Perioperative Management of Antiplatelets and Anticoagulants Among Patients Undergoing Elective Transurethral Resection of the Prostate

Abstract

Purpose:

To evaluate current practice in the perioperative management of antiplatelets (AP) and anticoagulants (AC) among men undergoing elective transurethral resection of the prostate (TURP), as well as the associated perioperative bleeding and thromboembolic complications.

Patients and Methods:

Retrospective review of consecutive elective TURP patients in a single tertiary institution from January 2011 to December 2013 (n = 293). Data on the regular use of AP/AC and the perioperative management approach were collected from patients' electronic medical records. Bleeding and thromboembolic complications were assessed up to 30 days postoperative. Association between AP/AC use and perioperative complications was assessed using the Kruskall-Wallis test (continuous variables) and the Fisher exact test (categoric variables).

Results:

There were 107/293 (37%) patients receiving long-term AP while there were 25/293 (9%) patients receiving long-term AC. A total of 72/107 (67%) patients ceased AP on an average of 7.6 days preoperatively, while 35/107 (33%) continued receiving AP. Patients with coronary stents (62%) and coronary bypass graft (67%) were significantly more likely to continued receiving AP (P < 0.001). AC was ceased in all patients preoperatively, with 16/25 (64%) receiving enoxaparin bridging. Overall, there were 31 (10%) incidents of bleeding complications and 5 (2%) thromboembolic events. AC users who had enoxaparin bridging had significantly higher risk of bleeding complications (44%), compared with non-AP/AC users (8%), AP users who ceased AP (4%), AP users who continued receiving AP (17%), and AC users who did not receive enoxaparin bridging (0%) (P < 0.001). AC users who received enoxaparin bridging also reported significantly higher thromboembolic complications (17%; P < 0.001) and prolonged hospital stay (mean 5.4 days) (P = 0.002), compared with other patients.

Conclusion:

Perioperative management of AP/AC should be based on the indications and the American College of Chest Physicians thromboembolic risk stratification. Regular AC users who had enoxaparin bridging are at increased risk of both perioperative bleeding and thromboembolic complications.

Introduction

Transurethral resection of the prostate (TURP) is currently the gold standard of management of symptomatic lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) in men who have failed medical therapy. The morbidities associated with TURP are not negligible, however, particularly the bleeding complications. In fact, TURP is one of the surgical procedures deemed to be of high bleeding risk based on the American College of Chest Physicians (ACCP) guidelines.¹ This is because of the high concentration of tissue plasminogen activators in the prostate gland, leading to an overactivation of the local fibrinolytic system during TURP.²

In a recent review, Rassweiler and associates³ reported a clot retention rate of 2% to 5% and a blood transfusion rate of 0.4% to 7% after TURP. Aggravating matters, increasing numbers of men who need TURP are on long-term antiplatelet agents (AP, e.g., aspirin and clopidogrel) and anticoagulants (AC, eg, warfarin) for various reasons, which unfortunately further increase their bleeding risk. The population-based National Health Interview Survey in the United States reported a nearly 60% increase in regular AP use in the general population in 2010, compared with 2005. More than one-third of the population aged 50 and above was reported to be long-term AP users.⁴

Cessation of AP and AC in the perioperative period, however, is associated with increased thromboembolic risk. AP cessation is associated with a three-fold risk of myocardial infarct when used for secondary prevention of acute coronary syndromes, and the risk is significantly higher in patients with coronary stents.⁵ Hence, the perioperative management of AP and AC in men undergoing TURP poses a huge management dilemma for urologists to balance the bleeding versus thromboembolic risks.

Given the lack of consensus on the perioperative management of AP and AC, there are huge variations in the current clinical practice, as highlighted in surveys conducted among urologists in the United Kingdom.^6,7 A total of 109 (38%) of 287 of the urologists surveyed performed TURP with patients continuing on aspirin while 178 (62%) requested their patients to cease aspirin on an average of 10 days pre-TURP, of whom 62% (110/178) ceased aspirin regardless of the indications for aspirin.

The aim of our study is to report on the current practice in the perioperative management of AP and AC in men undergoing elective TURP in a tertiary institution in Australia. We also aim to evaluate the bleeding and thromboembolic complications associated with our current practice.

