HoLEP for men on blood thinners

Why HoLEP is different on blood thinners

Stopping blood-thinning medication around surgery introduces its own risk - stroke, coronary stent occlusion, embolic events in atrial fibrillation - which most patients and their cardiologists prefer to minimise if they safely can. HoLEP minimises the time required to be off these medications.

• The laser cuts and coagulates at the same time. The pulsed holmium:YAG beam is absorbed in a very thin layer of tissue at the fibre tip, sealing the small arteries and veins of the prostate as they are divided.²
• Saline irrigation. Saline is used throughout rather than the hypotonic glycine used in classical TURP, so there is no risk of TUR syndrome if a long operation is needed in a man with other medical problems.⁹

What the evidence shows

• US high-volume series. An Indiana University / Methodist Hospital series compared 116 men on anticoagulation or antiplatelet therapy with 1,558 HoLEP patients who were not on such therapy. Lowest postoperative haemoglobin and transfusion rates were the same in both groups; bladder irrigation time and hospital stay were slightly longer for the anticoagulated men, but major bleeding and reoperation rates were not significantly different.¹¹
• Contemporary European experience. A 2024 retrospective analysis from a high-volume European centre of men undergoing HoLEP while on antithrombotic therapy confirmed a low rate of early haemorrhagic complications.¹²
• Guideline position. The American Urological Association specifically identifies HoLEP as an appropriate surgical option for men at higher bleeding risk, including those who cannot safely come off an anticoagulant.¹
• Additional reviews. Recent reviews confirm the safety of HoLEP under anticoagulation.¹⁸

Typical peri-operative approach

The decision about whether to pause, bridge or continue a blood thinner is made case by case in conjunction with the treating cardiologist or haematologist. The common regimens are:

• Aspirin alone. Usually continued through surgery without interruption.
• Dual antiplatelet therapy after a recent coronary stent. Surgery is commonly deferred until the patient is back on aspirin alone; aspirin is then continued through the procedure. Clopidogrel is sometimes continued if the stent is recent and the cardiologist cannot safely pause it.
• Warfarin. Typically paused 3-5 days pre-operatively with INR rechecked on the day; bridging with low-molecular-weight heparin if the indication is high-risk (mechanical mitral valve, recent thromboembolism).
• Direct oral anticoagulants (DOACs) - apixaban, rivaroxaban, dabigatran. Paused 24-48 hours pre-operatively depending on renal function, resumed within a few days post-operatively.

If you have been told that you cannot have a TURP because of your blood-thinning medication, it is worth asking specifically about HoLEP. In most cases it is possible to proceed with minimal or no interruption of the medication. In a small number of men - for example those with a very recent coronary stent or a new thromboembolic event - surgery is deferred until the antithrombotic regimen has been through its safest window.