Application of plasma electrocautery combined with self-made irrigation catheter in the treatment of bladder blood clot tamponade: A retrospective study of 21 patients

Application of plasma electrocautery combined with self-made irrigation catheter in the treatment of bladder blood clot tamponade: A retrospective study of 21 patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Application of plasma electrocautery combined with self-made irrigation catheter in the treatment of bladder blood clot tamponade: A retrospective study of 21 patients Shigao Xu, Pu Cao, Tieshi Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6009119/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: To explore the application effect of plasma electrocautery combined with self-made irrigation catheter in the treatment of bladder clot tamponade. Methods: We retrospectively analyzed 21 cases of bladder clot tamponade admitted to our hospital from October 2020 to October 2024. The patients were divided into two groups: the experimental group (plasma electrocautery combined with self-made irrigation catheter) and the control group (plasma electrocautery alone). We compared the two different surgical methods in terms of blood clot clearance time, size of blood clots removed, postoperative bladder irrigation time, and postoperative rebleeding. Results: The sizes of the blood clots removed in the two groups were (178.50±43.85) g and (167.27±50.12) g，respectively. The operation times were (51.00±12.01) minutes and (36.64±8.19) minutes, respectively. The postoperative bladder irrigation times were (2.05±0.76) days and (1.32±0.60) days, respectively. There was no statistically significant difference between the two groups in terms of the size of blood clots removed and the probability of postoperative rebleeding. However, it was statistically significant in terms of operation time and postoperative bladder irrigation time compared to the use of plasma electrocautery alone (P<0.05). Conclusion: The application of plasma electrocautery combined with a self-made irrigation catheter in the treatment of bladder blood clot tamponade could effectively improve the clearance rate of blood clots within the bladder and accelerate the recovery of patients' conditions. Bladder blood clot tamponade Plasma electrocautery self-made irrigation catheter Treatment Background Bladder blood clot tamponade is one of the more common and challenging emergencies in urology, which can be caused by various reasons(1-5), such as bleeding after transurethral resection of the prostate (TURP)， bleeding from bladder tumors and prostate cancer and so on. If not managed properly, it can cause significant suffering for the patient, increase their financial burden, severely affect the doctor-patient relationship, and even endanger the patients' life. Patients often present with inability to urinate, a distended bladder area, and dull percussion sounds over the bladder area. Ultrasound(4) or computerized tomography (CT) scans can provide a definitive diagnosis. Traditionally, open surgery has been used to clear bladder blood clots, but this approach involves significant patient trauma, a high risk of recurrent bleeding, and slow postoperative recovery. Other methods include bladder irrigation to flush out blood clots, plasma electrocautery combined with irrigation to clear blood clots, and tissue morcellators to remove blood clots. However, due to various factors such as poor visibility, lengthy surgical time, the high cost and limited availability of equipment, it is difficult to find a surgical method suitable for hospitals at all levels. Our hospital has attempted to use a plasma electrocautery in conjunction with a self-made irrigation catheter to treat with bladder blood clot tamponade. This method is relatively quick, effective, minimally invasive, and suitable for most hospitals. Patients and Methods We selected 21 cases of bladder blood clot tamponade from October 2020 to October 2024 in our hospital, including 10 males and 11 females, with ages ranging from 38 to 66 years old. Among them,10 cases were due to bladder tumor bleeding, 4 cases were due to bleeding after transurethral resection of the prostate (TURP), 4 cases were due to bleeding after percutaneous nephrolithotomy, and 3 cases were due to bleeding after ureteroscopy lithotripsy. Preoperatively, all 21 patients underwent catheterization, and a large amount of blood clots blocking the urethra were observed. Using traditional methods, such as repeatedly aspirating with a 20ml or 50ml syringe through the catheter, the bladder blood clots could not be sucked out of the bladder, and all patients were unable to urinate after catheter removal. Preoperatively, all cases were confirmed to had bladder blood clot tamponade by bedside ultrasound or CT scan. This study was approved by the hospital's ethical review board, and informed consent were obtained from all patients. The causes and composition of bleeding in the two groups of patients were shown in Table S1. Surgical Method After spinal or general anesthesia, the patient was placed in the lithotomy position. A 26Fr plasma resection scope (STORZE) was inserted into the bladder through the urethra to routinely inspect the urethra and bladder, observing for any significant urethral bleeding, bladder rupture, or bladder bleeding. A segment of a disposable ordinary suction catheter, approximately 20cm in length was used (Produced by Jiangsu HuaXia medical devices limited liability company with a diameter of 8mm, Fig S1). The plasma resection scope's water inlet was connected to saline solution to fill the bladder, and the outer sheath of the resection scope (26Fr, with a diameter of about 8.58mm) was left in place. A self-made irrigation catheter was connected inside the outer sheath of the resection scope. The position of the resection scope's outer sheath in the bladder was adjusted in a timely manner, and a 50ml syringe was connected to the tail end to intermittently create negative pressure to draw out blood clots (Fig S2 and S3). The plasma resection scope was used intermittently