Bell, Richard C.W.; (2000) Alterations in coagulation during transurethral prostatectomy. Masters thesis (M.S), University of London, Royal Free Hospital School of Medicine.

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Abstract

Introduction Bleeding remains a significant cause of morbidity following transurethral prostatectomy (TURP). Fibrinolysis has been implicated. However good evidence for this is lacking, and surgery is associated with a hypercoagulable state. Objective To evaluate the coagulation status and the role of fibrinolysis in patients undergoing TURP. Method Systemic fibrinolysis and global coagulation status was assessed by thrombelastography in a prospective study of 40 patients undergoing TURP. Urinary fibrinolytic activity was measured using the fibrin plate technique. Thrombin-antithrombin III (TAT) and D-dimer levels were measured as markers of systemic activation of the coagulation cascade, and the role of postoperative fibrinolytic 'shutdown' established by monitoring tissue plasminogen activator (tPA) and inhibitor (PAI-1) levels. The role of Factor XIII levels on clot fragility, and the effects of endotoxin on the clotting cascade were studied. Results No evidence of systemic or local fibrinolysis was found in any patient over the perioperative period. Thrombelastographic evidence of a hypercoagulable state was observed perioperatively. Systemic activation of the coagulation cascade was evident from the significant rise in TAT complexes 6 hours postoperatively (ANOVA p = 0.01). The significant increase in mean D-dimer levels 24 hours postoperatively (ANOVA p= 0.015) in the absence of any significant increase in mean tPA levels (ANOVA p= 0.737) indicates a physiological fibrinolytic response to the procoagulant state. The absence of any significant increase in PAI-1 antigen perioperatively (ANOVA p= 0.348) suggests that the observed hypercoagulability is not due to fibrinolytic 'shutdown’ reported in other forms of surgery. Elevated mean thrombelastographic maximum amplitude values and normal Factor XIII levels postoperatively discount bleeding due to clot fragility. Endotoxin does not appear to be a trigger for the observed activation of the coagulation cascade. Conclusion TURP is associated with a hypercoagulable state comparable with other surgical procedures. Np evidence of pathological fibrinolysis was observed.

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