Bloodless Prostate Cancer Surgery

I have heard the term Bloodless Surgery many times and am familiar with it. A google search will also give someone who may not be familiar with the term a better understanding of how it is used.

There are many things that can be done to help avoid blood transfusions such as minimizing blood draws, diluting the blood during surgery by giving extra fluids during surgery, and giving medicines to help replenish normal stores.

I personally do not like transfusing blood and feel that even giving a patient his own blood back, is not entirely without risk. There is a chance of bacterial infection and a small chance that the blood can be mixed up. A friend and former Chairman of Surgery at Saint Barnabas Medical Center recently wrote an informative newsletter about the disadvantages of blood transfusions:

Just as the physical universe is changing so too is the health care
universe.  I’m a great believer in the power of change; really the
acceptance of, and adaptation to, change. I remember a warning from my
days as a medical student.  Someone told me that as I traveled through a
life in medicine the questions would remain the same but the answers would
change. How true! Here are some questions that have had their answers
revised in light of better understanding.

After a major operation a patient’s hemoglobin is stable at 7.5 Gms. The
patient did not receive any blood during surgery.  Should the patient
receive 2 units of red cells now or not?  Old answer: Give 2 units of
packed red cells now. New answer: Do not transfuse if patient is stable.
Transfusions have many potential complications including an increased risk
for post operative infection. Another question: A patient is scheduled to
come in for an open radical prostatectomy.  Should he put one or two units
of his own blood in the bank in case he needs to be transfused?  Old
answer: Yes.  New answer: No. Blood loses 2,3, DPG and red cells deform
during storage  even for a week or two.  The best place for his blood is
in his veins.    In cardiac surgery risk adjusted morbidity, mortality and
length of stay are all closely correlated with the age of the blood

So all this sounds like I am in favor of bloodless surgery, which I am to an extent.
I have several issues. Any surgery which involves any incision has the potential to lose blood.

There is no such thing as bloodless surgery in the sense that blood will not be lost.
It is safe to lose blood and I think the term should be transfusion-less surgery as a more accurate, but maybe less marketable term.

The other issue is what I feel is my responsibility to inform the patient about what is likely to happen and what can potentially happen. My team at Beth Israel had an abstract presented at a national meeting earlier this year which concluded that we no longer had blood available for transfusion in the operating room. This was after 52 robotic prostatectomies. We are now past 150 robotic prostatectomies and have still not transfused a patient.

I still inform patients that a transfusion is possible, and other than several jehovah witnesses that I have operated on, I ask everyone to sign a blood consent. I am sure there will be a day when I feel one of my patients will need a blood transfusion and since the risks of receiving blood would be much less than the risks of the anemia they would have at the time which could lead to heart attacks and life threatening events, I would give the transfusion.

In conclusion, I tell my patients that it has been transfusion-less so far, but there is a small chance that they may need blood. I tell them I wouldn’t advise donating their own blood since the counts they start with would likely be a little lower and it is uncomfortable and likely it will not be needed. If they still want to donate blood, I will be happy to help them arrange to have this done.
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4 responses to “Bloodless Prostate Cancer Surgery”

  1. Marc Greenstein Avatar

    I 100% agree. There are no quarantees when comes to medicine and surgery. It is clear that robotic surgery significantly decreases bloodloss for any operation. It is nice to tell patients that the risk of transfusion is less than 1% (based on your experience at Beth Israel.) There is always the “what if”. A patient can bleed after the surgery is completed and they need to be informed of possibly needed a transfusion.
    As far as the term “bloodless”, that is all marketing tactics to me.

  2. Rita Avatar

    I agree that the term bloodless surgery is misleading. A more accurate term is blood conservation surgery.

  3. Naveen Kella Avatar

    I like the term blood conservation as well. I perform these surgeries in Texas at Urology San Antonio and have really liked reading your posts! I have had 2 patients needing transfusions in about 350 cases. Both were from bleeders post-op because the cases themselves were very routine…

  4. John Petrides Avatar
    John Petrides

    I like the term Transfusion-Less Surgery. It does sound better, but, it is somehow a bigger word for it.However, I wish to congradulate you for the very nice approach in dealing with this subject. Keep up the good work.