to inspect the blood clots and the condition inside the bladder. At this point, most of the blood clots could be removed. For the remaining small amount of blood clots, the plasma resection scope could be used with electrosection to assist in their removal (Electrosection power 120W, Coagulation power 80W). After all blood clots were completely removed, the plasma resection scope was used again to observe any bleeding inside the bladder and the urination from both ureteral orifices. If bleeding points were found during the surgery, they were coagulated to stop the bleeding. If a bladder tumor was detected during the surgery, a bladder tumor resection could be performed. If bladder damage was observed, it may be necessary to perform bladder repair treatment. After the surgery was completed and the scope was withdrawn, a 20Fr three-lumen catheter was left in place for continuous bladder irrigation. In a few days, we can perform ultrasound or CT scans to further confirm the clearance of blood clots in the patient's bladder (Fig S4 and S5). Observational Indicators The study compares the time taken to clear bladder blood clots, the size of the blood clots, the duration of postoperative irrigation, and the incidence of rebleeding between the two groups. The criteria for blood clot removal were: complete clearance of bladder blood clots visible to the naked eye during surgery, clear irrigation fluid, and unobstructed drainage through the catheter. Statistical Analysis Statistical analysis was performed using Statistical Package for Social Science 22.0 (SPSS Inc., Chicago, IL, USA). Quantitative data that conform to a normal distribution were represented as mean ± standard deviation (SD), and comparisons were made using t-tests to compare the differences. Count data were expressed as number of cases (%). A two-tailed test was used, and a difference was considered statistically significant when P <0.05. Results The outcomes were quite satisfactory for the 21 cases of bladder blood clot tamponade after active surgical removal of the blood clots. Among the 3 cases of bladder blood clot tamponade due to bleeding after ureteroscopy lithotripsy, 2 patients had abnormal liver function leading to coagulation dysfunction, which resulted in renal and ureteral bleeding that led to bladder blood clot tamponade, and 1 case was due to ureteral mucosal bleeding. During surgery, plasma resection combined with a self-made irrigation catheter was used to clear the bladder blood clots, with good surgical results. No bleeding from both ureteral orifices or significant bladder bleeding was observed during the surgery. In 4 cases of malignant tumor metastasis invading the bladder and 5 cases of primary bladder tumor bleeding, after clearing the blood clots, varying degrees of abnormal tissue invasion of the bladder wall were observed. Palliative tumor resection or radical tumor resection and electrocoagulation hemostasis were performed with the plasma resection scope. In 1 case of bladder invasion by a malignant tumor from another site, after blood clot removal, a rupture at the top of the bladder was discovered. After communicating with the patient's family, a laparoscopic bladder repair was performed. The sizes of the blood clots removed in the two groups were (178.50±43.85) g and (167.27±50.12) g, respectively. The surgery times were (51.00±12.01) minutes and (36.64±8.19) minutes, respectively. The postoperative bladder irrigation times were (2.05±0.76) days and (1.32±0.60) days, respectively. The number of postoperative rebleeding cases in the two groups was 1(10%) and 1(9%), respectively. There was no statistically significant difference in the size of the blood clots removed or the probability of postoperative rebleeding between the two groups. However, the use of plasma resection combined with a self-made irrigation catheter to remove bladder blood clots was statistically significant in terms of surgery time and postoperative bladder irrigation time compared to the use of a plasma resection scope alone( P <0.05) (Table S2). An 20Fr three-lumen catheter was left in place for continuous bladder irrigation with saline solution after surgery in both groups. The irrigation fluid was clear after surgery, and the urine color in the catheter was clear after stopping of bladder irrigation, with no significant active bleeding observed. Each group had 1 case of late-stage bladder tumor that bled again 1 week after surgical treatment, which was considered to be due to the sloughing off of the wound scab, leading to rebleeding. All patients were satisfied with the results after further treatment. Discussion Bladder blood clot tamponade is one of the common emergencies in urology(4), characterized by massive bleeding in the bladder or upper urinary tract, where blood clots coagulate and block the urethra within the bladder, preventing the blood clots from being expelled from the body, leading to a distended and painful bladder area for the patient. Patients are at risk of continuous urinary bleeding, urinary tract infections, and even bladder rupture(6). The causes of bladder blood clot tamponade in clinical practice are commonly as: patients who took anticoagulant drugs and anticholinergic drugs(1). Patients with bladder tumors or tumor invasion of the bladder, or bladder bleeding caused by large-scale changes in the bladder due to radiation exposure(7, 8). Inadequate hemostasis at the bladder neck and wound site after transurethral resection of the prostate; Bleeding after renal puncture or nephrostomy. Upper urinary tract bleeding due to renal or ureteral surgery, with blood clots coagulating in the bladder leading to bladder blood clot tamponade. Bleeding and blockage of the bladder after trauma to the urinary system. Other causes of bleeding in the bladder, prostate, or upper urinary tract. The management of bladder blood clot tamponade is time-consuming and labor-intensive, and it is also very painful for the patient. Therefore, how to quickly and effectively handle bladder blood clot tamponade is a problem that urologists need to pay attention. Clinical