Patients and Methods

Study population

In this retrospective observational study, we reviewed all patients who underwent elective TURP in a single tertiary institution in Victoria from January 2011 to December 2013. A total of 293 patients were identified from the urology unit audit database. All patients had TURP performed using the Gyrus^™ bipolar resectoscope with physiologic saline irrigation. Bipolar TURP is well recognized to be associated with lower risk of TUR syndrome. There is also evidence suggesting superior hemostatic capacity with bipolar TURP, possibly because of deeper coagulation depths, as well as the “cut-and-seal” effect of plasma created by the bipolar energy.⁸ At our institution, all TURPs were performed by urology trainees or fellows under the supervision of urology consultants.

Patients' electronic medical records were reviewed to collect data of interest. Preoperative data collected included: Age, indications for TURP, and prostate volume. Data on AP and AC collected included: Type of AP and AC used and their indications, preoperative cessation of AP and AC, and number of days AP and AC ceased preoperatively. In addition, for patients receiving regular AC, data to determine their ACCP thromboembolic risk categories and on the use of enoxaparin bridging were collected. The INR International Normalized Ratio (INR) on the day of operation was also collected. Postoperative data collected included: Weight of resected prostatic chips and the histopathology of the surgical specimens.

Outcomes

Bleeding complications are defined as an extended period of bladder irrigation (3 or more days postoperatively), a hemoglobin drop necessitating blood transfusion, clot retention necessitating recatheterization, or operative intervention. Thromboembolic complications are defined as any acute coronary events, cerebrovascular events (transient ischemic attack (TIA) and stroke), deep vein thrombosis, or pulmonary embolism. Acute coronary events are defined as any laboratory confirmed troponin rise, or acute ischemic changes on electrocardiography—angina without the confirmatory investigation results is not considered an event.

Both bleeding and thromboembolic complications are assessed up to 30 days post-TURP by reviewing both inpatient and emergency department records. To ensure completeness and accuracy of the complications, documentations from patients' outpatient clinic appointment (usually 2 to 3 months post-TURP) were also reviewed to identify any potential missed events. The study was approved by the Alfred Health Ethics Committee.

Statistical analyses

Association between AP and AC use and the bleeding and thromboembolic complications were assessed using the Kruskal-Wallis test for continuous variables and the Fisher exact test for categoric variables. Subset analyses were also performed among patients receiving regular AP (ie, those who ceased AP vs continued AP) and regular AC (i.e., those who received enoxaparin bridging vs those who did not). Bonferroni correction was applied to account for multiple testing, with threshold for significance defined as P < 0.003. All statistical analyses were performed using STATA/IC 13 (STATA Corp, College Station, TX).

Results

Table 1 shows the baseline characteristics of the patients in the current study. The average age at the time of TURP was 71 (standard deviation = 8.8). Approximately two-thirds of the patients (67%) had TURP for symptomatic obstructive LUTS, while a quarter of the patients (26%) who had TURP were catheter-dependent, having failed a trial of void. The median prostate volume was 60 cc (range 10–200 cc), and the median weight of resected prostatic tissues was 16 g (range 1–83 g). The majority of the histopathology of the prostatic tissues revealed BPH while 14% showed evidence of malignancies—39 were prostate cancers and 3 were urothelial carcinomas with prostatic invasion.

Table 1.

Baseline Characteristics of Study Population (n = 293)

Age at TURP–mean (SD)	71 (8.8)
Indications for TURP
Obstructive LUTS	195 (67%)
Recurrent retention (IDC in situ)	75 (26%)
Bladder stone	10 (3%)
Hematuria	9 (3%)
Preseed brachytherapy for prostate cancer	4 (1%)
Prostate volume, cc–median (range)	60 (10–200)
Resected prostatic chips weight, g–median (range)	16 (1–83)
Histopathology of prostatic chips
Benign	251 (86%)
Prostate cancer	39 (13%)
Urothelial carcinoma (prostatic invasion)	3 (1%)

TURP = transurethral resection of the prostate; SD = standard deviation; LUTS = lower urinary tract symptoms; IDC = indwelling catheter.

Perioperative management of AP

Of the 293 patients who underwent elective TURP, 107 (37%) patients were receiving long-term AP—90 (84%) receiving aspirin (100 mg), 7 (6%) receiving aspirin and clopidogrel (100 mg/75 mg), 4 (4%) receiving Asasantin (200 mg/25 mg), and 6 (6%) receiving clopidogrel only (75 mg) (Table 2). There were 39 (36%) patients who were receiving long-term AP for primary prevention, while 58 (54%) patients receiving long-term AP had known coronary artery disease (CAD) and 6 (6%) had a history of cerebrovascular events.

Table 2.

