Study design, materials and methods
A prospective cohort of LUTS/BPH patients who underwent HoLEP between January 2010 and December 2017 as a part of BPH Database Registry were enrolled for this study. The criteria for inclusion were patients whose age were over 50 years. Patients with genitourinary cancer, previous pelvic surgical history, and neurogenic bladder were excluded. Baseline evaluation included careful history taking, digital rectal examination, IPSS, Overactive Bladder Symptom Score (OABSS), serum PSA level, uroflowmetry, PVR measurement, urodynamic study, and prostate volume measured by transrectal ultrasonography. Under spinal or general anesthesia, HoLEP was performed with patient placed in a lithotomy position. Enucleation was performed using the 3 or 4 lobe technique with a 80W (2J x 40Hz) setting of Homium YAG laser, followed by morcellation of adenomas. Continuous bladder irrigation was performed with normal saline. Typically, on postoperative day one, urethral Foley catheter was removed. Intraoperative parameters included operative time, enucleation weight, and intraoperative complications. The use of anticoagulants and discontinuation methods during operation were collected. Postoperative evaluation was performed at 2 weeks, 3 months and 6 months. Patients were categorized as non-anticoagulation and anticoagulation groups and postoperative outcomes and complications associated with the use of anticoagulants were compared. A mean values with standard deviation (SD) were used for analysis of continuous variables. Categorical variables were analyzed by the ratio of events (%). Student t-test, chi-square test and Fisher's exact were used to compare the postoperative outcomes. Multivariate analysis was performed using logistic regression. Statistical significance was defined as a p-value ≤0.05.
A total of 955 patients (707 patients (74.0%) did not take anticoagulants, and 248 patients (25.9%) took one or more anticoagulants before surgery) with a mean age of 68.7(± 6.4) years were identified. The mean preoperative hemoglobin level was 13.5±2.6 g/dL in patients taking anticoagulants, and 71% of the patients were taking aspirin. Seventy-five patients (66.5%) discontinued anticoagulant therapy 5-7 days before surgery. Aspirin was the most commonly used drug, accounting for 71% of patients, followed by clopidogrel (22.9%). All other drugs had less than 3% use by patients. The most common cause of anticoagulants was angina, with 30% of users of anticoagulants had angina. The next two leading causes of anticoagulant use were artery disease prevention (10.1%) and cerebrovascular disease (8.9%). During the operation, 94.7% of patients discontinued anticoagulants, while 5.3% of patients replaced the anticoagulants with LMWH or maintained the original anticoagulant. 70 patients (28.2%) discontinued less than one week, 3 patients (1.2%) were switched to low-molecular-weight heparin therapy, and 10 patients (4.1%) were under continued anticoagulant therapy. There were no significant differences in the incidence rates of postoperative transfusion (p=0.894) or complications from anticoagulant use, thrombosis (p=0.946), hemorrhage requiring bladder irrigation (p=0.959), transurethral coagulation (p=0.894), cardiovascular events (p=0.845), and cerebrovascular events (p=0.848). Mean operation time were 57.0 and 55.2 mins (P=0.395); mean enucleation weight were 23.5 and 23.2 grams (p=0.844), respectively. There was no difference in intraoperative complication such as bladder injury, prostatic capsule perforation, or persistent bleeding. There was no difference in mid-term postoperative cardiovascular and cerebrovascular complication up to 6 months follow up.
Interpretation of results
BPH Patients taking anticoagulants compared to patients who did not take anticoagulants may have a higher risk of bleeding or cardiovascular and cerebrovascular risk, even if they temporarily withdrew anticoagulants before and after HoLEP. Nevertheless, our results showed that there was no significant difference in postoperative outcomes and complications associated with the use of anticoagulants between non-anticoagulation and anticoagulation groups. Our results also demonstrated that there was no significant difference in postoperative cardiovascular and cerebrovascular complication between non-anticoagulation and anticoagulation groups.