methods for managing bladder blood clot tamponade vary according to literature reports. For cases with mild bleeding and few blood clots, the common clinical method(9) is to use a disposable syringe to repeatedly aspirate through the catheter to extract blood clots from the body. This method is rather primitive and inefficient. It works well for small blood clots blocking the urethra, but is often not satisfactory for cases of bladder blood clot tamponade. Some scholars(10) use a thoracic catheter instead of a urethral catheter to deal with bladder clots and some scholars(11) used a rectal tube to deal with the problem. Some scholars(12-16) use urokinase, streptokinase and hydrogen peroxide and other thrombolytic treatments, which have shown some effect in certain patients. Some scholars(17, 18) believe that using an electroresection scope combined with an Ellik flushing ball and a metal urinary catheter to handle bladder impaction both yield satisfactory results, with no significant differences in postoperative rebleeding and postoperative bladder irrigation time between the two groups, but the metal urinary catheter has an advantage in terms of surgery time. Although both methods can clear blood clots, we believe that the flushing ball has a lower pressure and is not as efficient in clearing blood clots, and there is a possibility of bladder rupture during the flushing process for some patients(6). The metal urinary catheter is limited by its source and is not available in most grassroots hospitals, thus limiting its use. Some scholars believe that an electric suction device can be used to draw out blood clots. We believe that the suction power of an electric suction device is difficult to control, and the damage to the bladder cannot be estimated, and it cannot handle other conditions in the bladder, such as bleeding or tumors. At the same time, there are scholars(19, 20) who believe that tissue morcellators can be used for bladder blood clot removal. We believe that this method also has certain limitations. Tissue morcellators are mainly designed for prostate enucleation surgery. They can crush the enucleated prostate tissue and quickly suction it out of the body, greatly shortening the surgery time and being safe and reliable. Although tissue morcellators have a high efficiency in clearing blood clots, efficiency and risk coexist. Due to poor water circulation when using tissue morcellators, and many patients have fresh bleeding, it is very easy to damage normal bladder tissue and cause further damage to the bladder mucosa during the crushing and suctioning of blood clots. Additionally, tissue morcellators are relatively expensive and not all grassroots hospitals can be equipped, so their use is also limited（Summary of the methods published works concerning with patients of bladder blood clot tamponade, Table S3. NA = not available）. The plasma electrocautery combined with a self-made irrigation catheter used in our hospital has obvious advantages in handling patients with bladder blood clot tamponade. There was no statistically significant difference in the size of the blood clots removed or the probability of postoperative rebleeding between the two groups. However, the use of plasma resection combined with a self-made irrigation catheter to remove bladder blood clots was statistically significant in terms of surgery time and postoperative bladder irrigation time compared to the use of a plasma resection scope alone. When we clear bladder blood clots, we can first use the plasma resection scope to check the condition of the urethra and bladder. If bladder blood clot tamponade or bladder tumor invasion leading to bladder rupture is found during surgery, it is necessary to perform open or laparoscopic for bladder repair. We used the plasma electrocautery combined with a self-made irrigation catheter to clear bladder blood clots while electrocoagulating to stop bleeding. If conditions permit, palliative bladder tumor resection can be performed to reduce tumor load and greatly reduce the likelihood of subsequent bladder bleeding. On the other hand, the materials for our self-made irrigation catheter are very convenient, using ordinary disposable suction catheters, with negligible cost and very simple production methods. Since the diameter of the plasma resection scope's outer sheath and the self-made irrigation catheter are roughly the same, there is a small gap left around the plasma resection scope's outer sheath after inserting the irrigation catheter, and the irrigation catheter cannot break through the plasma resection scope's outer sheath into the bladder, causing no additional damage to the bladder. At the same time, the pressure can be manually controlled, with basically no damage to the bladder, which is a great advantage compared to the uncontrollable suction power of the electric suction device. However, in our practice, we found that fresh blood clots are processed faster compared to old blood clots. However, this study also has some shortcomings, such as being a single-center study, and the sample size is relatively small, which may have an impact on the results of the study. It is necessary to further accumulate and expand the sample size in future clinical work. Conclusion The plasma electrocautery combined with a self-made irrigation catheter used in our hospital has proven to be a reliable method for managing bladder blood clot tamponade. It is simple, time-saving, and labor-saving, which can alleviate the patient's pain and financial burden. Additionally, the materials required are easily obtainable and can be readily acquired in general hospitals, making it suitable for widespread adoption in most medical facilities. Declarations Acknowledgement None Funding None. Data availability statement The data generated and analyzed during the current study are available from the corresponding author and with the permission of the corresponding author. Author contributions Shigao Xu: writing-original draft, writing-review and editing. Pu Cao: carried out the operation. Tieshi Liu: writing-review and editing, carried out the operation. Ethics approval and consent to participate The present study was approved by institutional Review Board of The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine, and patients’ consent were obtained prior to tissue collection. Patient consent for publication The patients agreed to use his disease information for article publication. Competing interests The authors declare that they have no competing interests. References Miyamae K, Otsuka T, Otsuka Y, Nagayoshi M, Hamada Y. Clinical study of bladder tamponade resulting from clots of blood. The japanese journal of urology. 