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Sir,

We read with great interest the above article of Kordan et al. [1] dealing with transfusion requirements between open and robotic-assisted laparoscopic radical prostatectomy (RP). The article deals with an important issue, as bleeding makes RP one of the urological interventions at highest risk of necessitating transfusion because of possible intraoperative and/or postoperative blood loss.

In recent years, anaesthetists and surgeons, aware of these risks and their consequences, have been trying to determine and apply the most effective techniques for reducing bleeding. Transfusions increase the incidence of viral, prion and parasite infections, induce immunodepression and expose the recipients to the potential risk of human errors [2, 3]. Bleeding limits visibility in the operating field and makes some key steps, such as isolation of the prostatic apex and freeing the neurovascular bundles, less precise. Mechanical methods of haemostasis and electrocoagulation can damage the sphincter muscle and neurovascular structures, compromising their normal function. Last, but not least, intraoperative blood loss can increase the costs of the procedure because of the need for transfusions and/or closer monitoring of the patient. The role of blood loss in possible recurrence and metastatic dissemination is, on the other hand, debatable [4, 5]. It is clear from the above that blood loss causes a series of unfavorable conditions that can influence the patient’s outcome, the costs of the operation and sometimes a good surgical result.

CONTROLLED HYPOTENSION AND THE TRENDELENBURG POSITION TO REDUCE BLOOD LOSS DURING OPEN RP (PRESENTED AT: CONGRESSO DEL CENTENARIO NAZIONALE SOCIETÀ ITALIANA UROLOGIA ROME, 2008; 24TH ANNUAL MEETING OF THE EUROPEAN ASSOCIATION OF UROLOGY, STOCKHOLM, 2009 [6])

  1. Top of page
  2. CONTROLLED HYPOTENSION AND THE TRENDELENBURG POSITION TO REDUCE BLOOD LOSS DURING OPEN RP (PRESENTED AT: CONGRESSO DEL CENTENARIO NAZIONALE SOCIETÀ ITALIANA UROLOGIA ROME, 2008; 24TH ANNUAL MEETING OF THE EUROPEAN ASSOCIATION OF UROLOGY, STOCKHOLM, 2009 )
  3. REFERENCES

In recent years, we have evaluated and noted that the use of intraoperative controlled hypotension combined with adoption of the Trendelenburg position (30 °) during open RP can influence perioperative bleeding and transfusion requirements. Between September 2007 and September 2008, 51 patients with prostatic adenocarcinoma underwent RP together with staging pelvic lymphadenectomy, carried out by the same surgeon. In patients whose clinical stage permitted, a nerve-sparing technique was used. The blood loss was calculated by summing the weight of blood removed from the operating field to the difference in weight between the blood-soaked and dry gauzes. The preoperative haematocrit was measured in a blood sample taken from the fasting patient on the morning before admission; the postoperative haematocrit was evaluated the morning after the operation. The transfusion triggers adopted were those recommended by international [American Society of Anesthesiologists (ASA)] guidelines adapted to internal protocols: haematocrit <24% and haemoglobin <8 g/dL in haemodynamically stable patients; in the case of symptoms of compensation for presumed inadequate oxygen-carrying capacity, transfusion therapy could be started at higher values. Postoperative complications, including deep vein thrombosis, renal failure, myocardial infarction, pulmonary embolism, cerebrovascular accidents and local haematomas, were recorded.

The RP was conducted under mixed i.v./gaseous anaesthesia with remifentanil (0.1–0.3 µg/kg/min) and desflurane (minimum alveolar concentration [MAC] 0.5 = 3–4%) at a low flow rate (fresh gases O2/air 50% 1.5 L/min). The patient was placed in the Trendelenburg position after the abdominal incision and exposure of the viscera, and progressively reached the final inclination of 30 °. Hypotension was attained by exploiting the vasodilatation induced by desflurane and, in particular, its speed of effect caused by its fast onset and offset pharmacokinetic properties. The blood pressure was lowered to a mean value of between 55 and 70 mmHg. The controlled hypotension was interrupted after removal of the surgical specimen to allow the surgeon to control the operating field and ensure haemostasis. During the operation, fluid support was given to replace losses from exposure of the viscera and from diuresis.

The mean age of the patients who underwent RP was 64.2 years and the mean body mass index was 27.6 kg/m2. The ASA risk score ranged between 1 and 3 and the preoperative PSA level ranged between 1.4 and 63 ng/mL.

No patient developed electrocardiographic changes, alterations in the ST segment or other signs detectable by our haemodynamic monitoring and attributable to cardiac stress from reduced coronary artery perfusion. The mean operative duration was 139 min. The collected data show that sampled bleeding among our patients is skewed, having a sampled mean of 357.84 mL a median of 300.00 mL and a skewness of 1.41. Three patients (5.8%) required blood transfusion: each received 2 units of red cell concentrates for a total of 6 units. There were no postoperative complications. Intraoperative hypotension has been used in our centre for several years in various surgical specialties with good results. Using this strategy in urological patients, who share many characteristics with orthopaedic patients, we achieved smaller blood losses than those reported for open RP. One of the limitations of the present study is that it was not randomized but, having obtained such spectacular results compared with those of our historical series and a better view of the operating field, we considered that it was not ethical to return to the traditional technique and since 2008 we have continued to adopt this strategy in open RP to reduce blood loss and transfusion requirement.

We decided to act by new anaesthesiological techniques (maintain the surgical technique) and novel, more manageable, more rapidly eliminable drugs enable the safe use of anaesthesia in controlled hypotension to reduce blood loss. In our series of patients in which this method was used, intraoperative blood losses were below the mean for open RP and similar to those for laparoscopic and robotic RP.

REFERENCES

  1. Top of page
  2. CONTROLLED HYPOTENSION AND THE TRENDELENBURG POSITION TO REDUCE BLOOD LOSS DURING OPEN RP (PRESENTED AT: CONGRESSO DEL CENTENARIO NAZIONALE SOCIETÀ ITALIANA UROLOGIA ROME, 2008; 24TH ANNUAL MEETING OF THE EUROPEAN ASSOCIATION OF UROLOGY, STOCKHOLM, 2009 )
  3. REFERENCES