Evaluation of the short-term cessation and early initiation of antithrombotic therapy in high-risk patients undergoing HoLEP procedure for large prostates (> 100 mL): A critical evaluation

Background: To characterize the safety and efficacy of Holmium Laser Enucleation of Prostate (HoLEP) in patients with large prostates (>100ml) at high risk for thromboembolic events (TE) resuming antithrombotic treatment (AT) in the early postoperative period. Methods: Data for 378 men with large prostates treated with HoLEP for symptomatic benign prostatic hyperplasia between December 2016 and July 2020 were reviewed retrospectively. Of the patients, 134 had been receiving AT, (anticoagulant (AC), n=51; antiplatelet (AP), n=83). AT was resumed within 24 hours postoperatively. We determined pre-, peri-, and postoperative parameters, functional outcome, and adverse events for the 3-month period postoperatively in patients receiving AC and AP; and compared results with 203 patients without AT. Results: Patients receiving AC and AP were older (p=0.015) and had a higher median ASA score (p<0.001). Objective voiding parameters (Qmax, PVR) and urinary symptoms (IPSS, QoL) improved in the three groups (p<0.001). Median enucleation and morcellation efficiencies were 1.58 (IQR:0.87-3.13) and 5 (IQR:1-8.08), median catheterization and hospitalization time was 2 days (IQR:2-3) and 3 days (IQR:3-4), respectively. The perioperative results were similar in the three groups. Overall, one patient in the AP group required blood transfusion at 4 days postoperatively due to clot retention and significant hemoglobin decrease (p=0.216). There was no adverse TE in any patient within 3-month postoperatively. Conclusion: HoLEP is an effective and safe method in patients with a high risk of TE whose AT is discontinued for surgery, as it enables AT to be resumed as soon as possible.

Monopolar Transurethral Resection of the Prostate; Experience in a Tertiary Centre in Nigeria

Aim and Objectives: To determine the perioperative, short-term success and complications of TURP. Study Design: Retrospective study. Place and Duration of Study: The study was carried out at the Division of Urology, Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria, from January 2017 to December 2020. Methodology: This was a retrospective study, where the records of men who had TURP and were followed up for a year were reviewed. The data included the patients’ age, size of the prostate gland (grams), duration of surgery(mins), blood transfusion, clot retention, length of catheterisation (silicon catheter) in days, hospital stay (days), postoperative infection, postoperative incontinence, re-operation, bladder neck stenosis, urethral stricture and TURP syndrome. Results: Forty-five patients who had TURP from January 2017 to December 2020 were studied. The patients mean age was 66.33±7.60. The mean prostate size was 60.76±20.26. The mean duration of surgery, catheter duration and hospital stay were 58.89±11.93, 3.56±1.44 and 4.38±2.10, respectively. The overall complication was 3.5%. Postoperative infection was the commonest complication (epididymo-orchitis 11.1% and urosepsis 2.2%). Other complications included clot retention 4.4%, TURP syndrome 2.2%, bladder neck stenosis 2.2% and urge incontinence 2.2%. There was no urethral stricture, re-operation or bladder rupture. No mortality was recorded. Conclusion: This study showed that most TURP complications were minor and within acceptable rates. Its attraction includes short hospital stay and short duration of catheterisation. Overall, TURP performed within our institution were generally safe and well-tolerated.

Bipolar TURP in high-risk patients with large prostate gland: our experience

Background: The present gold standard monopolar-TURP is associated with a number of complications and has less safety margin in comorbid patients. Bipolar TURP is a modification of conventional M-TURP and has the potential to overcome its most prominent shortcomings with better safety profile in patients with comorbidities. Aim of the study was to evaluate the efficacy of bipolar-TURP in terms of operative and postoperative parameters.Methods: This prospective study was conducted in the department of urology SKIMS Srinagar, from April-2019 to October 2020. Forty-five patients with one or more comorbidities and BHP, with a prostate weight ≥60 gm was evaluated. Operative and postoperative parameters were recorded and patients followed with IPSS and uroflowmetry for a period of 6-months.Results: Of 45 patients who underwent B-TURP, pre-operative parameters were mean age(years) 66.59±9.88, mean prostate size (gm) 77.42±18.4, mean IPSS of 26.3±2.9, mean serum PSA (ng/dl) of 2.32±0.88, mean Qmax (ml/s)of 7.71±2.41 and PVRU of 113.45±16.5 ml. Operative and post-operative parameters were, mean operative time(min) of 68.14±29.6, TUR syndrome in none, mean change in Na+ of -0.98±0.75 meq/l, mean change in Hb of -1.66±0.68 g/dL, mean irrigation time (hours) 24.53±5.46, clot retention in 3 (6.66%) patients, transfusion in 2 (4.44%) patients, mean postoperative catheter time(hours) 69.5±10.5 and mean hospital stay 3.6±1.61 days. Two (4.44%) patients developed stricture urethra and were managed with urethral dilatation. IPSS and Qmax at 6-weeks were 10.2±2.18 and 16.22±2.31 ml and at 6-months were 6.43±1.16 and 19.12±3.14 ml respectively.Conclusions: B-TURP seems to be a more sensible choice for patients with underlying comorbidities or implanted cardiac devices.