2006;97(5):743-747. Matsui Y. A case of inflammatory myofibroblastic tumor of the urinary bladder with emergency clinical symptoms similar to bladder cancer. Urology case reports. 2021;38:101740. Maekawa S, Okubo K, Aoki Y, Okada T, Maeda H, Arai Y. A case of bladder hemangioma showing bladder tamponade during late pregnancy. Hinyokika kiyo Acta urologica Japonica. 2000;46(7):483-485. Steffens F, Grüne B, Rassweiler-Seyfried MC. Urinary bladder tamponade-an urological emergency. UROLOGIE. 2024;63(6):578-584. Davydov DS, Tsarichenko DG, Bezrukov EA, et al. Complications of the holmium laser enucleation of prostate for benign prostatic hyperplasia. Urologiia (Moscow, Russia : 1999). 2018(1):42-47. Liu KL, Wang X, Qu CB, Qi JC. The reasons and countermeasures of Bladder Rupture caused by Transurethral Clot Evacuation. PAKISTAN JOURNAL OF MEDICAL SCIENCES. 2021;37(3):903-907. Waneck R, Lechner G, Powischer G. Vascular embolisation in uncontrolled haemorrhages of the bladder caused by tumours and radiation RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin. 1979;130(2):193-196. Ueda N, Sato M, Matsukawa A, et al. Maintaining Serum Hemoglobin Levels Within the Physiological Range Prevented Bladder Tamponade Recurrence Due to Radiation-Induced Hemorrhagic Cystitis: A Case Report. Research and reports in urology. 2023;15:395-401. Clarebrough E, McGrath S, Christidis D, Lawrentschuk N. CATCH-22: a manual bladder washout protocol to improve care for clot retention. WORLD JOURNAL OF UROLOGY. 2018;36(12):2043-2050. Aydin C, Senturk AB, Akkoc A, Topaktas R, Aydin ZB, Ekici M. Clot Retention: Our Experiences with a Simple New Technique of Evacuation with a Thoracic Catheter. Cureus. 2019;11(3):e4329-e. Plawker MW, Hashmat AI. The rectal tube: an excellent catheter for severe clot retention. The Journal of urology. 1997;157(5):1781-1782. Xu M, Jin LA-O, Shan Y, Zhu J, Xue B. A simple and effective method for bladder blood clot evacuation using hydrogen peroxide. J Int Med Res. 2020;45(5):00060520924546. Della Corte M, Clemente E, Cerchia E, et al. Intravesical Agents in the Treatment of Bladder Clots in Children. Pediatric Reports [Internet]. 2023; 15(2):[282-92 pp.]. Warlick CA, Mouli SK, Allaf ME, Wagner AA, Kavoussi LR. Bladder irrigation using hydrogen peroxide for clot evacuation. UROLOGY. 2006;68(6):1331-1332. Jia B, Yin YY, Liu JY, Deng SW, Cai Y, Yao JB. Evaluation of Bladder Clots Using a Nonsurgical Treatment. UROLOGY. 2014;83(2):498-499. Nonato MB, Moraes RS, Herênio YMB, Nunes TF. Management of a Giant Urinary Bladder Clot with Intravesical Thrombolysis. JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY. 2023;34(1):154-155. Jiang CY, Ma L, Chen Y, Qin H. An effective method for evacuation of the bladder blood clot using a metal urinary catheter: A retrospective study of 49 patients. ASIAN JOURNAL OF SURGERY. 2023;46(5):1951-1953. Su YT, Huang KH, Chuang FC, Lan KC. Use of an Ellik evacuator to remove tenacious bladder clots resulting from transvaginal oocyte retrieval: 2 cases and a literature review. TAIWANESE JOURNAL OF OBSTETRICS & GYNECOLOGY. 2019;58(6):880-884. Doersch KM, Navetta AF, Bird ET, El Tayeb MM. Case series: Bladder clot evacuation using a prostate morcellation device. Can Urol Assoc J. 2017;11(7):E311-E314. Wu RH, Shang YG, Liu X, Chen W, Yi SH. Removal of large fibrotic bladder blood clots using prostatic tissue morcellator under real-time ultrasound guidance. FRONTIERS IN SURGERY. 2022;9:889529. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6009119","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":414711574,"identity":"1f052576-bb93-4388-9526-fc077cf7d977","order_by":0,"name":"Shigao Xu","email":"","orcid":"","institution":"The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Shigao","middleName":"","lastName":"Xu","suffix":""},{"id":414711575,"identity":"af9cf540-5a9a-47f8-83f6-8596e6afffd8","order_by":1,"name":"Pu Cao","email":"","orcid":"","institution":"The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Pu","middleName":"","lastName":"Cao","suffix":""},{"id":414711576,"identity":"2f1897d0-6bbb-46d3-b464-4332900a349a","order_by":2,"name":"Tieshi Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYBAC9gYgkWBgI8cGZBlAxBLwa+E5ACQ+FKQZ8wFZxGthnPHhcOI8CbhKQlr4z5hJ8xikJbZJvj1QzFOzjYGfPceA4ecOPFokckBabIzbpPMSjHmO3WaQ7HljwNh7BrcWewkesC2ybdI5Bsa8DbcZDG7kGDAzthF02GHGNskzEC32BLUw5JhJzjA4rNgmwQO1RYKQFom0YosPBmnGbDw5BoZzjt3mkTjzrOBgL16HHd54I+GPjZx8+xkzgzc1t+X425M3PviJRwsDA4eJBJTFZgB2KRAcwKcBmGQef4CymB/gVzkKRsEoGAUjFQAAQphLTgguDZwAAAAASUVORK5CYII=","orcid":"","institution":"The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine","correspondingAuthor":true,"prefix":"","firstName":"Tieshi","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2025-02-11 16:23:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6009119/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6009119/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":76754363,"identity":"507b4008-4a6e-42ed-b068-e99842af2c8a","added_by":"auto","created_at":"2025-02-20 10:38:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":386021,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6009119/v1/23286b80-ad56-445b-a48e-2515ade98558.pdf"},{"id":76257764,"identity":"948d67c4-a750-4c6e-b2f7-18510f1ec9af","added_by":"auto","created_at":"2025-02-14 05:29:51","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":541230,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-6009119/v1/3967be1ad1587a91cdb52ab7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Application