Eraky Akram M, Rubenstein Sidney C, Khan Adnan, Mokhtar Yasser, Gregorich Nicole M
Medical Education Department, Kansas City University of Medicine and Biosciences, Kansas City, MO 64106, USA.
Emergency Medicine, Freeman Health System, Joplin, MO 64804, USA.
Pathophysiology. 2024 Jul 12;31(3):367-375. doi: 10.3390/pathophysiology31030027.
Patients undergoing transurethral resection of the prostate (TURP) surgery can develop TURP syndrome and post-TURP bleeding. Post-TURP bleeding can be surgical, from arteries or venous sinuses, or non-surgical, due to coagulopathy preventing clot formation. Non-surgical post-TURP bleeding may be due to high concentrations of urokinase and tissue plasminogen activator (tPA) in the urine that cause fibrinolytic changes and increase bleeding risk. Urine urokinase and tPA may have both local and systemic fibrinolytic effects that may prevent blood clot formation locally at the site of surgery, and cause fibrinolytic changes systemically through leaking into the blood stream. Another post-TURP complication that may happen is TURP syndrome, due to absorption of hypotonic glycine fluid through the prostatic venous plexus. TURP syndrome may present with hyponatremia, bradycardia, and hypotension, which may be preceded by hypertension. In this case report, we had a patient with benign prostatic hyperplasia (BPH) who developed both TURP syndrome and non-surgical post-TURP bleeding. These complications were transient for one day after surgery. The local effect of urine urokinase and tPA explains the non-surgical bleeding after TURP by preventing clot formation and inducing bleeding. Coagulation studies showed fibrinolytic changes that may be explained by urokinase and tPA leakage into the blood stream. In conclusion, non-surgical bleeding after TURP can be explained by the presence of fibrinolytic agents in the urine, including urokinase and tPA. There is a deficiency in existing studies explaining the pathophysiology of the fibrinolytic changes and risk of bleeding after TURP. Herein, we discuss the possible pathophysiology of developing fibrinolytic changes after TURP. More research effort should be directed to explore this area to investigate the appropriate medications to treat and prevent post-TURP bleeding. We suggest monitoring patients' coagulation profiles and electrolytes after TURP because of the risk of developing severe acute hyponatremia, TURP syndrome, fibrinolytic changes, and non-surgical bleeding. In our review of the literature, we discuss current clinical trials testing the use of an antifibrinolytic agent, Tranexamic acid, locally in the irrigation fluid or systemically to prevent post-TURP bleeding by antagonizing the fibrinolytic activity of urine urokinase and tPA.
接受经尿道前列腺切除术（TURP）的患者可能会出现TURP综合征和TURP术后出血。TURP术后出血可能是手术性的，源于动脉或静脉窦，也可能是非手术性的，原因是凝血功能障碍导致无法形成血凝块。TURP术后非手术性出血可能是由于尿液中高浓度的尿激酶和组织型纤溶酶原激活剂（tPA）引起纤维蛋白溶解变化并增加出血风险。尿液中的尿激酶和tPA可能具有局部和全身的纤维蛋白溶解作用，这可能会阻止手术部位局部形成血凝块，并通过渗入血流而引起全身纤维蛋白溶解变化。另一种可能发生的TURP术后并发症是TURP综合征，这是由于低渗甘氨酸液通过前列腺静脉丛吸收所致。TURP综合征可能表现为低钠血症、心动过缓和低血压，在出现这些症状之前可能会有高血压。在本病例报告中，我们有一位良性前列腺增生（BPH）患者同时出现了TURP综合征和TURP术后非手术性出血。这些并发症在术后一天内是短暂的。尿液中尿激酶和tPA的局部作用通过阻止血凝块形成和诱导出血来解释TURP术后的非手术性出血。凝血研究显示纤维蛋白溶解变化，这可能是由于尿激酶和tPA渗入血流所致。总之，TURP术后的非手术性出血可以通过尿液中存在纤维蛋白溶解剂（包括尿激酶和tPA）来解释。现有研究在解释TURP术后纤维蛋白溶解变化的病理生理学和出血风险方面存在不足。在此，我们讨论TURP术后发生纤维蛋白溶解变化的可能病理生理学。应该投入更多的研究精力来探索这一领域，以研究治疗和预防TURP术后出血的合适药物。由于存在发生严重急性低钠血症、TURP综合征、纤维蛋白溶解变化和非手术性出血的风险，我们建议在TURP术后监测患者的凝血指标和电解质。在我们对文献的综述中，我们讨论了当前正在进行的临床试验，这些试验测试了使用抗纤维蛋白溶解剂氨甲环酸局部用于冲洗液或全身给药，通过拮抗尿液中尿激酶和tPA的纤维蛋白溶解活性来预防TURP术后出血。