A Case Report of Placenta Percreta

There has been an increased incidence of placenta accreta in recent decades, which is associated with an increase in cesarean delivery. A woman aged 39 years GIVP1111 at 8 months of gestation was a breech location with antepartum bleeding et. causa placenta previa totalis suspected percreta bladder infiltration and hematuria. The last abdominal ultrasound showed no visible clot retention and mild right-sided hydronephrosis (possibly a physiological condition). Due to doubts regarding the suspicion of placental invasion of the bladder, an MRI examination of the abdomen was performed. A network was irregular in shape and can not be oriented either right or left, some of which have been split. Attached to the placenta. It was not clear that the cervix and bladder were visible, the total weight was 500 grams, the size was 15x13x5 cm. Based on both macroscopic and microscopic histopathological examinations, it could be concluded that the uterus, adnexa, surgery: placenta percreta, adenomyosis uteri. Keywords: placenta percreta; uterus; antepartum bleeding

Intravesical Blood Clot Retention? How We Manage It, a Tertiary Hospital Preference

Intravesical blood clot retention is one of the Urological emergencies. Ongoing haematuria and blood clot formation in the bladder obstruct the urine outflow and lead to urinary retention, abdominal pain, anemia, urinary tract infection (UTI), and renal function deterioration. Most of the cases required cystoscopy blood clot evacuation and definitive surgery to stop the ongoing bleeding. This study aimed to discover the demography, characteristics, management, and complication of patients with intravesical blood clot retention in Dr. Soetomo General Acadenic Hospital, Surabaya from January 2017 until April 2020. This is an observational study, a retrospective-descriptive design. We conducted a review on the medical records of 97 patients, 76 males and 21 females with an average age of 54.9 years old. Of all patients initially treated conservatively using normal saline irrigation with a large three-way catheter (22-24 fr), four were successfully treated without surgery, and 89 patients underwent cystoscopy and definitive surgery. The mean operation time was 69,6 minutes, with an average blood clot volume of 167,7 ml (25-600 ml). Sources of bleeding were mostly originated from malignancy (58%), Benign Prostatic Hyperplasia (BPH) (10%), and hemorrhagic cystitis (7%). The most common comorbidity found was hypertension (13) and chronic kidney disease (10). Based on our experience, managing intravesical blood clot retention with cystoscopy continued with definitive surgery in a one-step procedure is a good approach. Urological malignancy is the most frequent abnormality that causes intravesical blood clot retention.

Transurethral Resection of Prostate (TURP): Surgery without Using a 3-Way Catheter

Transurethral resection of the prostate (TURP) continues to be an effective intervention for certain indications; and this procedure is still one of the most commonly performed in urology. The use of a 3-way catheter with continuous bladder irrigation (CBI) post-TURP is widely practiced in a bid to prevent clot retention. We report our unique experience with the use of 2-way urethral catheters post-TURP surgery. Methodology Data was prospectively collected for 143 consecutive patients who underwent a bipolar TURP between July 2015 and October 2017. The following outcomes where measured and compared against the literature: resection time, resected weight, haemoglobin level, hospital stay, catheterization days, transfusion rate and complications. Results Two-way 18-French catheters were used in 132/143 (91.7%) patients. The remaining 11/143 (8.3%) patients had a 3-way 22-French catheter and CBI immediately post-TURP. There were no incidences of clot retention requiring a return to theatre. There were 2/132 (1.5%) patients requiring transfusion who received 2-way catheterization. The average resection time was 44.8 (10-100) minutes, with a mean resected weight of 22.8 (2.0-70.0) grams. Post-operatively, we found minimal drop in haemoglobin levels, with a fall of 0.7 g/dL on average, with a range of 0.1-3.4 g/dL. Mean length of stay following TURP was 1.45 days (1-18), and 101/132 (76.5%) of patients had a successful trial without catheter on the first post-operative day. Conclusion Our outcomes compare favorably with the published data. This study suggests it may be possible to reduce the cost and resources associated with the use of 3-way catheters and CBI post-TURP surgery by using a 2-way catheter instead. Despite this, appropriate patient selection for this novel technique needs to be adopted. Our results would suggest that patients with smaller prostates or limited resections might be suitable for a 2-way urethral catheter post-TURP.