of plasma electrocautery combined with self-made irrigation catheter in the treatment of bladder blood clot tamponade: A retrospective study of 21 patients","fulltext":[{"header":"Background","content":"\u003cp\u003eBladder blood clot tamponade is one of the more common and challenging emergencies in urology, which can be caused by various reasons(1-5), such as bleeding after transurethral resection of the prostate (TURP)， bleeding from bladder tumors and prostate cancer and so on. If not managed properly, it can cause significant suffering for the patient, increase their financial burden, severely affect the doctor-patient relationship, and even endanger the patients\u0026apos; life. Patients often present with inability to urinate, a distended bladder area, and dull percussion sounds over the bladder area. Ultrasound(4) or computerized tomography (CT) scans can provide a definitive diagnosis. Traditionally, open surgery has been used to clear bladder blood clots, but this approach involves significant patient trauma, a high risk of recurrent bleeding, and slow postoperative recovery. Other methods include bladder irrigation to flush out blood clots, plasma electrocautery combined with irrigation to clear blood clots, and tissue morcellators to remove blood clots. However, due to various factors such as poor visibility, lengthy surgical time, the high cost and limited availability of equipment, it is difficult to find a surgical method suitable for hospitals at all levels. Our hospital has attempted to use a plasma electrocautery in conjunction with a self-made irrigation catheter to treat with bladder blood clot tamponade. This method is relatively quick, effective, minimally invasive, and suitable for most hospitals. \u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eWe selected 21 cases of bladder blood clot tamponade from October 2020 to October 2024 in our hospital, including 10 males and 11 females, with ages ranging from 38 to 66 years old. Among them,10 cases were due to bladder tumor bleeding, 4 cases were due to bleeding after transurethral resection of the prostate (TURP), 4 cases were due to bleeding after percutaneous nephrolithotomy, and 3 cases were due to bleeding after ureteroscopy lithotripsy. Preoperatively, all 21 patients underwent catheterization, and a large amount of blood clots blocking the urethra were observed. Using traditional methods, such as repeatedly aspirating with a 20ml or 50ml syringe through the catheter, the bladder blood clots could not be sucked out of the bladder, and all patients were unable to urinate after catheter removal. Preoperatively, all cases were confirmed to had bladder blood clot tamponade by bedside ultrasound or CT scan. This study was approved by the hospital\u0026apos;s ethical review board, and informed consent were obtained from all patients. The causes and composition of bleeding in the two groups of patients were shown in Table S1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Method\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter spinal or general anesthesia, the patient was placed in the lithotomy position. A 26Fr plasma resection scope (STORZE) was inserted into the bladder through the urethra to routinely inspect the urethra and bladder, observing for any significant urethral bleeding, bladder rupture, or bladder bleeding. A segment of a disposable ordinary suction catheter, approximately 20cm in length was used (Produced by Jiangsu HuaXia medical devices limited liability company with a diameter of 8mm, Fig S1). The plasma resection scope\u0026apos;s water inlet was connected to saline solution to fill the bladder, and the outer sheath of the resection scope (26Fr, with a diameter of about 8.58mm) was left in place. A self-made irrigation catheter was connected inside the outer sheath of the resection scope. The position of the resection scope\u0026apos;s outer sheath in the bladder was adjusted in a timely manner, and a 50ml syringe was connected to the tail end to intermittently create negative pressure to draw out blood clots (Fig S2 and S3). The plasma resection scope was used intermittently to inspect the blood clots and the condition inside the bladder. At this point, most of the blood clots could be removed. For the remaining small amount of blood clots, the plasma resection scope could be used with electrosection to assist in their removal (Electrosection power 120W, Coagulation power 80W). After all blood clots were completely removed, the plasma resection scope was used again to observe any bleeding inside the bladder and the urination from both ureteral orifices. If bleeding points were found during the surgery, they were coagulated to stop the bleeding. If a bladder tumor was detected during the surgery, a bladder tumor resection could be performed. If bladder damage was observed, it may be necessary to perform bladder repair treatment. After the surgery was completed and the scope was withdrawn, a 20Fr three-lumen catheter was left in place for continuous bladder irrigation. In a few days, we can perform ultrasound or CT scans to further confirm the clearance of blood clots in the patient\u0026apos;s bladder (Fig S4 and S5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObservational Indicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study compares the time taken to clear bladder blood clots, the size of the blood clots, the duration of postoperative irrigation, and the incidence of rebleeding between the two groups. The criteria for blood clot removal were: complete clearance of bladder blood clots visible to the naked eye during surgery, clear irrigation fluid, and unobstructed drainage through the catheter.