|Year : 2022 | Volume
| Issue : 1 | Page : 42-46
Is type and crossmatch really necessary for transurethral resection of prostate? A retrospective study from a tertiary care center in Northern India
Anubha Srivastava1, Bharat Singh1, Preeti Elhence1, Aneesh Srivastava2, Rajendra Chaudhary1
1 Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Division of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||08-Oct-2021|
|Date of Acceptance||07-Feb-2022|
|Date of Web Publication||29-Apr-2022|
Dr. Bharat Singh
Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background and Objectives: Rate of blood transfusion is considerably low in transurethral resection of the prostate (TURP). We follow type and crossmatch (TC) policy in TURP. The objective was to assess the suitability of TC policy along with the impact of preoperative (preop) prostate weight and hemoglobin (Hb) on the pattern of blood ordering (whether demand for TC was sent or not). Methods: Retrospective analysis of TURP patients was done from 2014 to 2017. Patients were divided into 2 groups on the basis of whether the demand for TC was sent or not. The age, preop prostate weight and preop Hb of patients where demand for TC sent was compared with patients where TC demand was not sent. Crossmatch to transfusion ratio (Crossmatch to transfusion ratio C/T ratio), Transfusion probability (%T) and Transfusion index (TI) were calculated. Results: Among the total 92 TURP patients, 42.4% (39/92) had TC samples sent preoperatively. Only three patients (3.2%, 3/92) required transfusion intraoperatively. CT ratio was 23.6, %T was 7.6% and TI was 0.07. Preop prostate weight and Hb were significantly higher and lower, respectively, for the group where request for TC was sent. Transfusion probability was also higher for this group. Conclusion: The blood utilization indices show the inadequate utilization of blood and that TC policy is unnecessary. Type and screen policy can be used for patients with large prostate and/or low Hb while type and hold would be appropriate for rest of the patients. Change in pretransfusion policy would reduce workforce and reagent wastage along with efficient inventory management.
Keywords: Pretransfusion testing policy, transfusion probability, transurethral resection of the prostate, type and crossmatch policy
|How to cite this article:|
Srivastava A, Singh B, Elhence P, Srivastava A, Chaudhary R. Is type and crossmatch really necessary for transurethral resection of prostate? A retrospective study from a tertiary care center in Northern India. Glob J Transfus Med 2022;7:42-6
|How to cite this URL:|
Srivastava A, Singh B, Elhence P, Srivastava A, Chaudhary R. Is type and crossmatch really necessary for transurethral resection of prostate? A retrospective study from a tertiary care center in Northern India. Glob J Transfus Med [serial online] 2022 [cited 2022 Sep 25];7:42-6. Available from: https://www.gjtmonline.com/text.asp?2022/7/1/42/344344
| Introduction|| |
Blood transfusion rates have decreased significantly in the last two decades due to better blood transfusion guidelines. Measures utilized include appropriate preassessment for elective procedures to allow identification and treatment of anemia and optimization of hemostasis intraoperatively. Most hospitals have a local policy on indications for blood transfusion and use alternatives where required. Local maximum surgical blood order schedule (MSBOS) for all hospitals and regular audits help the decision making regarding transfusion. In recent years, technical improvements in optics and resectoscopes have resulted in a significant decrease in the risk of bleeding and blood transfusion. Transurethral resection of the prostate (TURP) is the gold standard elective surgical technique in benign prostate hyperplasia (BPH) even though increasing number of minimally invasive endoscopic procedures are being made available as alternatives. Although blood loss in this procedure is lesser than open prostatectomy, however, blood transfusion may be necessary, like in other surgical procedures, due to reasons like blood loss, infection and irrigation fluid absorption. Various studies had shown that TURP complications including rate of bleeding and consequent blood transfusion has decreased as an aftermath of development of better technology and surgical techniques., The blood transfusion rates for TURP currently range between 2.0% and 7.0%.
