Stopping Anticoagulation Before TURP Does Not Appear to Increase Perioperative Cardiovascular Complications

doi:10.1016/j.urology.2011.05.053

Urology

Volume 78, Issue 6, December 2011, Pages 1380-1384

https://doi.org/10.1016/j.urology.2011.05.053 Get rights and content

Objective

To evaluate the impact of stopping anticoagulant medications prior to transurethral resection of the prostate on peri-operative cardiovascular complications.

Methods

Retrospective series (305 patients) undergoing TURP at a tertiary hospital between 2006 and 2010. All men were evaluated in preadmission clinics with defined protocols, with a low threshold for cardiovascular investigation. Incidence of postoperative bleeding and cardiovascular and cerebrovascular events was determined for 3 patient cohorts: group A—where anticoagulants were ceased preoperatively; group B—who were not receiving any anticoagulants; and group C—who underwent TURP while taking aspirin.

Results

Of 305 patients, 194 (64%) did not receive anticoagulation therapy, 108 (35%) stopped receiving anticoagulation therapy pre-TURP, and 3 (0.98%) underwent TURP while taking aspirin. Anticoagulants used were aspirin (22.6%), warfarin (4.9%), antiplatelets (4.9%), and combination treatments (3.9%). Incidence of postoperative hemorrhage (early and delayed) was not significant (P = .69) between group A (10/108) and group B (7/194). Transfusion rate was 0.6% (2/305). Overall incidence of cardiovascular events was 0.98% (group A, n = 1 vs group B, n = 2), and incidence of deep vein thrombosis (0.32%; group A, n = 0 vs group B, n = 1) was not statistically significant (P = .30 and P = .37, respectively). Overall incidence of cerebrovascular events (0.65%; group A, n = 1 vs group B, n = 1) was not significant (P = 1.00). There were no deaths.

Conclusion

Men who have discontinue anticoagulation therapy before TURP do not appear to have a higher incidence of cardiovascular or cerebrovascular events, or bleeding-associated morbidity. It is possible that the morbidity attributed to discontinuing anticoagulation in this population may be overemphasized. Larger prospective studies are needed to better evaluate this clinical problem.

Section snippets

Material and Methods

A list of all patients who underwent TURP from 2006-2010 were retrieved from the hospital's audit database. The medical records of all patients were obtained from off-site storage facilities. Each patient record was individually hand searched and the data stored in a database.

Inclusion criteria included bladder outlet obstruction secondary to benign prostatic hyperplasia or prostate cancer and those who previously underwent TURP, with a minimum of 6 weeks postoperative follow-up.

A total of 308

Results

The baseline demographics for the patient cohort (n = 305) are shown in Table 1.

In this series, 64% of patients (n = 194, group B) were not routinely receiving any anticoagulation preoperatively; 35% (n = 108, group A) were receiving anticoagulation, which was stopped before TURP; and in 0.98% (n = 3, group C), TURP was performed while patients were taking aspirin.

The indications for anticoagulation are shown in Table 2.

The postoperative complications for this cohort are summarized in Table 3.

Comment

The optimal management of the anticoagulated patient requiring TURP has continued to stimulate debate in recent years. As the proportions of these patients in our population steadily increases, there is an urgent need to provide clarification and evidence-based clinical guidelines that can assist in managing these individuals.1, 2, 3, 4

In our study population, 35% of patients were on anticoagulation therapy, comparable with the proportion found in other studies.1, 5 Antiplatelet drugs (eg,

Conclusions

Men who have anticoagulation therapy stopped before TURP do not appear to have a higher incidence of cardiovascular or cerebrovascular events, or bleeding-related morbidity when compared with anticoagulant-naïve patients in this retrospective study. Further clinical research is warranted to reexamine this issue and permit the development of evidence-based guidelines to manage the anticoagulated patient requiring TURP.

Acknowledgments

The authors wish to thank Ms. M. Roure from the Department of Urology, Westmead Hospital, for her assistance in data collection for this study.

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Cited by (22)

