A prospective study of calorimetric estimation of blood loss in TURP cases

Introduction: BEP is hyperplasia of prostatic stromal epithelial cells to form discreate nodules in transitional zone of prostate. It leads to constriction of urethral opening which gives rise to associated lower urinary tract symptoms such as frequency, urgency, nocturia. Initially disease can be managed by drug treatment but eventually most of the patients require surgical management. TURP remains gold standard treatment. Blood loss during and after procedure is major problem. This study was planned to evaluate the approximate blood loss with the help of simple technique of colorimatry. Method: This study is carried out on 50 patients with BEP who underwent TURP in our institute from October 2014 and June 2015. Irrigation fluid collected during TURP, post operative day 1 & 2 subjected to calorimetric estimation of blood loss using Drabkin’s reagent. Results: The results were suggestive of approximate average blood loss during TURP procedure as 267 ml, post operative day 1 blood loss 98.9ml and post operative day 2 loss was 58.1ml. However the average blood loss changes according to the size of prostate and duration of the procedure. Conclusion: calorimetric estimation of blood loss during and post operative period is an easy, economically feasible, quick method to guide the management of blood requirement for the patient. This can be useful in patients with BEP and bleeding diathesis.


Introduction
Benign prostatic hyperplasia (BPH) is characterized by the hyperplasia of prostatic stromal epithelial cells to form discrete nodule in transition zone of prostate. It ultimately constricts the urethral opening and gives rise to associated lower urinary tract symptoms (LUTS) such as urgency, frequency, nocturia, incomplete bladder emptying, and weak urine stream. However; this surgical technique is not without problems. As the surgical target area is highly vascular, TURP leads to heavy bleeding. This study was planned to evaluate the approximate blood loss that occurs as a result of bipolar TURP procedure. The overarching goal was to evaluate the blood loss that occurs with the help of simple technique of colorimetric.
It was also planned to find out the incidence of complications associated with bipolar TURP.

Aim
To study the average blood loss and complications which occur during TURP.

Objectives
A. To estimate the average blood loss that occurs after TURP by colorimetric method.
B. To evaluate the complications of TURP.

Materials and Methods
The study was conducted in a tertiary care teaching hospital .Institutional Ethical Committee permission was obtained prior to commencement of the study. We conducted this study on 50 patients of benign prostatic hypertrophy who undergone TURP surgery in our hospital between October 2014 and June 2015.
Type of Study: Descriptive, single centre study.

1) A patient having benign prostatic hypertrophy
2) Age more than 40 years 3) Prostatic symptoms not relieved by medical management 4) Prostate size up-to 100 cc Exclusion Criteria 1) Patient having bleeding disorder.

Procedure
 Colorimeter was set at green filter, i.e. 540 nm filter  Blanking with distilled water was done to adjust the optical density (OD) at zero.
 Then OD of Drabkin's reagent was measured.
 .This value was deducted from the OD reading of sample to nullify the effect of reagent's colour. (i.e.

Reagent Blanking was done)
 In a routine method of Hb estimation in whole blood, 20 microL. i.e. 0.02ml blood sample is added to 5ml of Drabkin's reagent and after 5 minutes of incubation, OD is measured at 540nm in colorimeter.
 In case of irrigation fluid, the concentration of Hb in fluid is very much diluted in comparison to whole blood.
 Due to this, the proportion of sample and reagent is taken differently while estimating Hb in fluid.

Mean ± SD Minimum Maximum
Age of patients (years) 66.67 ± 5.6 57 80 The mean age of patients enrolled in study was 66.7 ± 5.6. The youngest patient was 57 years old, while the oldest was 80 years old. The prostate size of patients was averagely 62.72 ± 6.77 cc. The minimum size reported was 54 cc, whereas the maximum reported size was 90 cc.

