Contemporary Management of Hemorrhage After Minimally Invasive Radical Prostatectomy

Prostatic Fossa Pseudoaneurysm After Robot-Assisted Radical Prostatectomy (RARP): A Case Report

BACKGROUND RARP is an established procedure in treatment of localized prostate cancer. Hemorrhagic complications in the postoperative period are rare, but sometimes life-threatening. Adequate monitoring and prompt intervention in these unusual scenarios rely on clinical judgement and blood and imaging studies. Prostatic fossa pseudoaneurysm formation after RARP is very rare and its etiology is not well known; it may be related to small vessel trauma. It becomes apparent with the development of hematuria 1-6 weeks after surgery. CASE REPORT A 58-year-old man underwent RARP with extended lymph node dissection for intermediate-risk prostate cancer, with bilateral preservation of neurovascular bundles and puboprostatic ligaments. He was discharged on day 2 without complications. In the following 4 weeks he came to the Emergency Department 3 times with hematuria and acute urinary retention. Four weeks after surgery, a pelvic CT angiogram showed a 20-mm pseudoaneurysm in the prostatic fossa, which was embolized by percutaneous angiography, with resolution of symptoms. He was discharged soon thereafter. CONCLUSIONS This case study describes a patient with prostatic fossa pseudoaneurysm after RARP. It was diagnosed 1 month after surgery and effectively managed by percutaneous embolization. Despite being a very rare condition, it must be kept in mind, especially when postoperative hematuria develops 1-6 weeks after surgery. Use of a management algorithm including serial blood tests, CT angiogram, and percutaneous angiography can lead to early detection and avoid life-threatening hemorrhage and overall postoperative morbidity.

Cost-effectiveness of routine type and screens in select urological surgeries

PURPOSE

To evaluate the cost-effectiveness of obtaining a preoperative type and screen (T/S) for common urologic procedures.

METHODS

A decision tree model was constructed to track surgical patients undergoing two preoperative blood ordering strategies as follows: obtaining a preoperative T/S versus not doing so. The model was applied to the National (Nationwide) Inpatient Sample (NIS) data, from January 1, 2006 to September 30, 2015. Cost estimates for the model were created from combined patient-level data with published costs of a T/S, type and crossmatch (T/C), a unit of pRBC, and one unit of emergency-release transfusion (ERT). The primary outcome was the incremental cost per ERT prevented, expressed as an incremental cost-effectiveness ratio (ICER) between the two preoperative blood ordering strategies. A cost-effectiveness analysis determined the ICER of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500.00.

RESULTS

A total of 4,113,144 surgical admissions from 2006 to 2015 were reviewed. The overall transfusion rate was 10.54% (95% CI, 10.17-10.91) for all procedures. The ICER of preoperative T/S was $1500.00 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S.

CONCLUSION

Routine preoperative T/S for radical prostatectomy (rate = 3.88%) and penile implants (rate = .91%) does not represent a cost-effective practice for these surgeries. It is important for urologists to review their institution T/S policy to reduce inefficiencies within the preoperative setting.

Population based study of morbidity and mortality rates associated to radical prostatectomy cases in Spain

INTRODUCTION

There is no population-based study that accounts for the number of radical prostatectomies (RP) carried out in Spain, nor regarding the morbidity and mortality of this intervention. Our objective is to study the morbidity and mortality of RP in Spain from 2011 to 2015 and to evaluate the geographic variation.

MATERIAL AND METHODS

We designed a retrospective observational study of all patients submitted to RP in Spain during five consecutive years (2011-2015). The data was extracted from the «Conjunto Mínimo Básico de Datos» (CMBD). We have evaluated geographic variations in terms of morbidity and hospital stay, and the impact of the mean annual surgical volume for each center on these variables.

RESULTS

Between 2011-2015, a total of 37,725 RPs were performed in 221 Spanish public hospitals. The mean age of the series was 63.9±3.23 years. Of all RPs, 50% were performed through an open approach, and 43.4% have been operated on in hospitals with <500 beds. We observed an important variability in the distribution of the cases operated on in the different regions. The regions that perform more RPs are Andalusia, Catalonia, Galicia, and Madrid. Our study shows a complication rate of 8.6%, with hemorrhage and the need for transfusion being the most frequent (5.3 and 4%, respectively). There are significant differences in bleeding rates and hospital stay among regions, which are maintained after adjusting for patient characteristics and type of hospital. When studying the annual surgical volume of each hospital, we find that the impact on the rate of hemorrhage or transfusion is linear; however, hospital stay remains stable at around 5 days from 60 RPs/year.

CONCLUSIONS

In national terms, morbidity and mortality rates after RP are comparable to those described in the literature. This study reveals a clear dispersion in the hospitals that carry out this intervention, showing clear differences in terms of morbidity and hospital stay between the different regions.

Pseudoaneurysm after Radical Prostatectomy: A Case Report and Narrative Literature Review

(1) Background: We report a very unusual presentation of pseudoaneurysm developed following a robot-assisted radical prostatectomy (RARP) with bilateral pelvic lymph node dissection. The patient was a 66-year-old male, admitted at the Emergency Department 20 days after discharge from RARP due to chest pain, lipothymia and occult bleeding, necessitating a blood transfusion and a moderate increase of serum troponin. Angiography showed a pseudo-aneurysm involving the inferior-epigastric artery pubic branch. The patient underwent percutaneous embolization with complete resolution. The aim of this study is to offer an overview on pseudoaneurysms developed as radical prostatectomy complications; (2) Methods: A literature search was conducted on Scopus and PubMed for pseudoaneurysms after RARP to analyze all the previously published cases. The search terms used were “pseudoaneurysm” and “prostatectomy” using the Boolean Operator “AND”. We used the default search strategy “all fields”; (3) Results: Herein, a narrative review is proposed to facilitate the approach to this emerging clinical challenge, due to both an implementing in diagnosis imaging techniques and a spread of robotic surgery in prostate cancer; (4) Conclusions: The management of radical prostatectomy complications still remains barely uniformed and needs to be precisely calibrated as the initial cure approach itself.