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed using Statistical Package for Social Science 22.0 (SPSS Inc., Chicago, IL, USA). Quantitative data that conform to a normal distribution were represented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), and comparisons were made using t-tests to compare the differences. Count data were expressed as number of cases (%). A two-tailed test was used, and a difference was considered statistically significant when \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe outcomes were quite satisfactory for the 21 cases of bladder blood clot tamponade after active surgical removal of the blood clots. Among the 3 cases of bladder blood clot tamponade due to bleeding after ureteroscopy lithotripsy, 2 patients had abnormal liver function leading to coagulation dysfunction, which resulted in renal and ureteral bleeding that led to bladder blood clot tamponade, and 1 case was due to ureteral mucosal bleeding. During surgery, plasma resection combined with a self-made irrigation catheter was used to clear the bladder blood clots, with good surgical results. No bleeding from both ureteral orifices or significant bladder bleeding was observed during the surgery. In 4 cases of malignant tumor metastasis invading the bladder and 5 cases of primary bladder tumor bleeding, after clearing the blood clots, varying degrees of abnormal tissue invasion of the bladder wall were observed. Palliative tumor resection or radical tumor resection and electrocoagulation hemostasis were performed with the plasma resection scope. In 1 case of bladder invasion by a malignant tumor from another site, after blood clot removal, a rupture at the top of the bladder was discovered. After communicating with the patient\u0026apos;s family, a laparoscopic bladder repair was performed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe sizes of the blood clots removed in the two groups were (178.50\u0026plusmn;43.85) g and (167.27\u0026plusmn;50.12) g, respectively. The surgery times were (51.00\u0026plusmn;12.01) minutes and (36.64\u0026plusmn;8.19) minutes, respectively. The postoperative bladder irrigation times were (2.05\u0026plusmn;0.76) days and (1.32\u0026plusmn;0.60) days, respectively. The number of postoperative rebleeding cases in the two groups was 1(10%) and 1(9%), respectively. There was no statistically significant difference in the size of the blood clots removed or the probability of postoperative rebleeding between the two groups. However, the use of plasma resection combined with a self-made irrigation catheter to remove bladder blood clots was statistically significant in terms of surgery time and postoperative bladder irrigation time compared to the use of a plasma resection scope alone(\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05) (Table S2). An 20Fr three-lumen catheter was left in place for continuous bladder irrigation with saline solution after surgery in both groups. The irrigation fluid was clear after surgery, and the urine color in the catheter was clear after stopping of bladder irrigation, with no significant active bleeding observed.\u003c/p\u003e\n\u003cp\u003eEach group had 1 case of late-stage bladder tumor that bled again 1 week after surgical treatment, which was considered to be due to the sloughing off of the wound scab, leading to rebleeding. All patients were satisfied with the results after further treatment.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBladder blood clot tamponade is one of the common emergencies in urology(4), characterized by massive bleeding in the bladder or upper urinary tract, where blood clots coagulate and block the urethra within the bladder, preventing the blood clots from being expelled from the body, leading to a distended and painful bladder area for the patient. Patients are at risk of continuous urinary bleeding, urinary tract infections, and even bladder rupture(6).\u003c/p\u003e\n\u003cp\u003eThe causes of bladder blood clot tamponade in clinical practice are commonly as: patients who took anticoagulant drugs and anticholinergic drugs(1). Patients with bladder tumors or tumor invasion of the bladder, or bladder bleeding caused by large-scale changes in the bladder due to radiation exposure(7, 8). Inadequate hemostasis at the bladder neck and wound site after transurethral resection of the prostate; Bleeding after renal puncture or nephrostomy. Upper urinary tract bleeding due to renal or ureteral surgery, with blood clots coagulating in the bladder leading to bladder blood clot tamponade. Bleeding and blockage of the bladder after trauma to the urinary system. Other causes of bleeding in the bladder, prostate, or upper urinary tract. The management of bladder blood clot tamponade is time-consuming and labor-intensive, and it is also very painful for the patient. Therefore, how to quickly and effectively handle bladder blood clot tamponade is a problem that urologists need to pay attention.\u003c/p\u003e\n\u003cp\u003eClinical methods for managing bladder blood clot tamponade vary according to literature reports. For cases with mild bleeding and few blood clots, the common clinical method(9) is to use a disposable syringe to repeatedly aspirate through the catheter to extract blood clots from the body. This method is rather primitive and inefficient. It works well for small blood clots blocking the urethra, but is often not satisfactory for cases of bladder blood clot tamponade. Some scholars(10) use a thoracic catheter instead of a urethral catheter to deal with bladder clots and some scholars(11) used a rectal tube to deal with the problem. Some scholars(12-16) use urokinase, streptokinase and hydrogen peroxide and other thrombolytic treatments, which have shown some effect in certain patients. Some scholars(17, 18) believe that using an electroresection scope combined with an Ellik flushing ball and a metal urinary catheter to handle bladder impaction both yield satisfactory results, with no significant differences in postoperative rebleeding and postoperative bladder irrigation time between the two groups, but the metal urinary catheter has an advantage in terms of surgery time. Although both methods can clear blood clots, we believe that the flushing ball has a lower pressure and is not as efficient in clearing blood clots, and there is a possibility of bladder rupture during the flushing process for some patients(6). The metal urinary catheter is limited by its source and is