Alternatives To Allogeneic Transfusion

The principal advantage of autologous transfusion is the avoidance of complications associated with allogeneic blood transfusion. In clinical practice today, we utilize three forms of autologous transfusions: predonation of autologous blood;

acute normovolemic hemodilution; and reinfusion of blood via cell saver.

Preoperative blood donation is still the standard of care in many institutions in the USA today. The first autologous transfusion was described in 1874.48 With this technique, patients get their own blood, which is the safest form of transfusion. With predonation, patients are reducing their exposure to allogeneic blood. During RRP without predonation, the patient allogeneic transfusion rate is 60-70%,17 but only 5-20% of patients who predonated blood required allogeneic transfusion. Nevertheless, predonation recently has undergone some critical reappraisal. In many centers, blood loss during RRP is steadily decreasing. Improved surgical technique has further contributed to diminished blood loss to the point that autologous predonation has become unnecessary.49 Also reappraisal of the trigger points for transfusion has diminished the overall need for blood during RRP. This surgery is usually performed in patients whose life expectancy is at least 10 years and significant comorbidity is infrequent. For sicker patients, we use alternative treatments, such as external beam radiation, seed implant or cryosurgery. One recent study showed no difference in homologous blood transfusion based on pre-operative autologous donation status.50 In their report, the recent rate of homologous transfusion was less than 3% overall with no difference between donors and nondonors. The American Society of Anesthesiologists Task force on Blood Component Therapy suggested that transfusion is usually indicated when hemoglobin is less than 6g/ml.51

Autologous blood transfusion in urology is steadily decreasing. Goad etal. identified three phases regarding the use of allogeneic transfusion for RRP.49 In the initial phase between 1983 and 1988, autologous blood donation was used preopera-tively in only 13%. The allogeneic transfusion rate was 62% for non-donors and 46% for donors. In the second phase from 1989 to 1991, autologous donation increased to 81% and the allogeneic transfusion decreased to 37% for non-donors and to 7% for donors. During the third phase from 1991-1992, the homologous transfusion rate further decreased to 11% for non-donors and to 4% for donors. The transfusion triggers were lowered to less than 7 mg/dl for hemodynamically stable patients.

Similar results in the use of allogeneic transfusion was reported by Toy etal.52 who found for patients who underwent RRP in a period from 1987 to 1991 rates of 66% for non-donors and 20% for donors. Koch and Smith reported even further decrease in the use of allogeneic transfusion.18 Their average intraoperative blood loss was only 579 ml and their allogeneic transfusion rate of only 2.4%. Their experience showed that 98% of patients can undergo RRP without transfusion. The discharge hematocrit in their patients was 33%. None of their patients had any ischemic cardiovascular or cerebrovascular accident in the postoperative period. Their conclusion was that the elimination of autologous blood donation was a cost-effective measure in their hands. Shekarriz et al. recently recommended against the use of autologous blood donation because the need for allogeneic transfusion was less than 1%.10

Autologous transfusion is much less risky than allogeneic but it is not risk-free. The process of donation itself can be complicated for some patients. In one report, the incidence of vasovagal reaction was 2-5%.53 Incorrect labeling of donated blood can lead to clerical error not only for allogeneic but also for autologous blood. Infection of stored blood is another possible risk. Collecting and storing of autologous blood is more expensive than for allogeneic blood. Autologous blood does not need to undergo the same degree of screening and testing and most of the unused blood is discarded.

Many of the reported series on blood loss are based on a single surgeon or a single institution, and broad extrapolations are not always applicable to the general urological community. Even in the most experienced hands, blood loss can be high. In those cases, two or three units of autologous blood are not sufficient and allogeneic transfusion will be necessary. In the near future, at least for urological oncology surgery, auto-logous transfusion will no longer be necessary.

In acute normovolemic hemodilution (ANH) blood is removed immediately before surgery and replaced by colloids or crystalloids. Although the patient's hematocrit is lowered, more colloids and crystalloids and smaller amounts of red blood cells are lost during the surgery.54 This method represents a cost-effective alternative to predonation of autologous blood.55 When acute normovolemic hemodilution is used, the blood never leaves the operating room, thereby completely eliminating potential clerical error; it is effective, simple and convenient. It is the only transfusion technique that provides fresh, whole blood for immediate use in the operating room. It probably is the most frequently underused form of auto-logous transfusion because it is perceived by some urologists as a technique that prolongs operating time, requiring additional personnel and costly monitoring.56 During the initial stage of RRP, there is no significant blood loss, especially if the patient is first undergoing pelvic lymphadenectomy. This gives the anesthesiologist the time to complete hemodilution after induction of anesthesia. Atallah etal. documented that hemodilution could be performed in awake or anesthetized patients without jeopardizing hemodynamic stability.57 In a study by Monk et al. the authors found that the central venous pressure remained normal throughout the hemodilu-tion.55 There was no perioperative cardiovascular morbidity. ANH was well tolerated even in elderly patients. The duration of hospital stay was shortened. ANH offers extra convenience for patients, as they do not need to come to the hospital for autologous predonation.

Cell savers have been used in surgical procedures since 1970. In cell saver the blood salvaged during surgery is passed through a filtration and centrifuge system, which separates functional red blood cells, which are then reinfused into the patient. Until recently, this technique has been avoided in oncological surgery for fear of reinfusing malignant cells. Many reports indicate that reinfusion with cell saver is safe and does not lead to increased rate of malignancy.58'59 Recently introduced leukocyte depletion filters eliminate residual malignant cells together with leukocyte-associated infectious viruses.60

Blood can be collected even postoperatively. Significant bleeding postoperatively is rare, especially bleeding requiring transfusion. A small hematoma can be treated expectantly. A larger one could cause some anatomic deformity in the anastomotic area between bladder and urethra, and should be explored as in any other surgery. Hedican and Walsh reported on seven patients with delayed postoperative bleeding in their series of 1350 patients.61 Four were treated surgically and did well. The remaining three were treated conservatively by draining their pelvic hematoma through urethral anastomosis; all three developed bladder neck contracture and urinary incontinence persisted in two patients.

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