抗栓药物对良性前列腺增生手术围术期出血影响的Meta分析
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摘要
目的系统评价应用抗栓药物对良性前列腺增生(BPH)手术围术期出血的影响。方法计算机检索Pubmed、Embase、Cochrane library、万方及中国知网数据库发表的有关BPH围术期抗凝治疗对术后出血影响的研究,检索时限为1990年1月至2018年5月。由2名评价者按照纳入与排除标准选择试验、提取资料和评价质量后,采用RevMan 5.3软件进行荟萃分析。结果纳入26篇研究,共4 314例患者,结果显示:TURP围术期持续服用抗栓药物与术前停用抗栓药物相比,术后出血风险大[OR=4.34,95%CI(2.29～8.23),P<0.000 01],输血率高[OR=2.96,95%CI(1.19～7.36),P=0.02];与从未服用抗栓药物相比,术后出血风险大[OR=5.52,95%CI(1.64～18.66),P=0.006]。激光BPH手术期间持续服用抗栓药物与术前停用抗栓药物相比,输血率高[OR=5.39,95%CI(1.49～19.53),P=0.01];与从未服用抗栓药物相比较,膀胱内血凝块残留率、输血率、术中血红蛋白下降值及术后留置导尿时间无明显差异(P>0.05);与低分子肝素替代相比较,术中血红蛋白下降值低[WMD=-0.46,95%CI(-0.58～-0.35),P<0.000 01]。结论 TURP围术期停用抗栓药物可以降低术后出血的风险;激光BPH手术围术期持续服用抗栓药物是安全可行的。
Objective To assess the effects of antithrombotic agents on the bleeding risk after transurethral resection of the prostate(TURP) in patients with benign prostatic hyperplasia(BPH).Methods Controlled clinical trials about the effects of perioperative anticoagulant therapy on postoperative bleeding in BPH patients published during Jan.1990 and May 2018 were searched in PubMed,Embase,the Cochrane Library,CNKI,and Wanfang Data.Two independent reviewers screened the studies according to the inclusion and exclusion criteria,extracted the data,evaluated the quality,and conducted a Meta-analysis using the RevMan 5.3 software.Results A total of 26 studies were included,with 4,314 cases involved.Analysis of these studies found that compared with interrupted use of antithrombotic agents,continuous use of antithrombotic drugs led to more frequent post-TURP bleeding [OR=4.34,95%CI(2.29-8.23),P<0.000 01],and higher transfusion rate [OR=2.96,95%CI(1.19-7.36),P=0.02].Compared with patients who never used antithrombotic agents,those who used antithrombotic agents continuously had higher bleeding risk [OR=5.52,95%CI(1.64-18.66),P=0.006].Those who continued using antithrombotic agents during laser treatment had higher transfusion rate than those who stopped using them before the operation [OR=5.39,95%CI(1.49-19.53),P=0.01],but had no significant differences in clot retention,blood transfusion rate,intraoperative hemoglobin decrease and postoperative catheter-indwelling time compared with those who never used antithrombotic agents(P>0.05).Those who continued using antithrombotic agents during TURP showed less intraoperative hemoglobin decrease [WMD=-0.46,95%CI(-0.58--0.35),P<0.000 01] than the patients who underwent low molecular weight heparin(LMWH) substitution.Conclusion Interruption of antithrombotic agents during TURP can prevent the risk of postoperative bleeding; continuous use of antithrombotic agents is safe and feasible during laser treatment of BPH; whether LMWH substitution is necessary during the discontinuation of antithrombotic agents is controversial.
