Hostname: page-component-848d4c4894-pftt2 Total loading time: 0 Render date: 2024-06-08T07:20:50.923Z Has data issue: false hasContentIssue false
  • English
  • Français

Fibrinolysis or hypercoagulation during radical prostatectomy? An evaluation of thrombelastographic parameters and standard laboratory tests

Published online by Cambridge University Press:  01 July 2008

S. Ziegler ,
A. Ortu ,
C. Reale ,
R. Proietti ,
E. Mondello ,
R. Tufano ,
P. di Benedetto  and
G. Fanelli
S. Ziegler*
Affiliation:
Università degli Studi di Parma, Azienda Ospedaliera di Parma, Department of Anesthesiology and Critical Care, Parma, Italy
A. Ortu
Affiliation:
Università degli Studi di Parma, Azienda Ospedaliera di Parma, Department of Anesthesiology and Critical Care, Parma, Italy
C. Reale
Affiliation:
Università degli Studi di Roma, Policlinico Universitario Umberto I, Department of Anesthesiology, Rome, Italy
R. Proietti
Affiliation:
Università Cattolica di Roma, Policlinico Gemelli, Department of Anesthesiology, Rome, Italy
E. Mondello
Affiliation:
Università di Messina, Policlinico G. Martino, Department of Anesthesiology, Messina, Italy
R. Tufano
Affiliation:
Policlinico Universitario Federico II di Napoli, Department of Anesthesiology and Critical Care, Naples, Italy
P. di Benedetto
Affiliation:
Azienda Ospedaliera Sant’Andrea, Department of Anesthesiology, Rome, Italy
G. Fanelli
Affiliation:
Università degli Studi di Parma, Azienda Ospedaliera di Parma, Department of Anesthesiology and Critical Care, Parma, Italy
*
Department of Anesthesiology and Critical Care, Azienda Ospedaliera di Parma, Università degli Studi di Parma, Parma, Italy. E-mail: zieglerstefanie@gmail.com; Tel: +39 0521 703567; Fax: +39 0521 984735
Get access

Summary

Background and objectives

Radical prostatectomy is at high risk for intraoperative and postoperative bleeding due to surgical trauma, release of urokinase and tissue type plasminogen activator. We conducted this prospective, observational multi-centre study to assess the degree of systemic fibrinolysis or hypercoagulation in the perioperative period. We studied serial changes in standard laboratory values and in thrombelastographic (TEG®; Haemoscope Corporation, Skokie, IL, USA) parameters including lysis at 30 and 60 min (LY-30, LY-60), alpha-angle (α) and maximum amplitude.

Methods

In all, 49 patients undergoing radical retropubic prostatectomy in five Italian University Hospitals were included. Blood samples were taken before surgery (T1), at the removal of the prostate (T2), 4 h after surgery (T3) and then 1 day after surgery (T4). Native blood samples were analysed using a thrombelastograph Haemoscope 5000 (Haemoscope Corporation).

Results

We did not see any relevant activation of fibrinolysis during any stage. Intraoperatively, we showed even more activated blood coagulation with consumption of fibrinogen and a reduced TEG® percentage clot lysis. Only at the first postoperative sample point we saw a trend towards a more fibrinolytic state indicated by increasing partial thromboplastin time, LY-30 and LY-60 values, and a peak of the fibrin degradation product D-dimers. This is consistent with a normal reaction to the hypercoagulable state before and is unlikely to be due to an intraoperative tissue type plasminogen activator release. We found no evidence of an uncontrolled activation of fibrinolysis on the day after surgery. On the contrary, α-values which indicate the rate of clot formation and which increase during hypercoagulation showed the tendency to rise slightly compared with the preoperative value.

Conclusion

Neither standard coagulation parameters nor TEG® values showed any significant activation of fibrinolysis or of hypercoagulation in the preoperative period. Nevertheless, hypercoagulation seems to have a substantial clinical impact as it has been shown that cardiovascular complications and pulmonary embolism were the most common causes of death after retropubic prostatectomy.