Factors causing bleeding include large prostate gland, concurrent urinary tract infections, indwelling urinary catheters and coagulopathy. These risk factors are usually identified preoperatively (preop) by the surgeon and for such high-risk patients (for bleeding), blood request is sent preoperatively. Hemodynamic instability during the procedure requiring immediate transfusion occurs rarely in cases of TURP.
In the last few years, we observed decrease in usage of blood in TURP patients at our center. This resulted in reservation of units that could not be used by other patients in need. Inventory management is also required as these units have to be labelled and kept separately. This leads to outdating of units, unnecessary workforce and reagent wastage due to performance of unnecessary crossmatching. Thus, it is a burden on finances and blood bank resources.
At our institute, MSBOS for TURP has not been revised for last 15 years and currently it is 2 units (range 1–3) of group specific, Type and AHG matched packed red blood cells (PRBC) reserved for 48–72 h. Though MSBOS is in place, surgeons send preoperative blood request for the cases either with high risk of bleeding or low preop hemoglobin (Hb). These units are issued as and when need arises in case of surgical or postoperative (postop) blood loss.
According to the American Association of Blood Banks, for the procedures that do not typically require blood, type and screen (TS) or type and hold (TH) policy can be instead of type and crossmatch (TC) orders. TS policy is recommended where patients probably will not need blood transfusion. Use of TS policy provides multiple advantages over TC policy to all the stakeholders who include blood banker, clinician, patient, and the hospital management.,
Aims and objectives
We performed this study with the aim to assess the suitability of TC policy along with incidence of blood transfusion in TURP patients. The impact of patient's age, preoperative (preop) Hb and prostate weight on the pattern of preoperative blood ordering (whether demand for TC was sent or not) was also assessed.
| Materials and Methods|| |
The study was carried out in the department of Transfusion Medicine in collaboration with the department of Urology at a tertiary care center in northern India. A retrospective analysis of patients who underwent TURP between January 1, 2014 and December 31, 2017 (3-year period) was performed. All patients with clinical and imaging evidence of obstructive benign prostatic hyperplasia planned for TURP were included. Patients were divided into 2 groups on the basis of whether the demand for TC was sent or not sent, respectively.
Patients were identified using the electronic Hospital Information System (HIS). Demographic, clinical and transfusion details of the patients were obtained from computerized HIS. These data were then cross-referenced with manual OT procedure notes and blood bank records. Transfusion details included number of units and patients crossmatched and transfused and units unutilized.
Request for TC was received for selected patients only. Although there was no fixed criterion, relatively older patients with large prostate (measured by transrectal ultrasound, TRUS) and low Hb on preoperative evaluation were selected for TC request (through personal communication). The age, preop prostate weight and preop Hb of patients where demand for TC sent was compared with patients where TC demand was not sent by the operating surgeon. This was to see whether these variables had any effect on the pattern of blood transfusion request and utilization by these patients.
The various quality indicators for blood utilization were also studied and calculated using following equations:
- Crossmatch to transfusion ratio (C/T ratio) = Number of units crossmatched/number of units transfused. A ratio of 2.5 and below is considered indicative of significant blood usage
- Transfusion probability (%T) = Number of patient transfused × 100/number of patients crossmatched. A value of 30% and above was considered indicative of significant blood usage
- Transfusion index (TI) = Number of red blood cell units transfused/number of patients crossmatched. A value of 0.5 or more was considered indicative of significant blood utilization.
Patients who received a blood transfusion were identified and their individual risk factors were assessed by case note review.
The study was approved by the Institutional Ethics Committee. Being retrospective in nature, this study did not impose any financial burden on the participants.
