DO WE NEED TO CROSSMATCH BLOOD FOR TRANSURETHRAL PROSTATECTOMY?

DEBAP. SARMA, M.D. From the Department of Pathology, Veterans Administration Medical Center and Louisiana State University Medical School, New Orleans, Louisiana

ABSTRACT Elective transurethral prostatectomy cases do not need a routine order for typing and crossmatching blood. Data from the literature and from personal experience in the blood bank of a 580-bed hospital are presented to support this conclusion.

Urologists usually order type and crossmatch of two units of blood for each case of elective transurethral prostatectomy (TURP). The blood bank personnel crossmatches the requested number of units and holds them in a reserved status for the specific patient. This blood is not available to any other patient until the physician releases the blood or the holding period exceeds the maximum allowable reserved period established by the blood bank (usually twenty-four to fortyeight hours). If this blood is not used, it may become outdated during the holding period. In a study of blood usage for elective surgical procedures in our institution, a 580-bed general medical and surgical care facility, I have noted that for a large number of surgical procedures frequently the number of units ordered for crossmatching exceeds considerably the number actually transfused.1 For 144 TURP cases 319 units of blood were crossmatched; however, only twenty-eight units of blood were transfused to 15 of those patients. Since 1979 in our blood bank we have implemented type and screen (T&S) for elective TURP cases. In T&S a determination of ABORh type and a screen of the patient's serum for unexpected antibodies are made. A reasonable inventory of ABO-Rh compatible units is kept in the blood bank. ABO-Rh compatible units (also

free of unexpected antibodies) can be dispatched immediately to the operating room in case of acute need. Crossmatching is begun immediately after the blood is released. Even without a crossmatch, the typed and screened blood is 99.99 per cent safe in regard to avoiding the transfusion of incompatible blood.2"4 Our experience with the elective TURP cases after implementing T&S is described, and it is shown that crossmatching can be safely substituted by type and screen for elective transurethral prostatectomies. Material, Methods, and Results For a twelve-month period, January 1 to December 31, 1980, elective TURP cases were reviewed in regard to the response of urologists to our substituting T&S for crossmatching. A total of 179 patients underwent elective TURP. Urologists requested T&S for 157 patients, 152 of whom did not receive any transfusion. The urologists, while in the operating room, asked the blood bank to crossmatch a total of eight units of blood for the other 5 patients in anticipation of excessive bleeding. Four of those patients received one unit each. No blood was ordered for 6 patients, and they did not receive any blood intraoperatively.
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TABLE I.

Average operative blood loss in transurethral prostatectomies

No. of Patients 100 29 44 43 20 76 110 144 50 62 678 Blood Loss (Ml.) 169 98 650 239 170 275 258 304 525 89 278

Comment How often does a patient need a blood transfusion during transurethral prostatectomy? To answer this question we must first determine how much blood is lost during a TURP pro cedure. Review of the urologic literature shows a large number of articles dealing with this question (Table I). Various methods have been used to measure blood loss, the most common of which is the determination of hemoglobin concentration of the irrigating fluid. It appears that on the average each patient rarely loses more than 300 ml. of blood. Since an adult man normally can donate one unit of blood (500 ml.) without any ill effects, the patient undergoing TURP should be able to tolerate such loss. This is well shown by the pattern of blood usage in these patients (Table II). Table II also shows that

Reference Nesbit and Conger5 Frank and Lloyd6 Goldman and Samellas7 Geist and Haglund8 Madsen, Kaveggia, and Atassi9 Robson and Sales10 Perkins and Miller11 Greene12 Jansen, Berseus, and Johansson13 Mackenzie, Levine, and Scheinman14 Combined averages

TABLE II.

Blood ordered and used for transurethral prostatectomies Average No. Crossmatched/Pt. Vs. Average No. Transfused/ Pt. Crossmatched 2.23/0.06 3.60/0.07 2.00/0.10 2.48/0.08 2.22/0.19

Reference Mintz et al. 15 Roualt and Gruenhagen16 Hough et al. " Boral et al. ls Sarma (1980) '
*NA = not available.