not available in most grassroots hospitals, thus limiting its use. Some scholars believe that an electric suction device can be used to draw out blood clots. We believe that the suction power of an electric suction device is difficult to control, and the damage to the bladder cannot be estimated, and it cannot handle other conditions in the bladder, such as bleeding or tumors. At the same time, there are scholars(19, 20) who believe that tissue morcellators can be used for bladder blood clot removal. We believe that this method also has certain limitations. Tissue morcellators are mainly designed for prostate enucleation surgery. They can crush the enucleated prostate tissue and quickly suction it out of the body, greatly shortening the surgery time and being safe and reliable. Although tissue morcellators have a high efficiency in clearing blood clots, efficiency and risk coexist. Due to poor water circulation when using tissue morcellators, and many patients have fresh bleeding, it is very easy to damage normal bladder tissue and cause further damage to the bladder mucosa during the crushing and suctioning of blood clots. Additionally, tissue morcellators are relatively expensive and not all grassroots hospitals can be equipped, so their use is also limited（Summary of the methods published works concerning with patients of bladder blood clot tamponade, Table S3. NA = not available）. \u003c/p\u003e\n\u003cp\u003eThe plasma electrocautery combined with a self-made irrigation catheter used in our hospital has obvious advantages in handling patients with bladder blood clot tamponade. There was no statistically significant difference in the size of the blood clots removed or the probability of postoperative rebleeding between the two groups. However, the use of plasma resection combined with a self-made irrigation catheter to remove bladder blood clots was statistically significant in terms of surgery time and postoperative bladder irrigation time compared to the use of a plasma resection scope alone. When we clear bladder blood clots, we can first use the plasma resection scope to check the condition of the urethra and bladder. If bladder blood clot tamponade or bladder tumor invasion leading to bladder rupture is found during surgery, it is necessary to perform open or laparoscopic for bladder repair. We used the plasma electrocautery combined with a self-made irrigation catheter to clear bladder blood clots while electrocoagulating to stop bleeding. If conditions permit, palliative bladder tumor resection can be performed to reduce tumor load and greatly reduce the likelihood of subsequent bladder bleeding. On the other hand, the materials for our self-made irrigation catheter are very convenient, using ordinary disposable suction catheters, with negligible cost and very simple production methods. Since the diameter of the plasma resection scope\u0026apos;s outer sheath and the self-made irrigation catheter are roughly the same, there is a small gap left around the plasma resection scope\u0026apos;s outer sheath after inserting the irrigation catheter, and the irrigation catheter cannot break through the plasma resection scope\u0026apos;s outer sheath into the bladder, causing no additional damage to the bladder. At the same time, the pressure can be manually controlled, with basically no damage to the bladder, which is a great advantage compared to the uncontrollable suction power of the electric suction device. However, in our practice, we found that fresh blood clots are processed faster compared to old blood clots.\u003c/p\u003e\n\u003cp\u003eHowever, this study also has some shortcomings, such as being a single-center study, and the sample size is relatively small, which may have an impact on the results of the study. It is necessary to further accumulate and expand the sample size in future clinical work.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe plasma electrocautery combined with a self-made irrigation catheter used in our hospital has proven to be a reliable method for managing bladder blood clot tamponade. It is simple, time-saving, and labor-saving, which can alleviate the patient\u0026apos;s pain and financial burden. Additionally, the materials required are easily obtainable and can be readily acquired in general hospitals, making it suitable for widespread adoption in most medical facilities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data generated and analyzed during the current study are available from the corresponding author and with the permission of the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eShigao Xu: writing-original draft, writing-review and editing.\u003c/p\u003e\n\u003cp\u003ePu Cao: carried out the operation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTieshi Liu: writing-review and editing, carried out the operation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study was approved by institutional Review Board of The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine, and patients’ consent were obtained prior to tissue collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patients agreed to use his disease information for article publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMiyamae K, Otsuka T, Otsuka Y, Nagayoshi M, Hamada Y. Clinical study of bladder tamponade resulting from clots of blood. The japanese journal of urology. 2006;97(5):743-747.\u003c/li\u003e\n\u003cli\u003eMatsui Y. A case of inflammatory myofibroblastic tumor of the urinary bladder with emergency clinical symptoms similar to bladder cancer. Urology case reports. 2021;38:101740.\u003c/li\u003e\n\u003cli\u003eMaekawa S, Okubo K, Aoki Y, Okada T, Maeda H, Arai Y. A case of bladder hemangioma showing bladder tamponade during late pregnancy. Hinyokika kiyo Acta urologica Japonica. 2000;46(7):483-485.\u003c/li\u003e\n\u003cli\u003eSteffens F, Gr\u0026uuml;ne B, Rassweiler-Seyfried MC. Urinary bladder tamponade-an urological emergency. UROLOGIE. 2024;63(6):578-584.\u003c/li\u003e\n\u003cli\u003eDavydov DS, Tsarichenko DG, Bezrukov EA, et al. Complications of the holmium laser enucleation of prostate for benign prostatic hyperplasia. Urologiia (Moscow, Russia : 1999). 