The data were analyzed using SPSS software (SPSS Inc. Released 2009. PASW Statistics for Windows, Version18.0. Chicago, USA: SPSS Inc.). The continuous data was expressed as mean with range and standard deviation. The comparison between groups was done using independent sample t-test. All the statistical analysis was carried out at 5% level of significance and P < 0.05 was considered significant.
| Results|| |
A total of 92 patients who underwent TURP were analyzed. The clinical details of all the patients included in the study are mentioned in [Table 1]. Mean preop and postop Hb were 12.1 and 11.6 g/dl, respectively, with a statistically insignificant fall of 0.5 g/dl postoperatively (P = −0.064). Half of the patients were affected by some kind of comorbidity, most commonly diabetes followed by hypertension. Preop mean weight of prostate was 118.1 g (measured by TRUS) while mean weight of resected prostate tissue was 53.7 g (weighed using a standard electronic weighing machine). Coagulation profile (including platelet count) was normal in all 92 patients except mild thrombocytopenia in two patients.
|Table 1: Clinical details of patients undergoing transurethral resection of the prostate (n=92)|
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Among the 92 patients who had TURP, 42.4% (39/92) had TC samples sent preoperatively. A total of 71 PRBC units were crossmatched and reserved for these 39 patients. No incompatibility was seen during any of the crossmatches done. Antibody screen was also negative in all these patients. Out of 39, only three patients required one unit of blood transfusion each intraoperatively for prolonged bleeding and dropping Hb. On the other hand, none of the patients required transfusion where demand was not sent. Hence, the 30-day transfusion rate in TURP was 3.2% (3/92).
All three patients who required transfusion had a large preop prostate size between 158.4 and 183.7 gm. Consequently, the amount of resected prostate tissue was also larger, weighing between 74 and 93 gm. The pathology was found to be benign in all the three cases. All three of them were diabetic and aged between 60 and 69 years. The preop Hb was 9.6, 10.9 and 9.8 g/dl while the postop Hb was 8.3, 9.1 and 8.5 g/dl, respectively.
[Table 2] demonstrates the comparison of age, prostate weight and preoperative Hb of patients where demand for TC was sent with patients where TC demand was not sent. We found that preop Hb was lower and prostate weight was significantly higher for the group where request for TC was sent.
|Table 2: Comparison of age, preoperative hemoglobin and prostate weight between two groups of transurethral resection of the prostate patients*|
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Mortality was not seen in any of the 92 patients studied. The CT ratio calculated was 23.6, %T was 7.6% and TI was 0.07 [Table 3].
|Table 3: Indicators of blood utilization in transurethral resection of the prostate patients (n=92)|
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| Discussion|| |
BPH is the most common benign neoplasm in males which frequently has a significant detrimental impact on the patient's quality of life, if left untreated. Various risk factors including size of prostate, operating time, and concurrent urinary tract infection have been associated with increased bleeding in TURP which may necessitate transfusion of blood.
The standard practice at our hospital is to crossmatch 2 units of blood (Range 1–3) for all patients undergoing TURP. A CT ratio of ≥2.5, %T of more than 30% and TI of ≥0.5 is regarded as indicative of adequate blood usage as given by Boral and Henry and Mead et al., CT ratio, %T and TI in this study clearly reflects the inadequate utilization of blood and other resources and that the current practice of TC policy is unnecessary for TURP patients.
At our centre, no fixed criteria are in place to send blood request in TURP patients. Surgeons used to send TC request for the case where patient is relatively older with large prostate and low preop Hb. On analysis, we found that decision to send TC request was significantly affected by preop prostate size and Hb level of the patient. In patients with larger preop prostate and low preop Hb, probability of blood transfusion was higher for obvious reasons. As a result, request for TC was sent for these patients with relatively large preop prostate and low preop Hb only and not for those with inverse characteristics. The surgeon's decision to send blood request for high transfusion probability cases only seems justified to some extent in view of comparatively higher %T (7.6%) in this group. No patient needed blood transfusion in the group where TC request was not sent (i.e., % T was 0%).