Objective To assess the effects of antithrombotic agents on the bleeding risk after transurethral resection of the prostate(TURP) in patients with benign prostatic hyperplasia(BPH).Methods Controlled clinical trials about the effects of perioperative anticoagulant therapy on postoperative bleeding in BPH patients published during Jan.1990 and May 2018 were searched in PubMed,Embase,the Cochrane Library,CNKI,and Wanfang Data.Two independent reviewers screened the studies according to the inclusion and exclusion criteria,extracted the data,evaluated the quality,and conducted a Meta-analysis using the RevMan 5.3 software.Results A total of 26 studies were included,with 4,314 cases involved.Analysis of these studies found that compared with interrupted use of antithrombotic agents,continuous use of antithrombotic drugs led to more frequent post-TURP bleeding [OR=4.34,95%CI(2.29-8.23),P<0.000 01],and higher transfusion rate [OR=2.96,95%CI(1.19-7.36),P=0.02].Compared with patients who never used antithrombotic agents,those who used antithrombotic agents continuously had higher bleeding risk [OR=5.52,95%CI(1.64-18.66),P=0.006].Those who continued using antithrombotic agents during laser treatment had higher transfusion rate than those who stopped using them before the operation [OR=5.39,95%CI(1.49-19.53),P=0.01],but had no significant differences in clot retention,blood transfusion rate,intraoperative hemoglobin decrease and postoperative catheter-indwelling time compared with those who never used antithrombotic agents(P>0.05).Those who continued using antithrombotic agents during TURP showed less intraoperative hemoglobin decrease [WMD=-0.46,95%CI(-0.58--0.35),P<0.000 01] than the patients who underwent low molecular weight heparin(LMWH) substitution.Conclusion Interruption of antithrombotic agents during TURP can prevent the risk of postoperative bleeding; continuous use of antithrombotic agents is safe and feasible during laser treatment of BPH; whether LMWH substitution is necessary during the discontinuation of antithrombotic agents is controversial.
引文
[1] OELKE M,BACHMANN A,DESCAZEAUD A,et al.EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction[J].Eur Urol,2013,64(1):118-140.
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[5] THURSTON AV,BRIANT SL.Aspirin and post-prostatectomy haemorrhage[J].Br J Urol,1993,71(5):574-576.
[6] ALA-OPAS MY,GRONLUND SS.Blood loss in long-term aspirin users undergoing transurethral prostatectomy[J].Scand J Urol Nephrol,1996,30(3):203-206.
[7] WIER?D FS,FRANDSEN NJ,JACOBSEN JD,et al.Risk of haemorrhage from transurethral prostatectomy in acetylsalylic acid and NSAID-treated patients[J].Scand J Urol Nephrol,1998,32(2):120-122.
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[9] WENDERS M,WENZEL O,NITZKE T,et al.Perioperative platelet inhibition in transurethral interventions:TURP/TURB[J].Int Braz J Urol,2012,38(5):606-610.
[10] DOTAN ZA,MOR Y,LEIBOVITCH I,et al.The efficacy and safety of perioperative low molecular weight heparin substitution in patients on chronic oral anticoagulant therapy undergoing transurethral prostatectomy for bladder outlet obstruction[J].J Urol,2002,168(2),610-614.
[11] TAYLOR K,FILGATE R,GUO D Y,et al.A retrospective study to assess the morbidity associated with transurethral prostatectomy in patients on antiplatelet or anticoagulant drugs[J].BJU Int,2011,108(2):45-50.
[12] ONG WL,KOH TL,FLETCHER J,et al.Perioperative management of antiplatelets and anticoagulants pmong patients undergoing elective transurethral resection of the prostate-a single institution experience[J].J Endourol,2015,29(11):1321-1327.
[13] CARMIGNANI L,MARENGHI C,FINKELBERG E,et al.Clinical course of patients receiving anti-platelets therapy who underwent thulium laser enucleation of the prostate[J].Urology,2014,84(4):S6.
[14] ELZAYAT E,HABIB E,ELHILALI M.Holmium laser enucleation of the prostate in patients on anticoagulant therapy or with bleeding disorders[J].J Urol,2006,175(4):1428-1432.
[15] TYSON MD,LERNER LB.Safety of holmium laser enucleation of the prostate in anticoagulated patients[J].J Endourol,2009,23(8):1343-1346.
[16] BISHOP CV,LIDDELL H,ISCHIA J,et al.Holmium laser enucleation of the prostate:Comparison of immediate postoperative outcomes in patients with and without antithrombotic therapy[J].Curr Urol,2013,7(1):28-33.
[17] EL TAYEB MM,JACOB JM,BHOJANI N,et al.Holmium laser enucleation of the prostate in patients requiring anticoagulation[J].J Endourol,2016,30(7):805-809.
