Impact of preoperative fasting duration and prostate mass on postoperative bleeding after transurethral enucleation of the prostate: A risk factor analysis

Abstract

Objective

This study explored the impact of preoperative fasting duration on patients who underwent transurethral enucleation of the prostate and analyzed the risk factors for postoperative bleeding.

Methods

A retrospective analysis was conducted among 51 patients who underwent transurethral enucleation of the prostate for benign prostatic hyperplasia between December 2021 and March 2024. Baseline and perioperative data were collected. The impact of long versus short preoperative fasting was compared. Univariate and multivariate logistic regression analyses were used to identify risk factors for bleeding complications after transurethral enucleation of the prostate.

Results

The mean hemoglobin difference in the short fasting group was 14.43 ± 11.23 g/L, while that in the long fasting group was 17.21 ± 12.21 g/L, showing a statistically significant difference (p = 0.048). The mean postoperative hospital stay was 3.39 ± 1.05 days in the short fasting group and 4.21 ± 1.68 days in the long fasting group, showing a statistically significant difference (p = 0.047). Univariate and multivariate regression analyses identified prostate mass (p = 0.045) and preoperative fasting duration (p = 0.033) as independent risk factors for postoperative bleeding in patients who had undergone transurethral enucleation of the prostate.

Conclusion

Patients who had undergone transurethral enucleation of the prostate after longer preoperative fasting experienced a more significant decline in hemoglobin levels and required longer postoperative hospitalization. Prostate mass and preoperative fasting duration were identified as independent risk factors for postoperative bleeding after transurethral enucleation of the prostate.

Keywords

Transurethral enucleation of the prostate fasting duration bleeding risk factors

Introduction

Benign prostatic hyperplasia (BPH) is a major cause of lower urinary tract symptoms in older men, with its prevalence increasing with age.^1,2 Surgical treatment is often the most effective intervention.³ Transurethral resection of the prostate has been considered the “gold standard” for BPH treatment for decades;⁴ however, in recent years, transurethral enucleation of the prostate (TUEP) has become increasingly popular and is being widely used.⁵

The purpose of preoperative fasting is to reduce the risk of perioperative aspiration and postoperative nausea and vomiting. However, prolonged fasting can have adverse effects on patients.⁶ A prolonged lack of water intake can lead to preoperative dehydration, affecting electrolyte balance and potentially causing intraoperative and postoperative complications such as hypotension and electrolyte disturbances.^7,8 Prolonged fasting can also lead to fatigue and weakness, affecting the patient’s preoperative physical status and postoperative recovery. Dehydration and hypoglycemia may increase the risk of postoperative nausea and vomiting, prolonging the recovery time.^9,10 This study aimed to explore the impact of prolonged versus short preoperative fasting on patients who underwent TUEP.

Bleeding is a common complication after TUEP, requiring timely control and treatment.¹¹ Although bladder irrigation and hemostatic medications are usually sufficient to control postoperative bleeding in most cases, some patients with more severe bleeding may require interventional embolization and other surgical interventions.¹² Previous studies have reported transfusion rates of 5.0%–7.5% due to postoperative bleeding.^13,14 Therefore, factors contributing to postoperative bleeding after TUEP are worth investigating as they can provide a reference for clinical treatment.

Methods

In total, 51 patients with BPH underwent TUEP at Peking University First Hospital-Miyun Hospital between December 2021 and March 2024. Among them, 23 were in the short fasting group and 28 were in the long fasting group. Baseline and perioperative data were collected. Baseline data included age, body mass index (BMI), and hypertension, diabetes, and coronary heart disease status. Perioperative data included prostate mass, heart rate on admission, systolic and diastolic blood pressure on admission, preoperative blood sodium (Na) level, preoperative blood potassium (K) level, preoperative hemoglobin level, intraoperative heart rate, intraoperative systolic and diastolic blood pressure, postoperative heart rate, postoperative systolic and diastolic blood pressure, surgery time, intraoperative blood loss, postoperative blood Na level, postoperative blood K level, and postoperative hemoglobin level. In our center, the routine fasting and water deprivation time is 10 p.m. the night before surgery, and patients were instructed to fast and abstain from water simultaneously. All surgeries were performed by the same physician who has extensive experience in urological procedures. None of the patients had taken anticoagulant or antiplatelet medications before surgery.

