What is Known and Objective: Currently, the safety and efficacy of Holmium Laser Enucleation of Prostate (HoLEP) in patients with large prostates (>100 ml) who are at high risk for Thromboembolic Events (TE) and receiving Antithrombotic Therapy (AT) are controversial. This study aims to characterise the safety and efficacy of the HoLEP in patients with large prostates (>100ml) at high risk for TE resuming AT in the early post-operative period.

Methods: We have reviewed retrospective data for 378 patients with large prostates treated with the HoLEP for symptomatic benign prostatic hyperplasia between December 2016 and July 2020. One hundred thirty-four of the patients had been receiving AT. Antiplatelet (AP) therapy was maintained. Patients taking vitamin K antagonists and new oral anticoagulants stopped taking the drug 5 and 2 days before the HoLEP, respectively. Postoperatively, anticoagulants (AC) were resumed within 24 hours. In patients receiving AT, we have determined “pre-operative, peri-operative, and post-operative” parameters, functional outcome, and adverse events for the 3 months after the operations. Subsequently, we have compared the results of 203 patients without AT.

Results and Discussion: Patients receiving AC and AP were older (p=0.015) and had a higher median ASA score (p<0.001). Objective-voiding parameters (Qmax, PVR) and urinary symptoms (IPSS, QoL) improved in the three groups (p<0.001). Median enucleation and morcellation efficiencies were 1.58 (IQR:0.87-3.13) and 5 (IQR:1-8.08), median catheterisation and hospitalisation time was 2 days (IQR:2-3) and 3 days (IQR:3-4), respectively. The peri-operative results were similar in the three groups. Overall, one patient in the AP group required blood transfusion at 4 days postoperatively due to clot retention and significant haemoglobin decrease (p=0.216). There was no adverse TE in any patient within the 3-months postoperatively.

What is new and Conclusion: In cases with large-sized prostates posing a high risk of bleeding as well as TE, the HoLEP procedure could be applied without leaving AP agents in a safe and highly efficient manner. Additionally, this procedure could be performed following the cessation of AC treatment with the chance of a quite early initiation of these agents to limit properly the potential risk of TE.