfusion of packed red blood cells, platelets, fresh frozen plasma and fibrinogen). However, the patient's condition worsened, and he was admitted to the intensive care unit 48 h later. Despite appropriate symptomatic treatment, the patient's condition continued to worsen. The prostatic origin of this condition was therefore suspected, and anti-androgenic treatment was started on day 9 (1,200 mg.day-1 ketoconazole and 2,000 mg.day-1 sodium fosfestrol). Within 48 h, the patient had began to recover in quite a spectacular manner. Ketoconazole starts blocking steroid synthesis within 4 h of giving it. This treatment can be used until oestrogen therapy starts having an effect (about one week). The low levels of testosterone in this case, before starting treatment, suggest that ketoconazole acted on the DIC by a possible cytotoxic effect on the carcinomatous cells.

Disseminated intravascular coagulation in carcinoma of prostate: role of estrogen therapy

Advanced carcinoma of the prostate may present as disseminated intravascular coagulation and its sequelae. It is postulated that the slow release of thromboplastic material from tumor cells eventually overcomes normal homeostatic mechanisms. High-dose intravenous diethylstilbestrol diphosphate successfully reversed this coagulopathy in 2 cases of metastatic carcinoma of the prostate.

Plasminogen activator content of neoplastic and benign human prostate tissues; fibrin augmentation of an activator activity

The plasminogen activator content of the extracts of excise prostate cancers (25 specimens) was determined with an azocasein assay and found to be on the average 1.7 times higher than that of extracts of excised prostate benign hyperplasias (29 specimens). Both groups contained the same average percentage of human urokinase type activator (approximately 45%) as determined by the inhibition of activity when anti-human urokinase antibody was included in the assay system. The two types of activators were partially purified and found to have distinctly different properties. The most striking difference was the large augmentation of activity o the non-urokinase enzyme in fibrinolysis. The implications of an enhanced fibrinolysis relative to azocaseinolysis (or other) is discussed, particularly with respect to its importance in the quantitation and characterization of activators by different investigators. Highly purified urokinase-like activator was found to be similar to commercial urokinase preparation with respect to molecular weight, isoelectric point, inhibition by the antibody, and inhibition by placenta inhibitor.

Surgical hemostasis

Every surgical procedure taxes the hemostatic defenses of the patient. If his hemostatic mechanism is sound, he is unlikely to have a bleeding problem during or after an operation, unless, of course, a suture or clip slips off. Two classes of patients do present bleeding problems to the surgeon. One group has a pre-existing bleeding tendency, the other acquires it during or after the operation. The recognition of patients with severe hemostatic disabilities, such as hemophilia, presents no problem since the patient is aware of the disease. The mild bleeder is less likely to be detected by screening tests than by adroit questioning. The major hemostatic defect that may develop during an operation, or shortly thereafter, is disseminated intravascular coagulation. This syndrome, always secondary, may accompany shock, mismatched blood transfusion, septicemia, or extensive malignancy. Its prevention or early recongnition is much easier than treatment after circulating platelets and some coagulation factors have been consumed and fibrinolysis is destroying fibrin and fibrinogen.

Haemostasis during transvesical prostatic adenomectomy. A controlled trial on the effect of drugs with antifibrinolytic and thrombin-like activities

Blood loss, plasma fibrinolytic activity, prothrombin, P.T.T., and fibrinogen plasma levels were measured in 30 patients subjected to transvesical adenomectomy. These parameters were evaluated during 7 consecutive days after the operation. Ten patients received the antifibrinolytic substance (AMCHA), ten patients received Bothrops Jararaca venom extract, and ten patients served as controls. The results show that the coagulating fraction of Bothrops Jararaca snake venom reduces intraoperative bleeding without influencing the haemostatic balance. Postoperative haematuria could be reduced by antifibrinolytic agents.