In this study, short fasting was defined as ≤12 h before surgery, and long fasting was defined as >12 h before surgery. The endpoint for risk factor analysis was postoperative bleeding, defined as a drop in hemoglobin level of ≥20 g/L from before the surgery to the first postoperative day. A drop in hemoglobin level of <20 g/L was not considered a postoperative bleeding complication. Hemoglobin drop (g/L) = preoperative hemoglobin − postoperative day 1 hemoglobin.

The inclusion criteria were as follows: (a) age 45–85 years; (b) patients scheduled to undergo TUEP; and (c) availability of complete baseline and follow-up data.

The exclusion criteria were as follows: (a) history of prostate cancer or postoperative pathology indicating prostate cancer; (b) coagulation disorders; and (c) cardiopulmonary dysfunction.

This study was conducted in accordance with the principles of the Helsinki Declaration (as revised in 2013) and approved by the Ethics Committee of Peking University First Hospital-Miyun Hospital. The need for informed consent was waived for this retrospective analysis. The data presented in this study have been de-identified to remove patient-identifying information.

Surgical technique

General anesthesia was used. After successful anesthesia induction, patients were positioned in the lithotomy position, and standard disinfection and draping were performed. Thulium laser energy was set at 60 W, 1.5 J. A 25 F cystoscope was inserted through the urethra to observe the prostate lobes, median lobe, anterior lobe hypertrophy, ureteral orifices, and bladder. A U-shaped groove was cut at the verumontanum level using a thulium laser fiber. Sharp and blunt dissection techniques were combined to enucleate the prostate lobes along the surgical capsule plane. The anterior lobe was enucleated at the level of the verumontanum, extending appropriately to the left and right lobes, entering the bladder at approximately 3 and 9 o'clock directions of the bladder neck, facilitating the visualization of the ureteral orifices. Then, the anterior lobe was enucleated, pushing the prostate into the bladder. Thorough hemostasis was achieved on the prostate wound surface. The enucleated prostate tissue was then morcellated and aspirated. Before withdrawing the scope, a normal urine jet from both ureteral orifices was observed, the prostate apex was completely open, and the urine flow was smooth under abdominal pressure, showing no leakage without abdominal pressure. A three-way urinary catheter was placed for continuous bladder irrigation.

Statistical analyses

Statistical analyses were performed using SPSS 22.0 (IBM Corp., Armonk, NY, USA). Quantitative variables included age, BMI, prostate mass, heart rate on admission, systolic and diastolic blood pressure on admission, preoperative blood Na level, preoperative blood K level, preoperative hemoglobin level, intraoperative heart rate, intraoperative systolic and diastolic blood pressure, postoperative heart rate, postoperative systolic and diastolic blood pressure, surgery time, intraoperative blood loss, postoperative blood Na level, postoperative blood K level, and postoperative hemoglobin level. Qualitative variables included sex as well as hypertension, diabetes, and coronary heart disease status. The Shapiro–Wilk test was used for normality testing. Normally distributed quantitative data were expressed as mean ±standard deviation, and skewed data were described as median (range). Normally distributed continuous variables were analyzed using t-tests, while non-normally distributed variables were analyzed using the Mann–Whitney U test. Categorical variables were analyzed using Fisher’s exact test. Univariate and multivariate regression analyses were performed to determine independent risk factors for postoperative bleeding after TUEP. The binary logistic regression model was used to calculate the strength of association between exposure factors and outcomes, which was expressed as odds ratios (ORs) and their 95% confidence intervals (CIs). A p-value <0.05 was considered to indicate statistical significance.

Results

Baseline data of patients

The baseline data of patients are shown in Table 1. In total, 51 patients with BPH underwent TUEP, with a mean age of 68.51 ± 7.16 years. The mean prostate mass was 73.84 ± 47.22 g. There were 23 patients (45.10%) in the short fasting group and 28 (54.90%) in the long fasting group.

