Monday, August 5, 2013

Our experience with Thulium LASER in patients on antiplatelet agents and anticoagulants

We operated 217 patients who were either on antiplatelet agents or anticoagulants. We did not hold on antiplatelet agents and those who were on anticoagulants were converted on heparin.

It has been noted that the most common complications in prostate surgery in more than 75 years of the age is cardiac causes. Fluid overload, pulmonary oedema, DVT, myocardial infarction etc. were the most common reasons for mortality.

As it has been seen that 30% of the patients with BPH have cardiac comorbidties. Most of the patients with cardiac ailments are now administered anti platelet agents either aspirin ( 81 mg/75 mg) or clopidogrel or combination of both. In view of elderly age , cardiac comorbidities, lithotomy position , immobilization during and after the surgery and the fluid overload because of the use of irrigation during the endoscopic prostatectomy withholding of antiplatelet agents or anticoagulants can be counterproductive.

TURP the present Gold standard is fraught with the risk of bleeding( some series have shown the bleeding after TURP is as high as 30%).Also TURP needs Glycine as the irrigant so resultant overload and TURP syndrome can decompensate already fragile cardiac system in elderly people.

The Thulium LASER is a continuous wave LASER ( 2 MICRON ).Its superior to electro cautery(TURP) both in terms of bleeding and resection. The continuous wave LASER is superior to Holmium LASER( the other LASER used commonly for prostatectomy) in terms of its ability to vaporize the prostate (in people who are more prone for bleeding and also finding suitable plane in large glands.

The patients were between the age group of 44-87 years. The data was collected from 2009 to the present.

We generally used spinal anaesthesia for most patients but 3 patients had to be given either general anesthesia (2 ) or local pudental block(1).

We used 24 Fr continuous flow resectoscope and 550 micron Fibre (Revolix 70 W thulium LASER).We preferred either vaporization or vaporesection methodology while tackling the prostate for the fear of bleeding . 

Out of 217 patients 112 were on aspirin,96 were on clopidogrel and 4 were on anticoagulants. 

Patients profile- 83 were on stent ,21 were post CABG while 5 were patients with valve replacement history. 

The mean gland size of 28 gm to 140 gm .Only 7 patients had post operative or intraoperative bleeding(3.2%).0.9% patients needed blood transfusion. The mean percentage fall in hemoglobin was 0.7 gm/dl.The patients with bleeding needed cystoscopy and clot evacuation.2 patients had delayed bleeding( 7 days to 4 weeks).For them appropriate antibiotic therapy was instituted and cystoscopy was done.4 patients had Acute Coronary Syndrome for which heparinisation and treatment in cardiac ICU was needed but they eventually recovered without further cardiac intervention. There were no mortality.

This shows that Thulium LASER prostatectomy is safe even in patients on antiplatelet agents and on anticoagulants.They should be properly evaluated preoperatively in terms of cardiac risk .We prefer to use vaporization or vaporesection with LASER for safety and we have found the risk ( cardiac or bleeding) ti be very low.

1 comment:

  1. Thanks for sharing the report on antiplatelet agents and anticoagulants . Most of the people face the anti platelet problem .
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