Although few patients from high-risk group needed blood transfusion, the % T was still lower than acceptable level of adequate blood utilization (i.e., %T <30%). This indicates that TC requests are inappropriate even for patients in high-risk group and thus highlights the need for optimization of preoperative blood ordering. In the light of low %T, it would be appropriate to follow TS policy for high-risk group of patients. On the other hand, TH policy would suffice for any emergency need of blood with low weight prostate and adequate preop Hb. By following TS policy, we could avoid unnecessary crossmatches and reservation of units in >90% (36/39) of the cases. In addition, most experienced urologists are able to predict preoperatively those patients that have more probability of transfusion. Moreover, TC policy should be reserved for patients with some irregular red cell antibody and where the surgeon believes that good hemostasis cannot been achieved.
As discussed earlier, mean preop prostate weight and Hb were significantly different between two groups of patients together with considerably higher % T in high-risk group. These findings suggested that preop prostate weight and Hb can be used as a trigger to order TS or TH in TURP. We propose a process flow to help clinical decision making for ordering appropriate pretransfusion testing. This will ensure appropriate allocation of resources along with promotion of rationale ordering of pretransfusion testing among surgeons [Figure 1]. Patients with preop prostate weight of >138 g and Hb <11 gm/dl, may require blood transfusion on few occasions (%T-7.6%). So, TS policy would be appropriate in this setting. While in rest of the cases (preop prostate weight <138 and Hb >11), TH approach would be appropriate [Table 3]. In case of emergency situation, blood can be issued within 10 min after performing IS crossmatch.
|Figure 1: Flowchart for pretransfusion testing in transurethral resection of the prostate cases|
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In the 3 patients where blood transfusion was required, preop size of prostate and preop Hb were considerably higher (in all 3 cases) and lower (in 2 cases), respectively, compared to mean value for the group of patients where sample was sent for TC. This fact reemphasizes that preop prostate weight and preop Hb can be used as a guide to choose suitable pretransfusion testing policy.
As demonstrated in this study, TURP is associated with low risk of transfusion. This could be due to routine use of 5-alpha reductase inhibitors in our center. These drugs decrease the size and vascularity of the prostate gland and hence the reduced risk of bleeding. Improved optics and resectoscopes have resulted in lower bleeding rates in recent years. Optimization of low preoperative Hb reduces chances of transfusion during TURP. Transfusion rates for TURP are 2.0%–7% according to recent literature. Our results are in accordance with other published studies with transfusion rate of 3.2% (3/92).
In a study by Fraser et al. in 1984, they said that of the 203 patients who were “grouped and saved” only, 30 (12%) cases were eventually crossmatched and 22 (8.5%) transfused. No significant issues were there as a consequence of the implementation of this policy. Implementation of such type of policy could have a significant impact on transfusion services. Aggarwal et al. found that TS with IS crossmatch was better than TC in terms of reduced crossmatch/transfusion ratio, outdating of red blood cell units, manhours saved and reduced blood unit issue turnaround time. Robertson et al. showed that with the easy availability of plasma expanders and the ability to provide crossmatched blood within 30 min of its request, no patient came to any detectable harm in their study on TS method of crossmatching.
The cost of medical care is a matter of concern. In order to meet the increasing demand for blood for routine surgeries while operating within patient's financial constraints, many blood banks have analyzed the records to provide guidelines as to which surgeries justify routine TC and which ones justify routine TS. Aggarwal et al. found in their study that the TS method lowers the cost of the transfusion services.
We acknowledge some limitations of this study. Being retrospective in nature, the likelihood of biases innate to retrospective studies could not be ruled out. As there were only three patients who received transfusion, we could not delineate any risk factors of bleeding and subsequent transfusion in TURP patients where transfusion was actually happened.
| Conclusion|| |
Inappropriate pretransfusion testing decisions and lack of transfusion protocols in hospitals result in irrational use of blood along with wastage of resources. This study supports discontinuing routine preoperative TC testing for patients undergoing TURP. We believe that a change in pretransfusion testing policy from TC to TS or TH would help in cost saving and reduction in workload without adversely affecting patient safety. Our findings can also be adopted by other centers practicing TURP in India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]