[18] SUN J,SHI A,TONG Z,et al.Safety and feasibility study of holmium laser enucleation of the prostate (HOLEP) on patients receiving dual antiplatelet therapy (DAPT) [J].World J Urol,2018,36(2):271-276.
[19] RUSZAT R,WYLER S,FORSTER T,et al.Safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing oral anticoagulation[J].Eur Urol,2007,51(4):1031-1041.
[20] KARATAS OF,ALKAN E,HORASANLI K,et al.Photoselective vaporization of the prostate in men with a history of chronic oral anti-coagulation[J].Int Braz J Urol,2010,36(2):190-197.
[21] SOHN JH,CHOI YS,KIM SJ,et al.Effectiveness and Safety of Photoselective Vaporization of the Prostate with the 120 W HPS Greenlight Laser in Benign Prostatic Hyperplasia Patients Taking Oral Anticoagulants[J].Korean J Urol,2011,52(3):178-183.
[22] 雒向宁,王禾,杨波.选择性绿激光前列腺汽化术患者围手术期维持口服抗凝药的安全性与手术效果探讨[J].中国现代医学杂志,2012,22(15):84-87.
[23] 唐飞,陈立军,赵立,等.选择性绿激光汽化术治疗正在口服抗凝药物良性前列腺增生症的临床观察[J].临床外科杂志,2012,20(10):743-745.
[24] 周松林,单玉喜.高功率绿激光治疗口服抗凝药前列腺增生患者的疗效及安全性[J/OL].中华腔镜泌尿外科杂志,2015,9(1):48-51.
[25] KNAPP GL,CHALASANI V,WOO HH.Perioperative adverse events in patients on continued anticoagulation undergoing photoselective vaporisation of the prostate with the 180-W Greenlight lithium triborate laser[J].BJU Int,2017,119(5):33-38.
[26] PIOTROWICZ G,SYRYLO T,JEDYNAK R,et al.Efficacy and safety of Photoselective Vaporization of the Prostate with 120 w 532 nm laser in patients with benign prostatic hyperplasia on anticoagulation or antiplatelet therapy:Observations on long-term outcomes[J].Photomed Laser Surg,2018,36(5):273-283.
[27] 赵豫波,刘萃龙,于春杰,等.抗凝替代治疗在经尿道前列腺绿激光汽化术中的应用价值分析[J].中国全科医学,2014,17(11):1317-1319.
[28] MACCHIONE L,MUCCIARDI G,GALI A,et al.Efficacy and safety of prostate vaporesection using a 120-W 2-mum continuous-wave Tm:YAG laser (RevoLix 2) in patients on continuous oral anticoagulant or antiplatelet therapy[J].Int Urol Nephrol,2013,45(6):1545-1551.
[29] SENER TE,BUTTICE S,MACCHIONE L,et al.Thulium laser vaporesection of the prostate:Can we operate without interrupting oral antiplatelet/anticoagulant therapy?[J].Inv Clin Urol,2017,58(3):192-199.
[30] NASPRO R,LERNER LB,ROSSINI R,et al.Perioperative antithrombotic therapy in patients undergoing endoscopic urologic surgery:where do we stand with current literature?[J].Minerva Urol Nefrol,2018,70(2):126-136.
[31] CULKIN DJ,EXAIRE EJ,GREEN D,et al.Anticoagulation and antiplatelet therapy in urological practice:ICUD/AUA review paper[J].J Urol,2014,192(4):1026-1034.
[32] DUCEPPE E,PARLOW J,MACDONALD P,et al.Canadian cardiovascular society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery[J].Can J Cardiol,2017,33(1):17-32.
[33] HAUSER S,ROGENHOFER S,ELLINGER J,et al.Thulium laser (Revolix) vapoenucleation of the prostate is a safe procedure in patients with an increased risk of hemorrhage[J].Urol Int,2012,88(4):390-394.
[34] RIVERA M,KRAMBECK A,LINGEMAN J.Holmium laser enucleation of the prostate in patients requiring anticoagulation[J].Curr Urol Rep,2017,18(10):77.
[35] NETSCH C,MAGNO C,BUTTICè S,et al.Thulium Vaporesection of the prostate and thulium vapoenucleation of the prostate in patients on oral anticoagulants:A retrospective three-centre matched-paired comparison[J].Urol Int,2016,96(4):421-426.