Perioperative Management of Antiplatelets (n = 107)

	Ceased AP	Continued AP	P value
Number of patients	72 (67%)	35 (33%)
Types of AP
Aspirin only	65 (72%)	25 (28%)	0.003
Aspirin + clopidogrel	1 (14%)	6 (86%)
Aspirin + dipyridamole (Asasantin)	1 (25%)	3 (75%)
Clopidogrel only	5 (83%)	1 (17%)
Indications for AP
Primary prevention	36 (92%)	3 (8%)	<0.001
CAD–no stent/CABG	16 (73%)	6 (27%)
CAD–CABG	5 (33%)	10 (67%)
CAD–stent	8 (38%)	13 (62%)
CVA (TIA/stroke)	4 (67%)	2 (33%)
PVD	3 (75%)	1 (25%)
Number of days AP ceased preoperative–mean, SD	7.6 (2.3)	n/a

AP = antiplatelets; CAD = coronary artery disease; CABG = coronary artery bypass graft; CVA = cerebro-vascular accident; TIA = transient ischemic attack; PVD = peripheral vascular disease; SD = standard deviation.

During the perioperative period, 35 (33%) patients continued on AP, while 72 (67%) ceased AP at a median of 7 days preoperatively. All patients who continued on AP were prescribed 100 mg aspirin alone, regardless of whether they were receiving long-term single or combinations AP. Patients receiving long-term AP for primary prevention were more likely to undergo perioperative AP cessation (92%) compared with those with known CAD and/or cerebrovascular disease (P < 0.001). 62% of patients with coronary stent and 67% of patients who had previous coronary artery bypass graft continued taking AP in the perioperative period. AP was recommenced at a median of 2 days (interquartile range: 1–3) post-TURP.

Perioperative management of AC

There were 25 (9%) patients in the cohort who were on long-term AC, all of whom were receiving warfarin (Table 3). Five of these patients were also on long-term AP. Atrial fibrillation was the main indication for patients receiving AC (72%). Based on the ACCP thromboembolic risk classification, 9 (36%) patients had low thromboembolic risks, 13 (52%) intermediate risk, and 3 (12%) were high risk. All 25 patients had their warfarin withheld on an average of 5 to 6 days before TURP. There were 18 (72%) patients who received enoxaparin bridging, once their INR became subtherapeutic (ie, less than 2.0 or 2.5, depending on the indications for AC). All three ACCP high-risk patients received enoxaparin bridging, while 85% and 44% of ACCP intermediate-risk and low-risk patients did so. On the day of operation, all but one patient (INR = 1.6) had an INR of less than 1.5. Warfarin was restarted at a median of 3 days post-TURP, with or without enoxaparin bridging, depending on indications for warfarin.

Table 3.

Perioperative Management of Anticoagulants (n = 25)

ACCP thromboembolic risk	Low	Intermediate	High
Number of patients	9 (36%)	13 (52%)	3 (12%)
Indications for AC
AF	8	9	1
History of DVT/PE	1	1	0
Clotting disorder	0	1	0
History of valve replacement	0	2	2
AC management preoperative
Ceased without enoxaparin bridging	5 (56%)	2 (15%)	0 (0%)
Ceased with enoxaparin bridging	4 (44%)	11 (85%)	3 (100%)
Number of days AC ceased preoperative – mean, SD	5.3 (1)	5.7 (1.4)	5.7 (1.2)

ACCP = American College of Chest Physicians; AC = anticoagulants; AF = atrial fibrillation; DVT = deep vein thrombosis; PE = pulmonary embolism; SD = standard deviation.

Complications

During the postoperative period, we reported 31 incidents of bleeding complications (10%) (Table 4), of which 8 (2%) patients had prolonged bladder irrigation, 24 (8%) needed recatheterization (at a median of 4 days post-TURP), 6 (2%) returned to the operating theater (at a median of 4 days post op-TURP), and 6 (2%) needed blood transfusions (median of 2 units packed red blood cells). Patients with larger prostates are more likely to have bleeding complications (P = 0.003), but no association was observed between the bleeding complications and the weight of the resected tissues (P = 0.09) or histopathology of the prostatic chips (P = 0.2).

Table 4.