The Surface Anodization of Titanium Dental Implants Improves Blood Clot Formation Followed by Osseointegration

The anodization of titanium dental implant influences the biologic processes of osseointegration. 34 grit-blasted and acid-etched titanium specimens were used to evaluate micro- and nano-roughness (Ra), contact angle (θ) and blood clot extension (bce). 17 samples were anodized (test) while the remaining were used as control. The bce, was measured using 10 µL of human blood left in contact with titanium for 5 min at room temperature. The micro- and nano-scale Ra were measured under CLSM and AFM, respectively, while the θ was analyzed using the sessile drop technique. The bone-implant contact (BIC) rate was measured on two narrow implants retrieved for fracture. bce was 42.5 (±22) for test and 26.6% (±13)% for control group (p = 0.049). The micro-Ra was 6.0 (±1.5) for the test and 5.8 (±1.8) µm for control group (p > 0.05). The θ was 98.5° (±18.7°) for test and 103° (±15.2°) for control group (p > 0.05). The nano-Ra was 286 (±40) for the test and 226 (±40) nm for control group (p < 0.05). The BIC rate was 52.5 (±2.1) for test and 34.5% (±2.1%) for control implant (p = 0.014). (Conclusions) The titanium anodized surface significantly increases blood clot retention, significantly increases nano-roughness, and favors osseointegration. When placing dental implants in poor bone quality sites or with immediate loading protocol anodized Ti6Al4V dental implants should be preferred.

Surgical Management and Post-Operative Outcomes of Urinary Outflow Obstruction: Experience of 50 Cases in Bangladesh

Background: Management of urinary outflow obstruction is very crucial.Objective: The purpose of the present study was to see the different management of urinary outflow obstruction with their post-operative outcomes.Methodology: This non-randomized clinical trial was conducted in the Department of Surgery at Rajshahi Medical College, Rajshahi, Bangladesh from September 1994 to December 1995 for a period of one year and three months. All the patients who were presented with bladder outflow obstruction and were admitted in the general surgical unit of the hospital were taken as study population. These patients were surgically managed in different procedures. The follow up was done to record the post-operative surgical outcomes.Result: A total number of 50 patients were recruited for this study. Benign enlargement of prostate was found in 13 cases of which 11(22.0%) cases were managed by suprapubic transvesical prostatectomy. Impacted urethral stone was found in 13 cases of which 4(8.0%) cases were managed by urethro-lithotomy followed by repair of urethra and indwelling catheter. Stricture urethra was found in 11 cases and all cases (100.0%) cases were managed by intermittent dilatation under general anesthesia. In 7 cases of rupture urethra, initially all patients were managed by suprabpublic cystostomy which was 7(14.0%) cases in number. All the 3 cases of carcinoma prostate were managed by prostatectomy and radiotherapy plus hormone therapy. A total number of 16 patients were managed by prostatectomy of which 1(2.0%) case was developed immediate postoperative hemorrhage which was managed by blood transfusion and continuous irrigation with normal saline. One patient developed postoperative clot retention due to blockage of Foley’s catheter, two patients developed postoperative incontinence, immediately after removal of the catheter. Out of 11 patients of impacted urethral stone, one developed urethral fistula and one developed UTI. Recurrent stricture urethra occurred in 3 patients. Seven patients with rupture urethra, 3 developed stricture urethra and 3 developed stricture urethra.Conclusion: In conclusion different surgical procedure are employed during the management of urinary outflow obstruction and immediate postoperative hemorrhage, postoperative clot retention, postoperative incontinence, urethral fistula, UTI and recurrent stricture urethra are the most common complication after surgical management of urinary outflow obstruction patients.Journal of National Institute of Neurosciences Bangladesh, 2017;3(2): 84-88