Holmium Laser Enucleation of the Prostate in Patients Requiring Anticoagulation
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Purpose of Review
This is to evaluate and discuss the literature surrounding holmium laser enucleation of the prostate (HoLEP) in patients on anticoagulation.
The relationship of benign prostatic hyperplasia (BPH) to bothersome lower urinary tract symptoms (LUTS) is well established with a majority of men over the age of 60 having significant symptoms. Patients with severe enough symptoms often require surgery and with cardiovascular disease ranking as the primary cause of death in the USA, a growing number will be taking antiplatelet (AP) or anticoagulation (AC) for primary or secondary prevention of disease. A review of the recent literature focusing on patients on AP/AC undergoing HoLEP noted minimal adverse effects in the postoperative course aside from prolonged bleeding requiring catheterization with continuous bladder irrigation.
Although patients with BPH and bothersome LUTS undergoing HoLEP are at a slightly greater risk for prolonged bladder irrigation secondary to bleeding, surgical outcomes are similar to men not on AP/AC. The literature surrounding newer direct oral anticoagulants (DOACs) and HoLEP is limited, and therefore, conclusions regarding continuation of DOACs cannot be drawn. However, HoLEP appears to be a safe and effective procedure for BPH-related LUTS in patients on AP/AC therapy.
KeywordsLower urinary tract symptoms Benign prostatic obstruction Holmium laser enucleation of the prostate (HoLEP) Anticoagulation
Lower urinary tract symptoms
Benign prostatic hyperplasia
Holmium laser enucleation of the prostate
Dual antiplatelet therapy
Acute urinary retention
direct oral anticoagulants
Coronary artery bypass grafting
American Society of Anesthesiologists
Compliance with Ethical Standards
Conflict of Interest
Marcelino Rivera declares no potential conflicts of interest.
Amy Krambeck reports personal fees from Lumenis, Boston Scientific, and Thermedx.
James Lingeman reports personal fees from Lumenis, Boston Scientific, and Beck Analytical; is an owner and medical directory of Beck Analytical; and owner and investor of Midwest Mobile Lithotripsy.
Human and Animal Rights and Informed Consent
All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 2.Kaplan SA, McConnell JD, Roehrborn CG, et al. Combination therapy with doxazosin and finasteride for benign prostatic hyperplasia in patients with lower urinary tract symptoms and a baseline total prostate volume of 25 ml or greater. J Urol. 2006;175(1):217–220; discussion 20-1. doi: 10.1016/S0022-5347(05)00041-8.CrossRefPubMedGoogle Scholar
- 3.Roehrborn CG, Siami P, Barkin J, et al. The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes in men with symptomatic benign prostatic hyperplasia: 4-year results from the CombAT study. Eur Urol. 2010;57(1):123–31. doi: 10.1016/j.eururo.2009.09.035.CrossRefPubMedGoogle Scholar
- 8.Tan AH, Gilling PJ, Kennett KM, et al. A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). J Urol. 2003;170(4 Pt 1):1270–4. doi: 10.1097/01.ju.0000086948.55973.00.CrossRefPubMedGoogle Scholar
- 9.• El Tayeb MM, Jacob JM, Bhojani N, et al. Holmium laser enucleation of the prostate in patients requiring anticoagulation. J Endourol. 2016;30(7):805–9. doi: 10.1089/end.2016.0070. The largest series of HoLEP patients on AC/AP therapy noted slightly longer continuous bladder irrigation but no longterm adverse sequalae. CrossRefPubMedGoogle Scholar
- 11.• Bishop CV, Liddell H, Ischia J, et al. Holmium laser enucleation of the prostate: comparison of immediate postoperative outcomes in patients with and without antithrombotic therapy. Curr Urol. 2013;7(1):28–33. doi: 10.1159/000343549. In a recent retrospective review the authors noted resection rates, operative times and enucleated weights were not different between the two cohorts. A transfusion rate of 7.7% was noted in the AC/AP group. CrossRefPubMedPubMedCentralGoogle Scholar
- 14.Patel MR, Hellkamp AS, Lokhnygina Y, et al. Outcomes of discontinuing rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation: analysis from the ROCKET AF trial (rivaroxaban once-daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation). J Am Coll Cardiol. 2013;61(6):651–8. doi: 10.1016/j.jacc.2012.09.057.CrossRefPubMedGoogle Scholar
- 18.Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction, 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation. 2016;134(10):e123–55. doi: 10.1161/CIR.0000000000000404.CrossRefPubMedGoogle Scholar
- 27.Health Quality O. Energy delivery systems for treatment of benign prostatic hyperplasia: an evidence-based analysis. Ont Health Technol Assess Ser. 2006;6(17):1–121.Google Scholar
- 34.Zhang YJ, Li MP, Tang J, et al. Pharmacokinetic and pharmacodynamic responses to clopidogrel: evidences and perspectives. Int J Environ Res Public Health 2017; 14(3) doi: 10.3390/ijerph14030301