Bleeding and Thromboembolic Complications, By Antiplatelet and Anticoagulant use and Perioperative Management

		Regular AP ^*			Regular AC ^*
	No regular AP or AC (n = 166)	Ceased AP (n = 69)	Continued AP (n = 32)	P value §	No bridging (n = 7)	Clexane bridging (n = 18)	P value ¶	P value ^†
Bleeding complications	14 (8%)	3 (4%)	5 (16%)	0.05	0 (0%)	8 (44%)	0.03	<0.001
CBI >2 days	3 (2%)	0 (0%)	1 (3%)	0.1	0 (0%)	4 (22%)	0.2	<0.001
Clot retention necessitating IDC reinsertion	11 (7%)	4 (6%)	4 (13%)	0.2	0 (0%)	5 (28%)	0.1	0.02
Operative intervention	3 (2%)	0 (0%)	1 (3%)	0.1	0 (0%)	2 (11%)	0.4	0.06
Blood transfusion	3 (2%)	0 (0%)	1 (3%)	0.1	0 (0%)	2 (11%)	0.4	0.06
Thromboembolic complications	1 (0.6%)	1 (1.4%)	0 (0%)	0.5	0 (0%)	3 (17%)	0.3	<0.001
Length of hospital stay, mean (SD)	2.5 (1.5)	3.0 (2.8)	2.6 (2.4)	0.1	2.6 (0.53)	5.4 (4.9)	0.2	0.002

5 patients receiving both regular AP and AC were included in the regular AC column.

†

Comparison across all five strata (no regular AP/AC, ceased AP, continued AP, no bridging, enoxaparin bridging).

§Comparison among regular AP patients (ceased AP, continued AP).

¶ Comparison among regular AC patients (no bridging, enoxaparin bridging).

AP = antiplatelet; AC = anticoagulant; CBI = Continuous Bladder Irrigation; IDC = indwelling catheter; SD = standard deviation.

When stratified by AP/AC use and their perioperative management strategies, there was a statistically significantly higher proportion of bleeding complications among long-term AC users who received enoxaparin bridging (8/18; 44%), compared with patients not receiving AP/AC (14/166; 8%), patients who continued on AP (5/32; 16%), and patients who ceased AP (2/69; 4%) (P < 0.001). Specifically, long-term AC users who had enoxaparin bridging were more likely to have prolonged bladder irrigation (4/18; 22%) compared with other patients (P < 0.001). There were no significant differences in the need for blood transfusion (P = 0.06) or operative intervention (P = 0.06), however. No bleeding complications were observed in regular AC users who did not receive enoxaparin bridging.

There were five (2%) incidents of thromboembolic events reported in our cohort in the postoperative period—three acute coronary events and two cerebrovascular events (Table 5). There were no morbidities or deaths from the cerebrovascular events. Patients receiving long-term AC who had enoxaparin bridging during the perioperative period (3/17; 17%) reported the highest proportion of thromboembolic complications (P < 0.001)—these three patients also reported bleeding complications. This translated into a statistically significantly prolonged hospital stay for long-term AC patients with enoxaparin bridging (mean = 5.4 days) compared with other groups of patients (P = 0.002).

Table 5.

Patients with Thromboembolic Complications

	AP/AC	Indication for AP/AC	Preoperative management of AP/AC	Thromboembolic complications	Bleeding complications
Patient 1	-	-	-	STEMI D8 postop	No
Patient 2	Clopidogrel	CAD–coronary stent	Preop: AP ceased D15 preop by patients (recommended D10 preop by treating team)Postop: AP to be restarted by GP in community when hematuria resolves	TIA D6 postop	No
Patient 3	Warfarin	Aortic valve replacement– ACCP intermediate risk	Preop: Therapeutic enoxaparin bridgingPostop: Therapeutic enoxaparin restarted D2 postop	NSTEMI D18 postop	Blood transfusion D4 postop;Hospital readmission and IDC reinsertion for clot retention D7 postop
Patient 4	Warfarin	AF–ACCP low risk	Preop: Therapeutic enoxaparin bridgingPostop: Warfarin restarted D2 postop without enoxaparin bridging	TIA D3 post-op (hospital re-admission under stroke unit)	Hospital readmission and IDC reinsertion for clot retention D8 postop
Patient 5	Warfarin	AF – ACCP int. risk	Preop: Therapeutic enoxaparin bridgingPostop: Aspirin and ticagrel or started D0 postop for STEMI	STEMI D0 postop (angioplasty)	Prolonged bladder irrigation (8 days)

AP = antiplatelet; AC = anticoagulant; STEMI = ST segment elevation myocardial infarction; postop = postoperative; D = day; CAD = coronary artery disease; preop = preoperative; TIA = transient ischemic attack; GP = general practitioner; ACCP = American College of Chest Physicians; NSTEMI = non-ST segment myocardial infarction; AF = atrial fibrillation.

