Effect of Selective Serotonin Reuptake Inhibitors On Intraoperative Blood Loss in Patients Undergoing Prostatectomy.

Selective serotonin reuptake inhibitors (SSRI's) are commonly used in the treatment of depression and anxiety disorders. They induce a mild inhibition of platelet aggregation; this is thought to be mediated by a depletion of platelet serotonin. Some studies have shown an association between SSRI intake and GI bleeding; aspirin and non-steroidal anti-inflammatory drugs (NSAID's) might increase the risk even more when used concomitantly. An increase in surgical bleeding during orthopedic procedures has also been noted in users of this class of medications. To our knowledge, there is no published data on the effect of SSRI's on hemostasis during prostatectomy. The objective of this study was to examine if patients taking a SSRI and undergoing prostatectomy had a higher rate of bleeding and required more red cell transfusions than patients not taking such a medication.

Institutional review board approval was obtained to perform this retrospective study; the initial phase was conducted on 1,308 adults undergoing either suprapubic, retropubic, perineal, laparoscopic or robotic-assisted laparoscopic prostatectomy for prostate cancer between 2002 and 2008 at the Lahey Clinic. The Department of Urology database was queried to identify relevant surgical cases, the amount of blood lost and the number of red cell transfusions given during each procedure. Patient records available through the Lahey electronic system were reviewed to identify pre-operative medications and comorbidities having a potential to affect surgical hemostasis. The use of antidepressants by type, aspirin, clopidogrel, NSAID's and anticoagulants was recorded, as were a history of liver disease, renal insufficiency, thrombocytopenia or any coagulopathy. Statistical analysis was conducted with the SAS software, version 9.2; means were compared using Student's T-test.

3.2% of the patients included in the analysis were on a SSRI until the day of the surgery. Aspirin, clopidogrel and warfarin were discontinued in view of the upcoming procedure, with rare exceptions. Analysis was stratified according to the type of prostatectomy, either open (suprapubic, retropubic or perineal) or laparoscopic (with or without robotic assistance). Mean age was 58.2 years for SSRI users and 59.2 years for non-users (p=0.31). There was no significant difference in the distribution of comorbidities between SSRI users and non-users. In the open prostatectomy group, use of aspirin in the immediate pre-operative period was more prevalent in the group of SSRI users compared to non-users (6.3% vs 0.8%, p=0.03), as was the uninterrupted use of NSAID's (6.3% vs 0.2%, p=0.0002); please see table 1 for details. In the open surgery group, mean volume of blood lost was 794 mL for SSRI users, compared to 878 mL for non-users (p=0.57). In the laparoscopic surgery group, mean blood loss was 178 mL in SSRI users vs 188 mL in non-users (p=0.69). In the laparoscopic procedure group, only 1 out of 807 patients was transfused. In the open surgery group, 31.3% of SSRI users required one unit of red cells, compared to 29.8% for non-users (p=NS). Only one patient died in the hospital; he belonged to the laparoscopic approach group (SSRI non-user).

In this study, the use of a SSRI did not confer an increased risk of surgical bleeding. This was noted even in patients undergoing open prostatectomy, in spite of more patients in the SSRI user group taking aspirin or a NSAID up to the day of the surgery.

No relevant conflicts of interest to declare.