Subclinical hemostatic activation and surgical volume predict peri-operative bleeding with radical prostatectomy

Abstract

5136 Background: Subclinical activation of hemostasis and fibrinolysis is common in cancer and has been linked with outcome. We have previously presented (2007 Prostate Cancer Symposium) preliminary data on the relationship of laboratory markers to age and prognostic variables. We now expand our report on peri-operative (op) complication implications in early prostate cancer. Methods: With IRB approval and informed consent, blood was collected prior to open radical retropubic prostatectomy with lymph node dissection. Pre-op therapy, thrombosis, and anticoagulation were exclusion criteria. Plasma was assayed in duplicate for D-dimer, thrombin-antithrombin complex (TAT), IL-6, and IL-8. Relationships to peri-op bleeding/thrombotic events (pre-op to POD#2 hemoglobin (Hgb) drop, estimated blood loss (EBL), transfusion, post-op thrombosis) were analyzed in univariate then multivariable linear regression. Results: 153 subjects have been analyzed. Median age was 63.1 (range 35–81), pre-op PSA was 5.92 ng/mL (0.23–26.2), and 118 (77%) were clinical stage T1c. 117 (76.5%) had disease confined to the prostate; 36 had pT3 and/or lymph node involvement. Pathologic Gleason scores were 6 or less in 68 (44.4%), 7 in 71 (46.4%), and 8 or higher in 14 (9%). Median EBL was 400 mL (range 50-3000), median Hgb drop was 3.5 g/dL (-0.1–6.6), and 8 (5.2 %) required RBC transfusion. One subject experienced a DVT. On univariate analysis, pre-op TAT (p<0.001) and D-Dimer (p=0.023) levels correlated with hemoglobin drop. Platelet count, INR, and aPTT did not predict EBL nor Hgb drop. The 8 who required transfusions had lower pre-op platelet counts than those not requiring transfusion (p=0.004). Higher surgeon volume correlated with lower EBL (p<0.001) and Hgb drop (p=0.002). Multivariable linear regression showed that TAT remained significantly associated with Hgb drop (p=0.008) and surgeon volume with EBL (p<0.001) and Hgb drop (p=0.002). Conclusions: Pre-op activation of the hemostatic system is associated with less surgically related bleeding when assessed by objective measures, predicting drop in Hgb better than PT, aPTT, or platelet counts. Surgeon volume may also predict bleeding by subjective and objective measures. No significant financial relationships to disclose.