Discussion

Balancing the bleeding and thromboembolic risk in the perioperative period has always been a challenge for urologists. Here, we reported our experience in the perioperative management of AP and AC among men undergoing elective TURP in a single tertiary institution in Australia. In our cohort, approximately 1 in 3 patients were receiving long-term AP, and 1 in 10 were receiving long-term AC. This is similar to the prevalence of AP and AC use reported in the literature.

In a study of 612 elective TURP patients in France, 24% and 10% of the patients were receiving regular AP and AC, respectively.⁹ Another two studies in New South Wales in Australia reported AP/AC prevalence of 36% to 44% among patients undergoing elective TURP.^10,11 These numbers highlighted the importance of the problem, because increasingly urologists are encountering patients who are receiving long-term AP and AC in their clinical practice.

It is important to distinguish between AP and AC, however, because these are two different classes of antithrombotic agents with different mechanisms of action. AP works by inhibiting the primary hemostasis mechanism (ie, platelet activation and formation of platelet plug), whereas AC targets the coagulation system to inhibit production of thrombin. There are various indications for AP and AC, and hence the perioperative management of AP and AC also varies, depending on their indications.

Most studies in the literature, however, tend to report on the perioperative management of AP and AC collectively, without clearly distinguishing the two types of antithrombotic agents.^10
–12 One of the strengths of our study is the clear distinction in the perioperative management of AP and AC, separately, which allows for better evaluation of the complications associated with our practice.

In our institution, AP was ceased on an average of 1 week before TURP in about two-thirds of the patients, depending on the indications for AP. The proportion of patients who continued on AP in our cohort (33%) appeared to be higher than that reported in the literature, most of which was less than 10%.^9
–11 Among the 35 patients who continued on AP in our cohort, 29 (83%) had known CADs, of whom 13 had coronary stents while 10 had previous coronary artery bypass grafts.

The cessation of AP, when used for secondary prevention, was reported to the associated with a three-fold increased risk of acute coronary events in a meta-analysis of more than 50,000 patients, and the risk was significantly higher among patients with coronary stents.⁵ This risk was likely further increased in the perioperative setting, because of a systemic activation of the coagulation cascade and reduced fibrinolytic activity—termed fibrinolytic shutdown—as a physiological response to achieve hemostasis, leading to a “hypercoagulability state.”^13,14

Among patients with coronary stents, the interval between coronary stent insertion and TURP as well as the type of coronary stent are important in determining the appropriate perioperative management of AP. In our cohort, there were 21 patients with coronary stents receiving long-term AP. Of these, eight (38%) ceased AP, and one reported thromboembolic events. Current guidelines recommend continuation of dual AP for a minimum of 6 weeks after bare metal stent (BMS) insertion and 6 months after drug eluting stent insertion, as a minimal safety measure.¹

Cardiac mortality has been reported to be as high as 86% in patients who ceased AP for noncardiac surgery less than 1 month post-BMS insertion.¹⁵ Because of the retrospective nature of our study, however, there is a lack of detailed documentation of the type of stents and date of insertion. This is one of the limitations of our study, which hinders our ability for more rigorous evaluation of our practice in terms of cessation versus continuation of AP among patients with known coronary disease. Nonetheless, we did not observe significant differences in the thromboembolic complications between those who ceased versus continued on long-term AP during the 30-day follow-up period in our study. Our overall thromboembolic complications among AP users of 1% (1/107) was also comparable to that reported in the literature.⁹

When we looked into the bleeding complications among AP users, we observed a trend toward a higher proportion of bleeding complications among patients who continued on AP (16%) compared with those who ceased AP (4%), which was not statistically significant. This could be because of a lack of statistical power, with a relatively small number of AP users (69 ceased and 32 continued) in our study.

The increased bleeding complications with continued AP use during TURP, however, has been well documented in the literature. In a randomized trial comparing patients who received AP versus placebo for a total of 10 days before TURP, Nielsen and colleagues¹⁶ reported increased postoperative blood loss in the AP group. There were no significant differences in the transfusion requirements or length of hospital stay, however.

