Commentary on “Initial Experience with Aspirin Use During Robotic Radical Prostatectomy”

In many urologists' opinion, radical prostatectomy offers the best long-term cure rates with the fewest long-term side effects in younger men (<65 years of age) diagnosed with clinically localized prostate cancer. This is especially true in men with large prostates and those with voiding dysfunction where radiation therapy can prove a detriment to overall quality of life. It has become a not uncommon occurrence to see a seemingly healthy appearing male diagnosed with prostate cancer in this age group who has a coronary artery stent in place. As Nowfar et al. ¹ point out in their introduction, 77% of percutaneous coronary interventions utilize stents, and a majority of these are of the drug-eluting variety. ² Stent thrombosis is a potentially catastrophic complication of halting antiplatelet therapy in a patient with a coronary stent in place. Forty percent of reported stent thrombosis cases occur in the perioperative setting with the elimination of antiplatelet therapy. ³ With a lack of randomized controlled data to guide the ideal duration of antiplatelet therapy following coronary stent placement, many medical physicians and cardiologists are recommending continuous antiplatelet therapy indefinitely and during the perioperative period. ⁴

The risk of bleeding with pelvic oncologic surgery is substantial, and in the case of radical prostatectomy, a large pelvic hematoma can affect surgical recovery, prolong catheter time, alter continence outcomes, and return of potency. The benefits of robotic prostatectomy (RAP) with regards to decreased blood loss compared with open surgery have been well reported. The authors of this small study ¹ (249 RAP procedures; 6 performed with the patient on aspirin) did not note any difference in perioperative outcomes in RAP performed on aspirin compared with those off aspirin. This is the first study I know of commenting on the safety of aspirin use during RAP. However, most urologists would still prefer patients off of antiplatelet therapy before pelvic oncologic surgery. Before my medical peers get excited about data such as these and recommend ALL patients with coronary stents continue aspirin use during RAP, I would like to make a note about this study. The authors completed 6 RAP procedures on patients with coronary artery stents while off of antiplatelet therapy, and there were no coronary events. The title and conclusions of this article could very well have been that discontinuing aspirin use prior to RAP in patients with coronary stents was a safe practice in carefully selected patients.

The current study involves a small cohort, and it is difficult to make definitive conclusions with such small numbers. My challenge to the urologic community is for our high-volume robotic prostatectomists (those with published series over 1,000 cases) to note their experience with surgery completed on patients while taking aspirin and those with coronary artery stents in whom antiplatelet therapy was halted. My challenge to the medical community is to give us good recommendations as to which patients with coronary artery stents can stop antiplatelet therapy and which cannot. It is clear that patients with previous stent thrombosis, left main artery stenting, multivessel stenting, and those with a stent in their only remaining graft should stay on antiplatelet therapy. ⁴ Other than those patients listed above, blanket statements that all previous coronary stent patients should continue antiplatelet therapy may rob someone of the potential benefits of RAP and may be asking the urologic surgeon to take unnecessary risk when it is not needed. On the flip side, better risk stratification may help aid in avoiding surgery completely in those at very high risk.