Real World Experience of Holmium Laser Enucleation of the Prostate with Patients on Anticoagulation Therapy - Beyond the Abstract

Holmium laser enucleation of the prostate (HoLEP) is a size-independent, durable and versatile treatment for benign prostatic hyperplasia (BPH). Due to the excellent hemostatic capabilities of the holmium laser, HoLEP has been demonstrated to be feasible in patients on active antiplatelet/anticoagulant (AP/AC) therapy. Enough positive data had been previously published to allow the American Urological Association (AUA) Practice Guidelines Committee to include HoLEP as an option for patients who are unable to interrupt AC therapy at the time of BPH surgery in the 2018 BPH surgical therapy guidelines.1


HoLEP has evolved significantly over the years with technical and technological modifications that have improved surgeon efficiency and patient outcomes.2,3 Much of the existing literature on the HoLEP and AC do not include these advancements, beyond proving feasibility. Two recent large studies from high-volume HoLEP centers characterize the European experience well,4,5 however postoperative care in the US and Europe can be quite different.

In a retrospective review of our prospectively managed HoLEP database, we reviewed 472 patients who underwent HoLEP from July 2018 through December 2019. There were 6.3% patients on clopidogrel and 17.2% on anticoagulation preoperatively. Eight patients either continued or bridged their AP/AC therapy. The mean prostate volume was 103.2 ± 68.6 ml. When comparing all groups (no AP/AC, AP, and AC), there were no differences in preoperative or perioperative variables, with the exception of age. With regards to complications, there was a higher rate of overall complications, but not in unplanned Emergency Department (ED) visits or Clavien ³3 complications. There was also a high rate of success (>83%) with same-day discharge in all groups, in selected patients.

Additionally, we evaluated AC patients on warfarin (35%) compared to direct oral anticoagulants (DOACs) (65%). Patients on warfarin were less likely to have undergone a prior BPH procedure (0 vs. 23.8%). Those on warfarin also experienced a lower rate of successful postoperative day one voiding trials (64% vs. 90%), a higher rate of 90-day complications (52% vs. 14%), and unplanned ED visits (35% vs. 4.8%). There was no difference in Clavien ³3 complications.  This may be due to the less predictable anticoagulation, especially with antibiotics, with warfarin compared to DOACs.

Our aim was to supplement current literature on the feasibility of HoLEP on AP/AC therapy with a modern experience of a large patient cohort outcomes. We demonstrate that even patients with large glands can undergo HoLEP safely without increasing the risk of severe complications or unplanned Emergency Department visits. This continues to solidify HoLEP as a safe and effective treatment for patients on AP/AC therapy. 

Written by: Deepak Agarwal, MD, MPH, Twitter: @DrDAgarwal, Tim Large, MD, MS, Twitter: @MakeMePeeMD, Marcelino Rivera, MD, Twitter: @EndoMarcelino, and Amy Krambeck, MD, Twitter: @amy_krambeck, Indiana University School of Medicine, Department of Urology, Indianapolis, Indiana

References:

  1. Foster, Harris E., Michael J. Barry, Philipp Dahm, Manhar C. Gandhi, Steven A. Kaplan, Tobias S. Kohler, Lori B. Lerner et al. "Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline." The Journal of urology 200, no. 3 (2018): 612-619.
  2. Dusing, Michael W., Amy E. Krambeck, Colin Terry, Brian R. Matlaga, Nicole L. Miller, Mitchell R. Humphreys, Ehud Gnessin, and James E. Lingeman. "Holmium laser enucleation of the prostate: efficiency gained by experience and operative technique." The Journal of urology 184, no. 2 (2010): 635-640.
  3. Large, Tim, Charles Nottingham, Christa Stoughton, James Williams Jr, and Amy Krambeck. "Comparative study of holmium laser enucleation of the prostate with MOSES enabled pulsed laser modulation." Urology 136 (2020): 196-201.
  4. Becker, Benedikt, Christopher Netsch, Jens Hansen, Axel Böhme, Andreas J. Gross, Mario Zacharias, and Karin Lehrich. "Perioperative safety in patient under oral anticoagulation during holmium laser enucleation of the prostate." Journal of endourology 33, no. 3 (2019): 219-224.
  5. Deuker, Marina, Jessica Rührup, Pierre I. Karakiewicz, Maria Welte, Luis A. Kluth, Severine Banek, Frederik C. Roos, Philipp Mandel, Felix K-H. Chun, and Andreas Becker. "Holmium laser enucleation of the prostate: efficacy, safety and preoperative management in patients presenting with anticoagulation therapy." World journal of urology (2020): 1-8.
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