In a recent study in Australia, Taylor and coworkers¹⁰ reported bleeding complications as high as 86% among patients who continued taking AP while undergoing TURP.¹⁰ In another study, Ala-Opas and Gronlund¹⁷ reported no differences in mean blood loss after TURP, between 40 AP users and 42 non-AP users; however, 2 (5%) of the AP patients reported late bleeding complications necessitating operative intervention whereas no late bleeding complications were observed in the non-AP users.¹⁷

Perioperative management of AC, on the other hand, is different from that for AP. While some earlier studies have reported performing TURP with patients continuing on warfarin,^18,19 almost all contemporary studies reported ceasing AC in the perioperative period for TURP, with or without enoxaparin bridging.^{9
–11,20,21} The decision on perioperative enoxaparin bridging among patients on long-term AC is guided by their thromboembolic risk, based on the ACCP risk stratification.¹

It is recommended to cease AC 5 days before the surgical procedure, with therapeutic enoxaparin bridging for patients at high thromboembolic risk, and no bridging for patients at low thromboembolic risk. There was no clear-cut recommendation for intermediate-risk patients, and individual patient factors need to be taken into consideration.¹ The ACCP risk stratification, however, was often not reported in most studies, making it impossible to evaluate the appropriateness of their enoxaparin bridging practice. In our cohort, all patients at high thromboembolic risk received enoxaparin bridging, which was in accordance with the ACCP guidelines.

On the other hand, nearly half of the patients at ACCP low thromboembolic risk in our cohort received enoxaparin bridging in the perioperative period, which may be deemed unnecessary based on the ACCP guidelines. The practice of overcoagulating this group of patients at low thromboembolic risk may have huge implications, especially when we observed statistically significantly higher proportion of bleeding complications with enoxaparin bridging.

The increased bleeding risk with enoxaparin bridging has been previously reported in the literature. In a study comparing 20 regular AC users who received intravenous unfractionated heparin infusion/enoxaparin bridging with 20 non-AC users, Dotan and colleagues²⁰ reported prolonged bladder irrigation and delayed catheter removal secondary to post-TURP bleeding in 55% of AC users, compared with 10% in non-AC users. The length of hospital stay was also significantly prolonged in the AC users (mean of 4.2 days) compared with non-AC users (mean of 2.1 days) in that study.

We also observed three thromboembolic complications in regular AC patients, who received enoxaparin bridging (17%), which was significantly more than other groups of patients in our cohort. Interestingly, all three patients also experienced bleeding complications (Table 5). Patients 4 and 5 initially experienced thromboembolic complications (a TIA and a ST segment elevation myocardial infarction, respectively), which triggered up-titrations of their AC and AP use. This resulted in a readmission with clot retention on postoperative day 8 for patient 4, and prolonged bladder irrigation leading to a delayed discharge for patient 5.

On the contrary, patient 3 was initially readmitted for the management of clot retention during which his AC use was interrupted, and a non-ST segment myocardial infarction occurred on postoperative day 18. Hence, although bleeding and thromboembolic events are often viewed as two separate ends of a spectrum, the treatment of one can predispose a patient toward the other.

No bleeding or thromboembolic complications were reported among regular AC users, who did not receive any enoxaparin bridging. This may suggest that TURP can potentially be safely performed among patients on long-term AC, on the condition that AC can be ceased without the need for enoxaparin bridging—ie, patients at ACCP low thromboembolic risk. It is also important to ensure a normalized INR on the day of operation.

Nonetheless, it is not possible to make strong recommendations based on only a small number of patients in this group in our cohort (n = 7). There is clearly a need for larger prospective studies to better evaluate the complications associated with different perioperative management of AC for patients undergoing elective TURP.

Conclusion

In our institution, the perioperative management of AP was based on the clinical indications for AP—patients with coronary artery bypass grafts and coronary stents are more likely to continue receiving AP throughout the perioperative period. For long-term AC users, while ACCP high-risk patients were appropriately bridged with enoxaparin, nearly half of the ACCP low-risk patients were overcoagulated in our institution. Overall, we reported both higher bleeding and thromboembolic complications among AC users who received enoxaparin bridging. This highlighted the challenges in the treatment of this extremely high-risk group of patients and the need for careful consideration of the risk-benefits as well as timing of TURP.

In the event that there are strong clinical indications for enoxaparin bridging in long-term AC users, alternative treatment options should be considered. These include selective vaporization of the prostate or holmium laser enucleation of the prostate, depending on each individual institution's preference and expertise.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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Perioperative Management of Antiplatelets and Anticoagulants Among Patients Undergoing Elective Transurethral Resection of the Prostate—A Single Institution Experience

Abstract

Purpose:

Patients and Methods:

Results:

Conclusion:

Introduction

Patients and Methods

Study population

Outcomes

Statistical analyses

Results

Perioperative management of AP

Perioperative management of AC

Complications

Discussion

Conclusion

Footnotes

Author Disclosure Statement

Abbreviations Used

References