Table 1.

Baseline characteristics of the patients.

Variable	Mean (SD) or n/N
Patients	51
Mean age (years)	68.51 ± 7.16
BMI (kg/m²)	23.55 ± 2.94
Hypertension, n (%)
Yes	15 (29.41)
No	36 (70.59)
Diabetes mellitus, n (%)
Yes	4 (7.84)
No	47 (92.16)
CHD, n (%)
Yes	4 (7.84)
No	47 (92.16)
Prostate mass (g)	73.84 ± 47.22
Heart rate at admission (beats per minute)	74.67 ± 6.51
Systolic blood pressure at admission (mmHg)	130 ± 12.09
Diastolic blood pressure at admission (mmHg)	79.27 ± 7.90
Preoperative blood Na (mmol/L)	140.24 ± 1.96
Preoperative blood K (mmol/L)	3.99 ± 0.30
Preoperative hemoglobin (g/L)	140.45 ± 14.46
Heart rate during surgery (beats per minute)	60.22 ± 10.93
Systolic blood pressure during surgery (mmHg)	125.98 ± 17.41
Diastolic blood pressure during surgery (mmHg)	70.82 ± 9.08
Postoperative heart rate (beats per minute)	74.29 ± 6.31
Postoperative systolic blood pressure (mmHg)	124.80 ± 14.05
Postoperative diastolic blood pressure (mmHg)	74.41 ± 12.42
Surgery duration (min)	110.86 ± 47.21
Intraoperative blood loss (mL)	69.80 ± 37.55
Postoperative hospital stay duration (days)	3.86 ± 1.50
Postoperative blood Na level (mmol/L)	140.21 ± 1.76
Postoperative blood K level (mmol/L)	3.91 ± 0.36
Postoperative hemoglobin (g/L)	124.59 ± 14.36
Fasting duration
≤12 h	23 (45.10)
>12 h	28 (54.90)

BMI: body mass index; CHD: coronary heart disease; Na: sodium; K: potassium.

Comparison of short and long preoperative fasting among TUEP patients

Clinical data of patients in the short and long fasting groups are shown in Table 2. The hemoglobin difference in the short fasting group was 14.43 ± 11.23 g/L, while that in the long fasting group was 17.21 ±12.21 g/L, showing a statistically significant difference (p = 0.048). The postoperative hospital stay was 3.39 ± 1.05 days in the short fasting group and 4.21 ± 1.68 days in the long fasting group, showing a statistically significant difference (p = 0.047).

Table 2.

Comparison of the prognosis of patients between the short fasting group and long fasting group.

Variable	Short fasting group	Long fasting group	p-value
Patients	23	28
Mean age (years)	69.43 ± 6.78	67.75 ± 7.79	0.406
BMI (kg/m²)	23.04 ± 2.39	23.98 ± 3.27	0.269
Hypertension, n (%)			0.276
Yes	5 (21.73)	10 (35.71)
No	18 (78.26)	18 (64.29)
Diabetes mellitus, n (%)			0.400
Yes	1 (4.35)	3 (10.71)
No	22 (95.65)	25 (89.29)
CHD, n (%)			0.059
Yes	0 (0)	4 (14.29)
No	23 (1)	24 (85.71)
Prostate mass (g)	69.18 ± 30.70	77.30 ± 56.17	0.565
Heart rate difference (beats per minute)	1.26 ± 10.28	−0.36 ± 5.73	0.483
Systolic blood pressure difference (mmHg)	2.39 ± 19.93	7.5 ± 14.39	0.301
Diastolic blood pressure difference (mmHg)	5.17 ± 15.42	4.61 ± 9.08	0.871
Blood Na difference (mmol/L)	0.19 ± 1.51	−0.10 ± 1.99	0.561
Blood K difference (mmol/L)	0.07 ± 0.39	0.08 ± 0.36	0.950
Hemoglobin difference (g/L)	14.43 ± 11.23	17.21 ± 12.21	0.048
Heart rate during surgery (beats per minute)	60.22 ± 10.89	60.21 ± 10.97	0.999
Systolic blood pressure during surgery (mmHg)	124.65 ± 14.25	127.07 ± 19.56	0.622
Diastolic blood pressure during surgery (mmHg)	70.43 ± 8.11	71.14 ± 9.79	0.728
Surgery duration (min)	124.04 ± 49.58	100.04 ± 42.19	0.077
Intraoperative blood loss (mL)	70.87 ± 38.66	68.93 ± 36.58	0.854
Postoperative hospital stay (days)	3.39 ± 1.05	4.21 ± 1.68	0.047