Can the prophylactic administration of tranexamic acid reduce the blood loss after robotic-assisted radical prostatectomy? Robotic Assisted Radical Prostatectomy with tranEXamic acid (RARPEX): study protocol for a randomized controlled trial

Background

The prophylactic administration of tranexamic acid reduces blood loss during procedures at high risk of perioperative bleeding. Several studies in cardiac surgery and orthopedics confirmed this finding. The aim of this prospective, double-blind, randomized study is to evaluate the effect of tranexamic acid on peri-and postoperative blood loss and on the incidence and severity of complications.

Methods/design

Based on the results of our pilot study, we decided to conduct this prospective, double-blind, randomized trial to confirm the preliminary data. The primary endpoint is to analyze the effect of tranexamic acid on perioperative and postoperative blood loss (decrease in hemoglobin levels) in robotic-assisted radical prostatectomy. The additional endpoint is to analyze the effect of tranexamic acid on postoperative complications and confirm the safety of tranexamic acid in robotic-assisted radical prostatectomy.

Discussion

No study to date has tested the prophylactic administration of tranexamic acid at the beginning of robotic-assisted radical prostatectomy. This study is designed to answer the question of whether the administration of tranexamic acid might lower the blood loss after the procedure or increase the rate and severity of complications.

Trial registration

ClinicalTrials.gov NCT04319614. Registered on 25 March 2020

Delayed spontaneous haematoma after minimally invasive prostatectomy

Minimally invasive radical prostatectomy has become the standard surgical approach in the United Kingdom. Haematoma formation is a recognised post-operative complication, but this tends to be regarded as an early complication and there is a paucity of clinical information on the challenges of delayed haematoma formation. We present an unusual case of a man presenting with a late post-operative bleed that occurred spontaneously 5 weeks after surgery. A haematoma developed and was associated with complete disruption of the vesico-urethral anastomosis, that imaging had shown to be intact 11 days post-operatively.

Level of evidence: 4

Postoperative Hemorrhagic Shock 7 Days After Robot-Assisted Radical Prostatectomy

Background: Delayed postoperative bleeding after robot-assisted radical prostatectomy (RARP) is a rare life-threatening condition. We present such a case wherein a patient developed hemorrhagic shock from a ruptured pseudoaneurysm arising from the epigastric artery and discuss its management. Case Presentation: A 71-year-old man with prostate cancer underwent RARP. The urethral catheter was removed on postoperative day 7; 80 minutes later, the patient suddenly lost consciousness and went into shock. Enhanced CT revealed intra-abdominal bleeding; however, the cause was unknown. Intraoperatively, bleeding was observed from the anterior abdominal wall, which likely corresponded to the epigastric artery. However, this was controlled with monopolar electrocautery. Because of unstable hemodynamics, hemostasis was immediately performed by laparotomy, and bleeding was noted from the previously coagulated right inferior epigastric artery. Therefore, the cause was considered to be the rupture of a pseudoaneurysm. Conclusion : Our experience suggests that monopolar electrocautery may be inadequate for controlling bleeding that may be encountered during RARP, possibly leading to pseudoaneurysm formation, which may cause a delayed life-threatening hemorrhage. Meticulous and precise hemostasis is key to avoiding this complication.

Routine Postoperative Hemoglobin Assessment Poorly PredictsTransfusion Requirement among Patients Undergoing Minimally Invasive Radical Prostatectomy

Introduction

An advantage of minimally invasive radical prostatectomy over open surgery is decreased blood loss. At our institution hemoglobin is routinely checked 4 and 14 hours postoperatively. We assessed the relevance of this practice in a contemporary cohort undergoing minimally invasive radical prostatectomy.

Methods

We retrospectively reviewed data from patients undergoing laparoscopic or robotic radical prostatectomy at our institution between January 2010 and September 2018. We identified 3,631 patients with preoperative and postoperative hemoglobin values, and assessed the role of routine hemoglobin assessment in determining need for transfusion within 30 days. Medicare reimbursement rates for 2019 were used for cost analysis.

Results

Of 3,631 patients in our cohort 44 (1.2%) required transfusion. At 4 hours following surgery the median hemoglobin decrease was 8.0% (IQR 4.8 to 11.4) for patients who did not receive transfusion and 12.5% (9.5 to 19.2) for those who received transfusion. At 14 hours the median decrease was 14.2% (IQR 10.0 to 18.4) vs 33.1% (22.6 to 38.6). Routine hemoglobin assessment had no role in the decision to transfuse in 18 patients (41%). No patient was transfused based on 4-hour values alone. Omitting 1 hemoglobin assessment could have resulted in institutional savings of $37,000 during this period.

Conclusions

As transfusion following minimally invasive radical prostatectomy is rare, scheduled postoperative hemoglobin assessments in the absence of symptoms are unnecessary to recognize bleeding events. The largest hemoglobin difference between men who did vs did not receive transfusion was seen at 14 hours postoperatively. Thus, this single hemoglobin evaluation is sufficient.