Keywords

PROSTATECTOMY, retropubicCOAGULATIONTHROMBOELASTOGRAPHY
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 25 , Issue 7 , July 2008 , pp. 538 - 543
Copyright
Copyright © European Society of Anaesthesiology 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Alibhai, SM, Klotz, LH. A systemic review of randomized trials in localized prostate cancer. Can J Urol 2004; 11: 2110–2117.Google Scholar
2.Schraudenbach, P, Bermejo, CE. Management of the complications of radical prostatectomy. Curr Urol Rep 2007; 8: 197–202.CrossRefGoogle ScholarPubMed
3.Gratzke, C, Schlenker, B, Seitz, M et al. Complications and early postoperative outcome after open prostatectomy in patients with benign prostatic enlargement: results of a prospective multicenter study. J Urol 2007; 177: 1419–1422.CrossRefGoogle ScholarPubMed
4.Nielsen, JD, Gram, J, Holm-Nielsen, A, Fabrin, K, Jespersen, J. Post-operative blood loss after transurethral prostatectomy is dependent on in situ fibrinolysis. Br J Urol 1997; 80: 889–893.CrossRefGoogle ScholarPubMed
5.Mannucci, PM. Hemostatic drugs. N Engl J Med 1998; 339: 245–253.CrossRefGoogle ScholarPubMed
6.Miller, RA, May, MW, Hendry, WF, Whitfield, HN, Wickham, JE. The prevention of secondary haemorrhage after prostatectomy: the value of antifibrinolytic therapy. Br J Urol 1989; 52: 26–28.CrossRefGoogle Scholar
7.Ward, MG, Richards, B. Complications of antifibrinolysis therapy after prostatectomy. Br J Urol 1979; 51: 211–212.CrossRefGoogle ScholarPubMed
8.Andersson, L. Antifibrinolytic therapy in genitourinary tract surgery. J Clin Pathol Suppl (R Coll Pathol) 1980; 14: 60–62.CrossRefGoogle ScholarPubMed
9.Mangano, DT, Tudor, JC, Dietzel, C. The risk associated with aprotinin in cardiac surgery. N Engl J Med 2006; 354: 353–365.CrossRefGoogle ScholarPubMed
10.American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology 2006; 105: 198–208.CrossRefGoogle Scholar
11.Fennerty, A. Venous thromboembolic disease and cancer. Postgrad Med J 2006; 82: 642–648.CrossRefGoogle ScholarPubMed
12.Bell, CRW, Cox, DJA, Murdock, PJ et al. Thrombelastographic evaluation of coagulation in transurethral prostatectomy. Br J Urol 1996; 78: 737–741.CrossRefGoogle ScholarPubMed
13.Bell, CRW, Murdock, PJ, Pasi, KJ, Morgan, RJ. Thrombotic risk factors associated with transurethral prostatectomy. BJU Int 1999; 83: 984–989.CrossRefGoogle ScholarPubMed
14.American College of Chest Physicians. Proceedings of the seventh ACCP Conference on antithrombotic and thrombolytic therapy: evidence-based guidelines. Chest 2004; 126: 172S–696S.CrossRefGoogle Scholar
15.Koya, MP, Manoharan, M, Kim, S, Soloway, MS. Venous thromboembolism in radical prostatectomy: is heparinoid prophylaxis warranted? BJU Int 2005; 96: 1019–1021.CrossRefGoogle ScholarPubMed
16.Zhu, JP, Davidsen, MB, Meyhoff, HH. Aspirin, a silent risk factor in urology. Scand J Urol Nephrol 1995; 29: 369–374.CrossRefGoogle Scholar
17.Zuckerman, L, Cohen, E, Vagher, JP, Woodward, E, Caprini, JA. Comparison of thromboelastography with common coagulation tests. Thromb Haemost 1981; 46: 752–756.Google ScholarPubMed
18.Kang, YG, Martin, DJ, Marquez, J et al. Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation. Anesth Analg 1985; 64: 888–896.CrossRefGoogle ScholarPubMed
19.Spiess, BD, Gillies, BS, Chandler, W, Verrier, E. Changes in transfusion therapy and reexploration rate after institution of a blood management program in cardiac surgical patients. J Cardiothorac Vasc Anesth 1995; 9: 168–173.CrossRefGoogle ScholarPubMed
20.Shore-Lesserson, L, Manspeizer, HE, DePerio, M, Francis, S, Vela-Cantos, F, Ergin, MA. Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg 1999; 88: 312–319.CrossRefGoogle ScholarPubMed
21.Samama, CM, Ozier, Y. Near-patient testing of haemostasis in the operating theatre: an approach to appropriate use of blood in surgery. Vox Sang 2003; 84: 251–255.CrossRefGoogle ScholarPubMed
22.Leonard, SA, Walsh, M, Lydon, A, O’Hare, B, Shorten, GD. Evaluation of the effects of levobupivacaine on clotting and fibrinolysis using thromboelastography. Eur J Anaesthesiol 2000; 17: 373–378.CrossRefGoogle ScholarPubMed
23.Ruttmann, TG, James, MF, Viljoen, JF. Haemodilution induces a hypercoagulable state. Br J Anaesth 1996; 76: 412–414.CrossRefGoogle ScholarPubMed
24.Ruttmann, TG, Lemmens, HJM, Malott, KA, Brock-Utne, JG. The haemodilution enhanced onset of coagulation as measured by the thrombelastogram is transient. Eur J Anaesthesiol 2006; 23: 574–579.CrossRefGoogle ScholarPubMed
25.Davydov, L, Cheng, JW. Tenecteplase: a review. Clin Ther 2001; 23: 982–997.CrossRefGoogle ScholarPubMed
26.von Hundelshausen, B, Stemberger, A, Jelen-Esselborn, S et al. Blood coagulation and fibrinolysis in prostate surgery. Fortschr Med 1992; 110: 126–130.Google ScholarPubMed
27.Alibhai, SMH, Leach, M, Tomlinson, G. Examining the location and cause of death within 30 days of radical prostatectomy. BJU Int 2005; 95: 541–544.CrossRefGoogle ScholarPubMed
28.Lepor, H, Nieder, AM, Ferrandino, MN. Intraoperative and postoperative complications of radical retro pubic prostatectomy in a consecutive series of 1000 cases. J Urol 2001; 166: 1729–1733.CrossRefGoogle Scholar
29.Leandri, P, Rossignol, G, Gautier, JR, Ramon, J. Radical retropubic prostatectomy: morbidity and quality of life. Experience with 620 consecutive cases. J Urol 1992; 147: 883–887.CrossRefGoogle ScholarPubMed
30.Cisek, LJ, Walsh, PC. Thromboembolic complications following radical retropubic prostatectomy: influence of external sequential pneumatic compression devices. Urology 1993; 42: 406–408.CrossRefGoogle ScholarPubMed
31.Klein, S, Slaughter, T, Vail, P et al. Thromboelastography as a perioperative measure of anticoagulation resulting from low molecular weight heparin: a comparison with anti-Xa concentrations. Anesth Analg 2000; 91: 1091–1095.CrossRefGoogle ScholarPubMed
32.Orlikowski, CEP, Payne, AJ, Moodley, J, Rocke, DA. Thrombelastography after aspirin ingestion in pregnant and non-pregnant subjects. Br J Anaesth 1992; 69: 159–161.CrossRefGoogle ScholarPubMed