BMI: body mass index; CHD: coronary heart disease; Na: sodium; K: potassium.

Risk factors for postoperative bleeding after TUEP

The clinical data of patients in the control and bleeding groups are shown in Table 3. The control group included 35 (68.63%) patients, and the bleeding group included 16 (31.37%) patients. The mean prostate mass was 69.92 ± 28.78 g in the control group and 99.88 ± 62.25 g in the bleeding group, showing a statistically significant difference (p = 0.012). In the control group, 15 (42.86%) patients underwent long preoperative fasting, while in the bleeding group, 13 (81.25%) patients underwent long preoperative fasting; this difference was also statistically significant (p = 0.011).

Table 3.

Comparison of the prognosis of patients between the control group and bleeding group.

Variable	Control group	Bleeding group	p-value
Patients	35	16
Mean age (years)	67.83 ± 7.39	70 ± 6.36	0.319
BMI (kg/m²)	23.89 ± 3.29	22.81 ± 1.78	0.229
Hypertension, n (%)			0.391
Yes	9 (25.71)	6 (37.50)
No	26 (74.29)	10 (62.50)
Diabetes mellitus, n (%)			0.403
Yes	2 (5.71)	2 (12.50)
No	33 (94.29)	14 (87.50)
CHD, n (%)			0.159
Yes	4 (11.43)	0 (0.00)
No	31 (88.57)	16 (100.00)
Prostate mass (g)	69.92 ± 28.78	99.88 ± 62.25	0.012
Heart rate at admission (beats per minute)	74.31 ± 6.33	74.44 ± 6.82	0.569
Systolic blood pressure at admission (mmHg)	130.11 ± 13.08	129.75 ± 9.55	0.92
Diastolic blood pressure at admission (mmHg)	78.86 ± 8.19	80.19 ± 7.13	0.578
Preoperative blood Na (mmol/L)	140.24 ± 1.74	140.25 ± 2.33	0.982
Preoperative blood K (mmol/L)	4.00 ± 0.28	3.95 ± 0.32	0.577
Preoperative hemoglobin (g/L)	138.97 ± 14.25	143.69 ± 14.40	0.285
Heart rate during surgery (beats per minute)	58.89 ± 10.32	63.12 ± 11.65	0.207
Systolic blood pressure during surgery (mmHg)	127.09 ± 16.90	123.56 ± 18.23	0.504
Diastolic blood pressure during surgery (mmHg)	71.4 ± 9.37	69.56 ± 8.28	0.504
Surgery duration (min)	108.66 ± 46.59	112.4 ± 47.99	0.622
Intraoperative blood loss (mL)	70.57 ± 36.64	69.33 ± 10.41	0.829
Fasting duration			0.011
≤12 h	20 (57.14)	3 (18.75)
>12 h	15 (42.86)	13 (81.25)

BMI: body mass index; CHD: coronary heart disease; Na: sodium; K: potassium.

Univariate and multivariate regression analyses identified prostate mass (p = 0.033) and preoperative fasting duration (p = 0.016) as risk factors for postoperative bleeding after TUEP. Prostate mass (p = 0.045) and preoperative fasting duration (p = 0.033) were also independent risk factors for postoperative bleeding (Table 4).

Table 4.

Univariate and multivariate analyses of bleeding in patients who underwent transurethral enucleation of the prostate.