2018(1):42-47.\u003c/li\u003e\n\u003cli\u003eLiu KL, Wang X, Qu CB, Qi JC. The reasons and countermeasures of Bladder Rupture caused by Transurethral Clot Evacuation. PAKISTAN JOURNAL OF MEDICAL SCIENCES. 2021;37(3):903-907.\u003c/li\u003e\n\u003cli\u003eWaneck R, Lechner G, Powischer G. Vascular embolisation in uncontrolled haemorrhages of the bladder caused by tumours and radiation RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin. 1979;130(2):193-196.\u003c/li\u003e\n\u003cli\u003eUeda N, Sato M, Matsukawa A, et al. Maintaining Serum Hemoglobin Levels Within the Physiological Range Prevented Bladder Tamponade Recurrence Due to Radiation-Induced Hemorrhagic Cystitis: A Case Report. Research and reports in urology. 2023;15:395-401.\u003c/li\u003e\n\u003cli\u003eClarebrough E, McGrath S, Christidis D, Lawrentschuk N. CATCH-22: a manual bladder washout protocol to improve care for clot retention. WORLD JOURNAL OF UROLOGY. 2018;36(12):2043-2050.\u003c/li\u003e\n\u003cli\u003eAydin C, Senturk AB, Akkoc A, Topaktas R, Aydin ZB, Ekici M. Clot Retention: Our Experiences with a Simple New Technique of Evacuation with a Thoracic Catheter. Cureus. 2019;11(3):e4329-e.\u003c/li\u003e\n\u003cli\u003ePlawker MW, Hashmat AI. The rectal tube: an excellent catheter for severe clot retention. The Journal of urology. 1997;157(5):1781-1782.\u003c/li\u003e\n\u003cli\u003eXu M, Jin LA-O, Shan Y, Zhu J, Xue B. A simple and effective method for bladder blood clot evacuation using hydrogen peroxide. J Int Med Res. 2020;45(5):00060520924546.\u003c/li\u003e\n\u003cli\u003eDella Corte M, Clemente E, Cerchia E, et al. Intravesical Agents in the Treatment of Bladder Clots in Children. Pediatric Reports [Internet]. 2023; 15(2):[282-92 pp.].\u003c/li\u003e\n\u003cli\u003eWarlick CA, Mouli SK, Allaf ME, Wagner AA, Kavoussi LR. Bladder irrigation using hydrogen peroxide for clot evacuation. UROLOGY. 2006;68(6):1331-1332.\u003c/li\u003e\n\u003cli\u003eJia B, Yin YY, Liu JY, Deng SW, Cai Y, Yao JB. Evaluation of Bladder Clots Using a Nonsurgical Treatment. UROLOGY. 2014;83(2):498-499.\u003c/li\u003e\n\u003cli\u003eNonato MB, Moraes RS, Her\u0026ecirc;nio YMB, Nunes TF. Management of a Giant Urinary Bladder Clot with Intravesical Thrombolysis. JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY. 2023;34(1):154-155.\u003c/li\u003e\n\u003cli\u003eJiang CY, Ma L, Chen Y, Qin H. An effective method for evacuation of the bladder blood clot using a metal urinary catheter: A retrospective study of 49 patients. ASIAN JOURNAL OF SURGERY. 2023;46(5):1951-1953.\u003c/li\u003e\n\u003cli\u003eSu YT, Huang KH, Chuang FC, Lan KC. Use of an Ellik evacuator to remove tenacious bladder clots resulting from transvaginal oocyte retrieval: 2 cases and a literature review. TAIWANESE JOURNAL OF OBSTETRICS \u0026amp; GYNECOLOGY. 2019;58(6):880-884.\u003c/li\u003e\n\u003cli\u003eDoersch KM, Navetta AF, Bird ET, El Tayeb MM. Case series: Bladder clot evacuation using a prostate morcellation device. Can Urol Assoc J. 2017;11(7):E311-E314.\u003c/li\u003e\n\u003cli\u003eWu RH, Shang YG, Liu X, Chen W, Yi SH. Removal of large fibrotic bladder blood clots using prostatic tissue morcellator under real-time ultrasound guidance. FRONTIERS IN SURGERY. 2022;9:889529.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bladder blood clot tamponade, Plasma electrocautery, self-made irrigation catheter, Treatment","lastPublishedDoi":"10.21203/rs.3.rs-6009119/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6009119/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective: To explore the application effect of plasma electrocautery combined with self-made irrigation catheter in the treatment of bladder clot tamponade.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: We retrospectively analyzed 21 cases of bladder clot tamponade admitted to our hospital from October 2020 to October 2024. The patients were divided into two groups: the experimental group (plasma electrocautery combined with self-made irrigation catheter) and the control group (plasma electrocautery alone). We compared the two different surgical methods in terms of blood clot clearance time, size of blood clots removed, postoperative bladder irrigation time, and postoperative rebleeding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: The sizes of the blood clots removed in the two groups were (178.50±43.85) g and (167.27±50.12) g，respectively. The operation times were (51.00±12.01) minutes and (36.64±8.19) minutes, respectively. The postoperative bladder irrigation times were (2.05±0.76) days and (1.32±0.60) days, respectively. There was no statistically significant difference between the two groups in terms of the size of blood clots removed and the probability of postoperative rebleeding. However, it was statistically significant in terms of operation time and postoperative bladder irrigation time compared to the use of plasma electrocautery alone (P\u0026lt;0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusion: The application of plasma electrocautery combined with a self-made irrigation catheter in the treatment of bladder blood clot tamponade could effectively improve the clearance rate of blood clots within the bladder and accelerate the recovery of patients' conditions.\u003c/p\u003e","manuscriptTitle":"Application of plasma electrocautery combined with self-made irrigation catheter in the treatment of bladder blood clot tamponade: A retrospective study of 21 patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-14 05:29:46","doi":"10.21203/rs.3.rs-6009119/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"11979bcf-0a6a-422c-afe2-4e8e44cef560","owner":[],"postedDate":"February 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-20T10:38:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-14 05:29:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6009119","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6009119","identity":"rs-6009119","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}