Pts. Crossmatched Vs. Pts. Transfused* 47/NA 30/NA 573/52 25/1 144/15

Units Crossmatched Vs. Units Transfused 105/3 109/2 1139/82 62/2 319/28

A request for type and crossmatch was received for the remaining 16 cases. Indications included "very large prostate" and anemia. A total of 34 units of blood were Crossmatched, of which nine units were transfused to 5 patients. A maximum of four units were transfused intraoperatively in one fifty-four-year-old man in whom 70 Gm. of prostatic chips were resected. There was no need to transfuse uncrossmatched blood to any patient during this study. In every case in which the patient was only typed and screened and the urologist wanted to transfuse intraoperatively, there was adequate time for the blood bank to crossmatch the blood before the transfusion was started. Close communication and cooperation between the surgical team and the blood bank personnel were instrumental in the efficient patient care.
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routinely we have been crossmatching two or more units of blood per case of TURP, very few of which are used. Of course, there will be individual cases with special problems, such as, very large prostates, anemia, bleeding tendencies, etc., where an adequate number of units should be typed and Crossmatched. However, for routine cases a T&S on the patient's blood would be adequate to meet any need for unanticipated transfusion. Since 1979 our experience with type and screen cases of transurethral prostatectomy has confirmed that T&S is a safe alternative to crossmatching with no hazard to patient. It also relieves the blood bank of inventory problems, reduces outdating of blood, and allows for more efficient blood bank service with reduced overall cost.
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Veterans Administration Hospital New Orleans, Louisiana 70148

References
1. Sarma D: Use of blood in elective surgery, JAMA 243: 1536 (1980). 2. Boral LI, and Henry JB: The type and screen: a safe alterna tive and supplement in selected surgical procedures, Transfusion 17: 165 (1977). 3. Boral LI, Hill SS, Apollon CJ, and Folland A: The type and screen, revisited, Am. J. Clin. Pathol. 71: 578 (1979). 4. Boyd P, Sheedy KC, and Henry JB: Type and screen, use and effectiveness in elective surgery, ibid. 73: 694 (1980). 5. Nesbit RM, and Conger KB: Studies of blood loss during transurethral prostatic resection, J. Urol. 46: 713 (1941). 6. Frank RM, and Lloyd FA: A clinical study on the effective ness of adrenosem in transurethral resection, J. Urol. 82: 243 (1959). 7. Goldman EJ, and Samellas VV: Blood loss during prostatec tomy, ibid. 86: 637 (1961). 8. Geist RW, and Haglund RV: Failure of intravenous injections of estrogens (Premarin) to decrease loss of blood during trans urethral prostatic resection, ibid. 87: 593 (1962). 9. Madsen PO, Kaveggia L, and Atassi SA: The effect of

estrogens (Premarin) and regional hypothermia on blood loss during transurethral prostatectomy, ibid. 92: 314 (1964). 10. Robson CJ, and Sales JL: The effect of local hypothermia on blood loss during transurethral resection of the prostate, ibid. 95: 393 (1966). 11. Perkins JB, and Miller HC: Blood loss during transurethral prostatectomy, ibid. 101: 93 (1969). 12. Greene LF: Use of hemostatic bag after transurethral prostatic resection, ibid. 106: 915 (1971). 13. Jansen H, Berseus O, and Johansson JE: A simple photo metric method for determination of blood loss during trans urethral surgery, Scand. J. Urol. Nephrol. 12: 1 (1978). 14. Mackenzie AR, Levine N, and Scheinman HZ: Operative blood loss in transurethral prostatectomy, J. Urol. 122: 47 (1979). 15. Mintz PD, Nordine RB, Henry JB, and Webb WR: Expected hemotherapy in elective surgery, N.Y. State J. Med. 76: 532 (1976). 16. Roualt C, and Gruenhagen J: Reorganization of blood ordering practices, Transfusion 18: 448 (1978). 17. Hough AJ, Russel W, Driver G, and Gardner WA: Blood transfusion practices in surgery: an approach to intrahospital analysis, South. Med. J. 71: 1100 (1978). 18. Boral LI, et al: A guideline for anticipated blood usage during elective surgical procedures, Am. J. Clin. Pathol. 71: 680 (1979).

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Sarema DP (1982): Do we need to crossmatch blood for transurethral prostatectomy? Urology 20:151153. PMID: 7112818 [PubMed - indexed for MEDLINE]