	Univariate analysis		Multivariate analysis
Characteristic	OR (95% CI)	p-value	OR (95% CI)	p-value
Hypertension, yes vs. no	0.693 (0.142–1.757)	0.280
Diabetes, yes vs. no	0.971 (0.037–3.911)	0.415
BMI	0.116 (0.914–1.378)	0.269
Age	0.034 (0.893–1.047)	0.406
Prostate mass	1.020 (1.002–1.039)	0.033	1.021 (1.000–1.042)	0.045
Heart rate at admission	0.034 (0.887–1.055)	0.448
Systolic blood pressure at admission	0.001 (0.955–1.046)	0.981
Diastolic blood pressure at admission	0.05 (0.884–1.023)	0.175
Preoperative blood Na	0.079 (0.812–1.442)	0.589
Preoperative blood K	0.473 (0.096–4.043)	0.620
Preoperative hemoglobin	0.007 (0.969–1.046)	0.736
Heart rate during surgery	0.000 (0.951–1.052)	0.999
Systolic blood pressure during surgery	0.008 (0.976–1.041)	0.622
Diastolic blood pressure during surgery	0.009 (0.949–1.072)	0.782
Surgery duration	0.011 (0.977–1.001)	0.077
Intraoperative blood loss	0.001 (0.984–1.013)	0.854
Fasting duration, ≤12 h vs. >12 h	0.173 (0.042–0.718)	0.016	0.190 (0.041–0.874)	0.033

OR: odds ratio: CI: confidence interval; BMI: body mass index; Na: sodium; K: potassium.

Discussion

Preoperative fasting provides the stomach enough time to empty to prevent aspiration of gastric content during general anesthesia. Our center routinely enforces fasting from 10 p.m. the night before surgery. However, due to fluctuations in surgical schedules, patients scheduled for surgery later in the day may undergo prolonged fasting. This retrospective study primarily found that longer fasting duration correlated with prolonged postoperative hospital stays and more significant blood loss.

Prolonged preoperative fasting can lead to hypovolemia and metabolic imbalances, potentially increasing the risk of adverse events such as arterial hypotension, venous access difficulty, and hypoglycemic events.¹⁵ Rajan et al.¹⁰ found that consuming carbohydrates 2 h before surgery reduced postoperative nausea and vomiting as well as shortened hospital stays. Zhou et al.¹⁶ reported a case wherein prolonged preoperative fasting caused hunger ketosis acidosis. Gregory et al.¹⁷ found that intraoperative hypotension could be exacerbated by preoperative fasting and that it was significantly associated with major cardiovascular events. In our study, we found no significant differences in the pre- and postoperative blood pressure, heart rate, blood Na level, and blood K level between the long and short fasting groups. However, significant differences were observed in the drop in hemoglobin level (p = 0.048) and postoperative hospital stay (p = 0.047). The increased hemoglobin loss after prolonged fasting and water deprivation may be associated with the following factors: (a) prolonged fasting and water deprivation (e.g. >12 h) can lead to insufficient water intake, causing blood concentration due to dehydration. This results in a pseudoformal elevation of hemoglobin levels in preoperative blood tests. If true blood loss occurs postoperatively, the actual volume of blood loss may be underestimated because the preoperative concentrated values mask the true baseline; (b) fasting and water deprivation reduce the blood volume and increase blood viscosity, activating platelets and coagulation factors and inducing vascular endothelial injury and microthrombus formation. Short-term mild dehydration may promote coagulation; however, prolonged severe dehydration (e.g. >24 h) can lead to platelet dysfunction and consumption of coagulation factors, paradoxically increasing the risk of bleeding. In this study, the only difference between prolonged preoperative fasting/water deprivation and short-term fasting/water deprivation was observed in the postoperative hemoglobin level, while no difference was found in the intraoperative blood loss. This may also be attributed to blood concentration. Clinically, fasting duration should be carefully monitored to avoid prolonged fasting. Although preoperative fluid infusion can expand the blood volume to an extent, it may still cause adverse events. Regarding the infusion protocol for glucose saline, we suggest determining the dosage based on the patient’s body weight. For ordinary patients, we consider that a volume of 500–1000 mL of glucose saline may be appropriate.