[36] 包贤涛,刘修恒,陈志远,等.长期服用阿司匹林患者经尿道前列腺切除术围术期使用低分子肝素替代治疗对出血的影响[J].广西医学,2018,40(3):276-278.
[2] 冷培俊,杨晓峰,尚琳.经尿道前列腺电切术围手术期抗凝药物的管理[J].现代泌尿外科杂志,2018,23(2):150-156.
[3] BIONDI-ZOCCAI GG,LOTRIONTE M,AGOSTONI P,et al.A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50 279 patients at risk for coronary artery disease[J].Eur Heart J,2006,27(22):2667-2674.
[4] WASTON CJ,DEANE AM,DOYLE PT,et al.Identifiable factors in post-prostatectomy haemorrhage:the role of aspirin[J].Br J Urol,1990,66(1):85-87.
[5] THURSTON AV,BRIANT SL.Aspirin and post-prostatectomy haemorrhage[J].Br J Urol,1993,71(5):574-576.
[6] ALA-OPAS MY,GRONLUND SS.Blood loss in long-term aspirin users undergoing transurethral prostatectomy[J].Scand J Urol Nephrol,1996,30(3):203-206.
[7] WIER?D FS,FRANDSEN NJ,JACOBSEN JD,et al.Risk of haemorrhage from transurethral prostatectomy in acetylsalylic acid and NSAID-treated patients[J].Scand J Urol Nephrol,1998,32(2):120-122.
[8] NIELSEN JD,HOLM-NIELSEN A,JESPERSEN J,et al.The effect of low-dose acetylsalicylic acid on bleeding after transurethral prostatectomy-a prospective,randomized,double-blind,placebo-controlled study[J].Scand J Urol Nephrol,2000,34(3):194-198.
[9] WENDERS M,WENZEL O,NITZKE T,et al.Perioperative platelet inhibition in transurethral interventions:TURP/TURB[J].Int Braz J Urol,2012,38(5):606-610.
[10] DOTAN ZA,MOR Y,LEIBOVITCH I,et al.The efficacy and safety of perioperative low molecular weight heparin substitution in patients on chronic oral anticoagulant therapy undergoing transurethral prostatectomy for bladder outlet obstruction[J].J Urol,2002,168(2),610-614.
[11] TAYLOR K,FILGATE R,GUO D Y,et al.A retrospective study to assess the morbidity associated with transurethral prostatectomy in patients on antiplatelet or anticoagulant drugs[J].BJU Int,2011,108(2):45-50.
[12] ONG WL,KOH TL,FLETCHER J,et al.Perioperative management of antiplatelets and anticoagulants pmong patients undergoing elective transurethral resection of the prostate-a single institution experience[J].J Endourol,2015,29(11):1321-1327.
[13] CARMIGNANI L,MARENGHI C,FINKELBERG E,et al.Clinical course of patients receiving anti-platelets therapy who underwent thulium laser enucleation of the prostate[J].Urology,2014,84(4):S6.
[14] ELZAYAT E,HABIB E,ELHILALI M.Holmium laser enucleation of the prostate in patients on anticoagulant therapy or with bleeding disorders[J].J Urol,2006,175(4):1428-1432.
[15] TYSON MD,LERNER LB.Safety of holmium laser enucleation of the prostate in anticoagulated patients[J].J Endourol,2009,23(8):1343-1346.
[16] BISHOP CV,LIDDELL H,ISCHIA J,et al.Holmium laser enucleation of the prostate:Comparison of immediate postoperative outcomes in patients with and without antithrombotic therapy[J].Curr Urol,2013,7(1):28-33.
[17] EL TAYEB MM,JACOB JM,BHOJANI N,et al.Holmium laser enucleation of the prostate in patients requiring anticoagulation[J].J Endourol,2016,30(7):805-809.
[18] SUN J,SHI A,TONG Z,et al.Safety and feasibility study of holmium laser enucleation of the prostate (HOLEP) on patients receiving dual antiplatelet therapy (DAPT) [J].World J Urol,2018,36(2):271-276.
[19] RUSZAT R,WYLER S,FORSTER T,et al.Safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing oral anticoagulation[J].Eur Urol,2007,51(4):1031-1041.
