Antithrombotic Therapy Raises Bleeding Odds in BPH Surgery, Especially with EnucleationAntithrombotic medications linked to higher bleeding risks during prostate surgery

This meta-analysis pooled data from 6091 patients undergoing endoscopic surgery for benign prostatic hyperplasia (BPH) to evaluate perioperative outcomes associated with ongoing antithrombotic therapy (antiplatelet or anticoagulant) compared with no antithrombotic treatment. The study type is a meta-analysis; the phase, setting, follow-up duration, funding, and conflicts of interest were not reported. The population comprised patients undergoing endoscopic BPH surgery, and the intervention was ongoing antithrombotic therapy, with no antithrombotic treatment as the comparator.

The primary outcomes assessed were bleeding-related complications, operative time, postoperative hemoglobin decrease, catheterization duration, and continuous bladder irrigation time. Secondary outcomes included transfusion, hemostasis, urinary complications, and hospital stay. Across all surgical modalities, operative time, postoperative hemoglobin decrease, catheterization duration, and continuous bladder irrigation time were comparable between groups, with no effect size or p-value reported.

For bleeding-related complications, the results differed by surgical modality. After transurethral resection of the prostate (TURP), bleeding-related complications were significantly more frequent in antithrombotic users (OR 1.90; 95% CI 1.05-3.41; p=0.03). After enucleation, bleeding-related complications were also significantly more frequent in antithrombotic users (OR 2.91; 95% CI 1.71-4.93; p<0.0001). In the anticoagulant subgroup undergoing enucleation, the odds were even higher (OR 4.80; p=0.0002). Bleeding requiring surgical hemostasis after enucleation was more common in antithrombotic users (OR 3.69; 95% CI 1.73-7.84; p=0.0007), as was acute urinary retention (OR 1.36; 95% CI 1.04-1.77; p=0.02). In contrast, after photoselective vaporization of the prostate (PVP), transfusion, hemostasis, and urinary complication rates were comparable regardless of antithrombotic therapy, with no effect size or p-value reported. Hospital stay was marginally longer among antithrombotic users after TURP and PVP (p<0.05).

Safety findings were limited to the bleeding-related complications, transfusion, hemostasis, and urinary complications listed above. Serious adverse events, discontinuations, and tolerability were not reported. The meta-analysis did not report limitations, funding sources, or conflicts of interest. The authors note that the association is derived from observational studies, and caution against overstating the findings: PVP is not the only safe option, and anticoagulants do not always cause bleeding.

The practice relevance stated is that PVP may be preferred for high-risk patients requiring uninterrupted antithrombotic therapy, and that continuation of antithrombotic therapy during PVP appears safe. These findings suggest that clinicians should consider the surgical modality when managing antithrombotic therapy in patients undergoing endoscopic BPH surgery. For TURP and enucleation, the elevated bleeding risks warrant careful perioperative planning, while PVP may offer a safer profile for patients who cannot interrupt antithrombotic therapy. However, the observational nature of the included studies means that residual confounding cannot be excluded, and causality cannot be inferred.

Several questions remain unanswered. The optimal perioperative management strategy for antithrombotic therapy (continuation, interruption, or bridging) is not defined. The duration of follow-up and long-term outcomes were not reported. The impact of specific antithrombotic agents, doses, and indications on bleeding risk is unclear. Additionally, the lack of data on serious adverse events, discontinuations, and tolerability limits the safety assessment. Future research should address these gaps to guide clinical decision-making.