International Journal of Surgery & Orthopedics
Available online at: www.surgicalreview.in 45 | P a g e At the end of 1 st post-operative day, mean volume of fluid collected was 11.53 ± 1.37 litres. 7.9 litres was the minimum volume collected in a patient and 14.2 litres was the maximum volume of fluid collected in a patient.
The mean volume of irrigation fluid collected on 2 nd post-operative day was 5.75 ± 0.83 litres, minimum volume being 4.5 litres. The maximum volume of fluid collected was 9.0 litres in one of patients.  The average volume of total fluid collected after TURP surgery was 31.85 ± 3.27 litres, the minimum volume being 25.2 litres and the maximum volume being 38.9 litres.
The average estimated blood loss during TURP surgery was 266.9 ± 42.6 ml. The estimated minimum blood loss was 198.0 ml, while the maximum estimated blood loss was 374.2 ml.
On the 1 st post-operative day, averagely 98.8 ± 14.8 ml blood loss was estimated. 73.0 ml was the minimum detected blood loss, while 131.9 ml was the maximum blood loss detected in a patient.
The average blood loss detected on 2 nd post-operative day was 58.0 ± 16.23 ml. The minimum blood loss estimated was 29.6 ml, while the maximum blood loss estimated was 90.9 ml.

International Journal of Surgery & Orthopedics
Available online at: www.surgicalreview.in 46 | P a g e The average estimated total blood loss, resulting from TURP surgery was 423.9 ± 68.0 ml, maximum being 565.9 ml and minimum being 317.0 ml

Discussion
The prostate gland (normal weight: 20 g) encircles the urethra as it emerges from the base of the bladder. It comprises glandular (secretory acini) and non-glandular (smooth muscle and fibrous tissue) components enclosed by a fibrous capsule. It has a rich blood supply and venous drainage is via the large, thin-walled sinuses adjacent to the capsule.
It is described as having four histological zones (McNeal zones): the central, peripheral, anterior (fibromuscular), and transitional (periurethral) zones. The transitional zone surrounds the proximal urethra in two pear-shaped lobes.
It comprises 5% of normal prostatic volume and is the site of BPH and also ∼10% of prostatic carcinomata. Twenty per cent of men aged 40 yr have hyperplasia of the transition zone, increasing to 50% at 50 yr and 70% at 60 yr. The hyperplastic tissue eventually encroaches on the proximal urethra, causing obstruction. The normal prostatic tissue becomes compressed against the capsule, and is often referred to as the 'surgical capsule'.
In theory blood loss during TURP can be estimated by assessing the haemoglobin concentration of discarded irrigation fluid; by measuring the electrical conductivity of discarded irrigation fluid; or in laboratory by radioactive albumin or red cell labelling techniques.
Urine-strip method can be used to estimate total blood loss in irrigating fluid in patients with TUR-P operation.
This is practical and useful in immediate post-operative evaluation of blood loss to consider the need of blood transfusion 5.  The novel 51Cr RBCs labelling method allowed evaluating blood loss not only during the surgical procedure but also during the postoperative period, on average, blood loss from the procedure until postoperative day 3 was more than 500 mL, which is larger than previously reported amounts as measured by other methods.
Because significant blood loss might occur during the postoperative period, the 51Cr method should be used to measure blood loss when evaluating new emerging techniques to manage BPH 11.
The extend of blood loss associated with TURP is multifactorial and it is impossible to measure the effect of single factor while controlling other factors some of the factors such as local vascularity are impossible to measure.
Of the measured factors weight of the resected prostate tissue is clearly the most important and its assessment should help in anticipating blood loss rationalizing the cross matching 12.

Colorimetric method of blood loss estimation during
TURP is an cost effective easy and quick method to guide the requirement blood transfusion during intra operative and post operative period.
2. Estimation of average blood loss for given set of patient at TURP helps in formulation of hospital policy for pre operative optimisation of the patient. 3. High risk cases such as patients with deranged coagulation profile and bleeding diathesis such as thalesemia, sickle cell anaemia, haemophilia etc who are at high risk of bleeding during TURP; Colorimetric method of blood loss estimation would be an vital tool to guide the transfusion. 4. In developing countries such as India this cost effective & easy method can be a routine guide for management of blood loss.