[20] KARATAS OF,ALKAN E,HORASANLI K,et al.Photoselective vaporization of the prostate in men with a history of chronic oral anti-coagulation[J].Int Braz J Urol,2010,36(2):190-197.
[21] SOHN JH,CHOI YS,KIM SJ,et al.Effectiveness and Safety of Photoselective Vaporization of the Prostate with the 120 W HPS Greenlight Laser in Benign Prostatic Hyperplasia Patients Taking Oral Anticoagulants[J].Korean J Urol,2011,52(3):178-183.
[22] 雒向宁,王禾,杨波.选择性绿激光前列腺汽化术患者围手术期维持口服抗凝药的安全性与手术效果探讨[J].中国现代医学杂志,2012,22(15):84-87.
[23] 唐飞,陈立军,赵立,等.选择性绿激光汽化术治疗正在口服抗凝药物良性前列腺增生症的临床观察[J].临床外科杂志,2012,20(10):743-745.
[24] 周松林,单玉喜.高功率绿激光治疗口服抗凝药前列腺增生患者的疗效及安全性[J/OL].中华腔镜泌尿外科杂志,2015,9(1):48-51.
[25] KNAPP GL,CHALASANI V,WOO HH.Perioperative adverse events in patients on continued anticoagulation undergoing photoselective vaporisation of the prostate with the 180-W Greenlight lithium triborate laser[J].BJU Int,2017,119(5):33-38.
[26] PIOTROWICZ G,SYRYLO T,JEDYNAK R,et al.Efficacy and safety of Photoselective Vaporization of the Prostate with 120 w 532 nm laser in patients with benign prostatic hyperplasia on anticoagulation or antiplatelet therapy:Observations on long-term outcomes[J].Photomed Laser Surg,2018,36(5):273-283.
[27] 赵豫波,刘萃龙,于春杰,等.抗凝替代治疗在经尿道前列腺绿激光汽化术中的应用价值分析[J].中国全科医学,2014,17(11):1317-1319.
[28] MACCHIONE L,MUCCIARDI G,GALI A,et al.Efficacy and safety of prostate vaporesection using a 120-W 2-mum continuous-wave Tm:YAG laser (RevoLix 2) in patients on continuous oral anticoagulant or antiplatelet therapy[J].Int Urol Nephrol,2013,45(6):1545-1551.
[29] SENER TE,BUTTICE S,MACCHIONE L,et al.Thulium laser vaporesection of the prostate:Can we operate without interrupting oral antiplatelet/anticoagulant therapy?[J].Inv Clin Urol,2017,58(3):192-199.
[30] NASPRO R,LERNER LB,ROSSINI R,et al.Perioperative antithrombotic therapy in patients undergoing endoscopic urologic surgery:where do we stand with current literature?[J].Minerva Urol Nefrol,2018,70(2):126-136.
[31] CULKIN DJ,EXAIRE EJ,GREEN D,et al.Anticoagulation and antiplatelet therapy in urological practice:ICUD/AUA review paper[J].J Urol,2014,192(4):1026-1034.
[32] DUCEPPE E,PARLOW J,MACDONALD P,et al.Canadian cardiovascular society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery[J].Can J Cardiol,2017,33(1):17-32.
[33] HAUSER S,ROGENHOFER S,ELLINGER J,et al.Thulium laser (Revolix) vapoenucleation of the prostate is a safe procedure in patients with an increased risk of hemorrhage[J].Urol Int,2012,88(4):390-394.
[34] RIVERA M,KRAMBECK A,LINGEMAN J.Holmium laser enucleation of the prostate in patients requiring anticoagulation[J].Curr Urol Rep,2017,18(10):77.
[35] NETSCH C,MAGNO C,BUTTICè S,et al.Thulium Vaporesection of the prostate and thulium vapoenucleation of the prostate in patients on oral anticoagulants:A retrospective three-centre matched-paired comparison[J].Urol Int,2016,96(4):421-426.
[36] 包贤涛,刘修恒,陈志远,等.长期服用阿司匹林患者经尿道前列腺切除术围术期使用低分子肝素替代治疗对出血的影响[J].广西医学,2018,40(3):276-278.