Monopolar Transurethral Resection of Prostate
2018, A Comprehensive Guide to the Prostate: Eastern and Western Approaches for Management of BPH
Monopolar transurethral resection of prostate (TURP) is the primary surgical treatment option for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Herein, perioperative considerations, surgical techniques, and complications associated with monopolar TURP are reviewed. We also discuss short- and long-term clinical outcomes and compare its efficacy with other emerging technologies. A literature search for English language publications using the PubMed and Embase databases was performed. Keywords included “monopolar” and “TURP.” A total of 191 articles were analyzed, of which 46 were suitable for analysis based on clinical relevance and importance of content. No other medical or surgical intervention has surpassed monopolar TURP in terms of symptomatic improvement and durability for treating men with LUTS due to BPH. Furthermore, recent developments in anesthesia and advances in surgical instrumentation have ensured that monopolar TURP remains the reference urological procedure for patients with voiding LUTS. Although recently developed technologies such as bipolar TURP and laser enucleation of the prostate demonstrate favorable perioperative outcomes; robust long-term follow-up data are lacking. Therefore, monopolar TURP will continue to remain as the reference surgical procedure for treating men with voiding LUTS due to BPH as it has proven long-lasting improvement of patient symptoms with a low reoperation rate.
Transurethral bipolar plasmakinetic vapo-enucleation of the prostate: Is it safe for patients on chronic oral anticoagulants and/or platelet aggregation inhibitors?
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Citation Excerpt :
Abstention from PAI and/or OAC drugs before surgery for prevention of bleeding remains a matter of controversy. It was found that there was insignificant risk of perioperative morbidity, whilst withdrawal of PAI and/or OAC drugs led to more cardio-cerebro-vascular adverse events during TURP [13,14]. A recent meta-analysis confirmed that bipolar transurethral resection with saline (B-TURP) was as effective as M-TURP, with statistically significant better intra- and postoperative safety, hospital stay and reduced post-discharge re-hospitalisation.
To assess the safety and efficacy of bipolar plasmakinetic enucleation and resection of the prostate (PKERP) for the management of benign prostatic hyperplasia (BPH) in patients on oral anticoagulant (OAC) therapy and/or platelet aggregation inhibitors (PAIs).
In all, 91 patients were recruited and underwent PKERP whilst they were receiving PAIs (aspirin, 56 patients; clopidogrel, three; aspirin and clopidogrel, 11). In all, 15 patients were receiving an OAC drug perioperatively, whilst another six patients were on dual PAIs and OACs. The primary outcomes were the perioperative morbidity and mortality rates. The secondary outcomes were functional outcomes including maximum urinary flow rate (Q_max), International Prostate Symptoms Score (IPSS), and post-void residual urine volume (PVR).
The mean (SD) age of the patients was 65 (5.9) years, preoperative adenoma volume was 80.9 (30.4) mL, and the operative time was 67 (23) min. No patient developed serious perioperative cardiovascular complications. The mean (SD) duration of hospital stay was 1.79 (1) days and the postoperative catheterisation time was 1.14 (0.76) days. The mean (SD) haemoglobin drop was 0.74 (0.61) g/dL, blood transfusion rate was 2.2%, and the clot retention rate was 2.2%. The mean (SD) postoperative Q_max was 18.6 (4.37) mL/s as compared to 7.2 (3.2) mL/s preoperatively (P < 0.001), and the preoperative IPSS was reduced from 24.3 (6.1) to 5.7 (2.3) postoperatively (P < 0.05). Prostate volume measured by transrectal ultrasonography was significantly reduced from a mean (SD) of 80.9 (30.4) mL preoperatively to 29.5 (10.6) mL postoperatively (P < 0.001).
Minimally invasive PKERP may be considered as a safe and effective treatment option for managing patients with BPH receiving OAC/PAI drugs.
Peri-operative management of patients with anticoagulation or antiplatelet therapy in benign prostatic hyperplasia surgery
2016, Progres en Urologie - FMC
Proposer une mise au point sur la gestion périopératoire des patients sous antithrombotiques (anticoagulants oraux ou antiagrégants plaquettaires) nécessitant la prise en charge chirurgicale d’une hypertrophie bénigne de prostate (HBP).
Une revue non systématique des articles publiés sur le sujet a été réalisée.
La résection transurétrale de prostate est associée à une augmentation du risque hémorragique et thromboembolique chez les patients sous antithrombotiques. Les techniques utilisant l’énergie laser diminuent ce risque et sont à privilégier dans cette population. Un traitement chirurgical par laser de l’HBP peut être réalisé sous aspirine mais sa réalisation sous clopidogrel ou anticoagulation efficace n’est pas recommandée. Le choix d’interrompre, de poursuivre ou de remplacer le traitement antithrombotique dépendra des comorbidités du patient, du traitement initial et de la technique chirurgicale utilisée.
La gestion périopératoire des patients sous antithrombotiques lors d’une chirurgie de l’HBP repose sur l’évaluation multidisciplinaire du risque thrombotique et hémorragique.
To propose a focus on the peri-operative management of patients under antithrombotic (AT) requiring surgical treatment of benign prostatic obstruction (BPO).
A non-systematic review of the literature available on this topic was performed.
New techniques using laser energy reduce the bleeding and thrombotic risk associated with transurethral resection of prostate. Laser procedures can be performed without stopping aspirin and should be the first choice treatment in this population. However, the level of evidence is too low to recommend the continuation of clopidogrel or other AT during laser procedures. The choice to withdraw, continue or bridge the AT should relies on the patient comorbidities, the initial treatment, and the surgical technique.
