Surgical Treatment Options for Benign Prostatic Obstruction

Beyond Prostate Volume

Claudia Deyirmendjian; Dean Elterman; Bilal Chughtai; Kevin C. Zorn; Naeem Bhojani


Curr Opin Urol. 2022;32(1):102-108. 

In This Article

Antithrombotic Therapy

As our patient population is increasing in age with increasing comorbidities, a large number of men requiring BPO surgery are concomitantly undergoing antithrombotic therapy, which includes anticoagulant and antiplatelet agents. Anticoagulated patients present an increased risk of bleeding during and after surgery. For this reason, best practice guidelines from the American Urological Association (AUA) and European Association of Urology (EAU) prioritize specific treatments, namely laser enucleation of the prostate (LEP) and photoselective vaporization of the prostate (PVP). Bipolar plasma transurethral vaporization of the prostate (BiTUVP) may also be offered to patients under antithrombotic therapy.

The holmium:YAG laser is the most studied laser used to perform enucleation of the prostate. The excellent hemostatic properties of the holmium laser can be attributed to its wavelength and low tissue penetration with pulsed laser energy which allows for effective coagulation.[1] In a study comparing patients under antithrombotic regimens undergoing holmium LEP (HoLEP) and transurethral resection of the prostate (TURP) – the current gold standard treatment for BPO – patients in the HoLEP group experienced a significantly lower hemoglobin drop, whereas maintaining similar improvements in functional outcomes.[2] A cohort analysis by El Tayeb et al. reported that transfusion rates as well as drop in AUA symptom score after 6 months were similar in patients who did and did not receive antithrombotic therapy, but length of hospital stay, and continuous bladder irrigation were significantly less in the nonantithrombotic group.[3]

The thulium:YAG laser is another widely used laser energy for prostate enucleation with a similar safety profile and efficacy compared to holmium:YAG. In a meta-analysis of 5 studies, mean hemoglobin drop with thulium:YAG LEP (ThuLEP) varied between 0.5 and 1.6 g/dl, which was similar to HoLEP in this study.[4] A recent prospective randomized study demonstrated a much lower hemoglobin drop with ThuLEP compared to HoLEP, in nonanticoagulated patients (0.45 vs 2.77 g/dl; P = 0.005).[5] This may be due to the continuous laser energy of the thulium:YAG laser which improves hemostasis. In large prostates, Zhang et al. demonstrated no difference in intra-operative hemoglobin drop between HoLEP and ThuLEP, respectively (0.8 vs 0.7 g/dl; P = 0.154).[6]

A third and novel laser modality of interest is the thulium fiber laser, first reported in 2018. Thulium fiber LEP (ThuFLEP) delivers a pulsed laser with a shallower depth of penetration and at a more optimal wavelength which increases its absorption in water leading to better hemostatic properties. In a retrospective study including patients taking antiplatelet therapy, ThuFLEP achieved similar postoperative results to HoLEP and no difference in postoperative bleeding, clot retention or transfusion rates were found.[7]

PVP, also known as Greenlight laser vaporization, emits light at a wavelength of 532 nm, which favors blood absorption while sparing water molecules in prostate tissue. A 2019 meta-analysis comparing PVP in nonanticoagulated and anticoagulated patients showed that a total of 1 patient among 616 from the anticoagulated group required a blood transfusion.[8] One retrospective analysis included in the meta-analysis indicated that, although hospital stay was longer for anticoagulated patients, there were no significant differences in functional outcomes, including change in IPSS, Qmax and PVR.[9] In a sample of 20 patients taking novel oral anticoagulants, Sachs et al. reported no cases of clot retention or transfusions, however, 4 (20%) patients required re-catheterization for urinary retention.[10]

BiTUVP is a technique that uses bipolar energy to ablate prostate tissue with a transurethral electrode. BiTUVP is able to ablate and coagulate tissue simultaneously and has been recommended as an alternative to TURP for patients who are anticoagulated. A series of 7 randomized trials on BiTUVP showed slight improvement or no difference in IPSS and maximum flow rate (Qmax) compared to monopolar and bipolar TURP, and had superior hemostasis reflected by a very low transfusion rate (0–1.2% vs 0–6.5%).[11] Kranzbühler et al. reported on 26 patients using antiplatelet agents and acetylsalicylic acid undergoing BiTUVP and none had intraoperative bleeding complications, but one has to acknowledge the small number of patients in this series.[12]