Postoperative bleeding is the second-most concerning complication after urinary incontinence following TUEP.¹⁸ This study found significant differences in prostate mass between the control and bleeding groups (p = 0.012), with larger prostate mass associated with a higher likelihood of postoperative bleeding. Additionally, preoperative fasting duration showed a significant association with bleeding volume (p = 0.011), with longer fasting duration increasing the postoperative bleeding volume. Mian et al.¹⁹ found that prostate size was significantly associated with the incidences of bladder neck contracture and urethral stricture but not significantly with postoperative bleeding, contrary to our findings, possibly owing to differences in surgical techniques and experience.

This study identified prostate mass (p = 0.033) and preoperative fasting duration (p = 0.016) as risk factors for postoperative bleeding after TUEP. Prostate mass (p = 0.045) and preoperative fasting duration (p = 0.033) were also independent risk factors for postoperative bleeding. Teng et al.¹⁸ found that prostate size was a risk factor for bleeding and clot retention after BPH surgery. Tagreda et al.²⁰ also found that prostate size significantly affects postoperative bleeding and surgical outcomes. Chen et al.²¹ studied the impact of prostate size on perioperative and postoperative outcomes of TUEP and found that prostate size affected blood loss and surgical outcomes. Wuensch et al.²² found that longer preoperative fasting increased the risk of postoperative bleeding, especially in major surgeries. Larger prostate mass is linked to higher surgical difficulty and larger wound surfaces, increasing the likelihood of bleeding, thereby emphasizing the need for thorough and careful hemostasis during surgery. Long preoperative fasting should be avoided, and patients should be provided with appropriate carbohydrates or fluids when delays occur in surgery time.

Prolonged preoperative fasting and water deprivation may not only lead to excessive postoperative hemoglobin loss but also cause dehydration and electrolyte disorders, thereby weakening immune system function and increasing the risk of postoperative infections.^16,23,24 Therefore, in clinical practice, it is essential to optimize fasting management to reduce the related risks while ensuring surgical safety. This primarily involves reasonably scheduling surgery to avoid prolonged fasting and water deprivation. For patients at risk of prolonged fasting, adequate supplementation with glucose saline should be ensured to increase the blood volume.

This study has certain limitations. First, the sample size was relatively small, potentially introducing bias in the analysis. Additionally, as the study was conducted at a single center, it lacks multicenter data, potentially limiting the generalizability of the results.

Conclusion

Patients undergoing TUEP with longer preoperative fasting experienced a more significant decline in hemoglobin level and required longer hospital stays. Prostate mass and preoperative fasting duration were identified as independent risk factors for postoperative bleeding.

Supplemental Material

sj-pdf-1-imr-10.1177_03000605251369111 - Supplemental material for Impact of preoperative fasting duration and prostate mass on postoperative bleeding after transurethral enucleation of the prostate: A risk factor analysis

Supplemental material, sj-pdf-1-imr-10.1177_03000605251369111 for Impact of preoperative fasting duration and prostate mass on postoperative bleeding after transurethral enucleation of the prostate: A risk factor analysis by Zihui Gao, Jiazhao Cui and Chunji Wang in Journal of International Medical Research

Footnotes

Acknowledgements

None.

Author contributions

Conception and design: Chunji Wang and Zihui Gao

Administrative support: Chunji Wang and Zihui Gao

Provision of study materials or patients: Chunji Wang and Zihui Gao

Collection and assembly of data: Chunji Wang and Zihui Gao

Data analysis and interpretation: All authors

Manuscript writing: All authors

Final approval of manuscript: All authors

Data availability statement

The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declaration of conflicting interests

None declared.

Ethical statement

The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The trial was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the Ethics Committee of Peking University First Hospital-Miyun Hospital (NO.: 2023-017-001).

Funding

None.

Informed consent

The need for informed consent for this retrospective analysis was waived.

ORCID iDs

Zihui Gao

Chunji Wang

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