The peri-operative management of patients under AT during surgery for BPO is based on a multidisciplinary assessment of thrombotic and bleeding risk.
Anticoagulation and antiplatelet therapy in urological practice: ICUD/AUA review paper
2014, Journal of Urology
Citation Excerpt :
Bridging patients on warfarin with LMWH during the perioperative period is preferable to continuing warfarin. In contrast, several articles show that patients undergoing TURP on chronic anticoagulation with and without bridging are at significantly higher risk for bleeding complications upon resuming AC/AP.32–36 TRUSBx complications for patients on continuing aspirin or low dose aspirin were studied in prospective, controlled trials and a meta-analysis (total more than 3,000 patients).37–42
Given the lack of urology specific directives for the periprocedural management of anticoagulant and antiplatelet medications, the AUA (American Urological Association) and ICUD (International Consultation on Urological Disease) named an international multidisciplinary panel to develop consensus based recommendations.
A systematic literature review was queried by a methodologist for 3 questions. 1) When and in whom can anticoagulant/antiplatelet prophylaxis be stopped in preparation for surgery? 2) What procedures can be safely performed without discontinuing anticoagulant/antiplatelet prophylaxis? 3) What periprocedural strategies can adequately balance the risk of major surgical bleeding vs the risk of major thrombotic event? Hematology and cardiology guidelines, and 79 articles were selected for full review.
Multidisciplinary management of anticoagulant/antiplatelet medications for patients with recent thromboembolic events, mechanical cardiac valves, atrial fibrillation and cardiac stents would reduce the high morbidity and mortality of inexpertly discontinuing or modifying these lifesaving therapies. No elective procedures requiring interruption of dual antiplatelet therapies should be performed with a recent bare metal or drug eluting stent. The risk of significant bleeding complications is low for patients who require continuation of aspirin for ureteroscopy, transrectal prostate biopsies, laser prostate outlet procedures and percutaneous renal biopsy. Open extirpative prostate and renal procedures can be performed with a low risk of significant hemorrhage for patients on aspirin and those requiring heparin based bridging strategies. The current literature does not give direction on the timing of the resumption of anticoagulant/antiplatelet prophylaxis other than that it be resumed as soon as the risk of bleeding has decreased.
A total of 2,674 nonredundant article abstracts were obtained and assessed for relevance to key questions outlined by the panel. Overall 106 articles were selected for full text review and accepted or rejected based on the relation to the topic, quality of information and key questions. A total of 79 articles were accepted. Reasons for rejection (27 articles) included abstract only (12), insufficient information or unrelated to topic (13) and redundancy (2). We extracted study design, patient population, followup period and results from accepted articles, which serve as the evidence base.
Perioperative stroke following transurethral resection of prostate: high index of suspicion and stabilization of physiological parameters can save lives
2018, Brazilian Journal of Anesthesiology
Relatamos o caso de um paciente hipertenso, 72 anos, que desenvolveu hipertensão grave seguida de deterioração neurológica no pós‐operatório imediato após ressecção transuretral de próstata. Embora os testes laboratoriais e a gasometria tenham excluído a síndrome de ressecção transuretral de próstata ou qualquer outra causa metabólica, a diminuição da pressão sanguínea não conseguiu melhorar os sintomas. Uma tomografia computadorizada craniana, realizada 4 horas após o aparecimento de sintomas neurológicos, revelou infartos gangliocapsular bilateral e talâmico à direita. AAS oral foi aconselhado para prevenir um acidente vascular cerebral recorrente precoce. O tratamento de apoio e a ventilação mecânica garantiram a estabilidade fisiológica e o paciente obteve recuperação completa durante os próximos dias, sem qualquer déficit neurológico residual.
We report a case of a 72 year old hypertensive male who developed severe hypertension followed by neurological deterioration in the immediate postoperative period after transurethral resection of prostate. While arterial blood gas and laboratory tests excluded transurethral resection of prostate syndrome or any other metabolic cause, reduction of blood pressure failed to ameliorate the symptoms. A cranial CT done 4 hours after the onset of neurological symptoms revealed bilateral gangliocapsular and right thalamic infarcts. Oral aspirin was advised to prevent early recurrent stroke. Supportive treatment and mechanical ventilation ensured physiological stability and the patient recovered completely over the next few days without any residual neurological deficit.
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2023, Cirugia y Cirujanos (English Edition)

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: Financial Disclosure: Henry Woo is a paid consultant to American Medical Systems Inc.

: Funding Support: Funding for the data collection & retrieval for this study was obtained from Australian Clinical Trials, Pty. Ltd.

View full text

Prostatic Diseases and Male Voiding DysfunctionStopping Anticoagulation Before TURP Does Not Appear to Increase Perioperative Cardiovascular Complications

Objective

Methods

Results

Conclusion

Section snippets

Material and Methods

Results

Comment

Conclusions

Acknowledgments

J Urol

J Urol

Prog Urol

Br J Anaesth

Chest

Impact of oral anticoagulation on morbidity of transurethral resection of the prostate

World J Urol

Complications of transurethral resection of the prostate (TURP)—incidence, management, and prevention

Eur Urol

Anti-platelet agents in urology

BJU Int

Prostatic Diseases and Male Voiding Dysfunction
Stopping Anticoagulation Before TURP Does Not Appear to Increase Perioperative Cardiovascular Complications