Published data show clearly that the percentage of elderly cases with co-morbid diseases (i.e. coronary artery disease, cardiac valve disease, peripheric arterial disease, deep vein thrombosis, and pulmonary emboli) is steadily increasing. The majority of these cases carry the risk of TE requiring AT with certain agents like acetylsalicylic acid, platelet aggregation inhibitors, NOAC, and coumadine, etc.). Taking this fact along with the increasing prevalence of aged men with BPH under the above-mentioned treatment into account, endoscopic surgical interventions to remove the outlet obstruction in these cases carry the increased risk of certain severe complications either during (bleeding) or immediately after (prolonged bleeding, longer catheterization and/or thromboembolic events) the procedures.¹⁰ In the light of the possible procedure-related perioperative bleeding risk and post-operative TE, the AC treatment regimen needs to be well balanced to limit the chance of above mentioned sometimes life-threatening problems. In other words, a responsible endourologist aims to remove the obstructing prostatic adenoma without having a risk of bleeding which may originate from the use of these agents. However, cessation of these agents may not be possible in a certain percentage of cases or at least initiation of the AC treatment may be necessary shortly after the procedure.

Related with this issue, it has been well demonstrated that preoperative cessation and/or late initiation of these AC agents may cause an increased risk of thromboembolic agents in patients undergoing TUR-P or open prostatectomy procedures. Taking the shortcomings of AC treatment cessation into account, in this present study prior to HoLEP surgery, we prepared a protocol and following the detailed consultation with responsible cardiologists, bridging with LMWH was done in AC receiving cases. Additionally, acetylsalicylic acid has been initiated in patients receiving antiplatelet agents (clopidogrel, etc). Endoscopic removal of the adenomas with HoLEP procedure was done in these cases under either clexane or aspirin treatments. More importantly, we initiated the routine management with AC agents 24 hours after the procedures as soon as the urine color becomes clear. This approach by initiating the classical AC agents shortly after the procedure aimed to decrease the risk of TE which have been reported to a certain extent in cases leaving the AC agents for a reasonable time period.

We believe that the rational application of this protocol in cases with large volume prostates will not only limit the risk of bleeding and associated complications but also the very early initiation of the AC agents could be possible in this risk group of cases due to the complete removal of enlarged adenomas with excellent bleeding control. It is very clear that the most important demand of the responsible cardiologists is the initiation of AC as early as after the procedure and establishment of this precise balance with this protocol will certainly limit the risk of TE.⁶Although the surgical procedure ( HoLEP) could be performed under AT in patients with small-sized prostates, the performance of the procedure in large-sized prostates will certainly increase the risk of severe bleeding and associated problems.^11-13 Evaluation of our cases demonstrated that although cases undergoing AP ve AC treatment were older with associated co-morbid diseases, the efficiency of enucleation and morcellation procedures were similar in both groups. Bleeding in terms of Hb drop was evaluated with the postoperative Hb values obtained at two different time intervals (postoperative 12 hours and 1 week) after the procedure.

As we initiated the AC treatment 24 hours after the procedure and the drop in Hb levels could reflect the dilutional changes we thought that the effect of AC treatment might be very limited for the changes in Hb levels noted after 12 hours. For that reason, to demonstrate the possible effect of AC management on post-operative Hb changes we focused on the Hb levels detected 1 week after the procedures. In cases receiving acetylsalicylic acid to replace for antiplatelet agents, we accepted that the changes in Hb levels 12 hours after the procedure may originate from the acetylsalicylic acid application. We compared our findings with the data of similar studies and found that the results were comparable.^{12, 13}

Regarding prolonged catheterization issues in the three groups, we found that the results were different (p = 0.028, 3x2 chi-square test). Also, the AP and AC groups were compared with the NT group in terms of prolonged catheterization and our findings showed that catheterization time was significantly longer in cases undergoing AP treatment when compared with the ones without any treatment (AP vs NT; OR: 2.77, 95% CI: 1.28-5.96, p=0.007 and AC vs NT; OR: 1.67, 95% CI:0.61-4.55, p=0.391, 2x2 chi-square test). It has been shown that antithrombotic therapies have a significant effect on hospitalization and catheterization time.^{14, 15} Additionally, although not statistically significant, one case in the AP group required blood transfusion with clot retention after the procedure (AP vs NT; OR: 1.012, 95% CI: 0.988–1.037, p=0.29). No patient did show TE after the procedure in three groups.

Last but not least, evaluation of the efficiency in the removal of obstruction during 3-months evaluation period in all groups in terms of preoperative and post-operative Qmax, PVR, IPSS, and QoL parameters demonstrated no significant difference between three groups. These findings in turn again indicated the successful removal of the obstruction with HoLEP procedure in all group cases. In other words, our findings demonstrated the efficient as well as a successful performance of HoLEP in cases with large-sized prostates with or without AP medication.

Our study may have some certain limitations. First of all retrospective nature of our study methodology may be a major limitation. Secondly, the performance of all procedures by an experienced surgeon may have had a positive effect on the outcomes. Additionally, the use of the ASA score instead of the Charlson co-morbidity index may constitute another limitation. Last but not least, the lack of the duration of irrigation time could be the final possible limitation. However, despite these possible limitations, we believe that in the light of the very limited data published in the literature focusing on the possibility of early initiation of AC management particularly following the surgical intervention for large prostates, our findings could contribute to the existing information with reliable clinical implications.

Our results clearly demonstrate that HoLEP procedure could be applied without leaving AP in a safe and highly efficient manner in cases with large-sized prostates carrying a high risk of bleeding as well as thromboembolic events. Additionally, this procedure could be performed following the cessation of AC treatment with the chance of very early initiation of these agents to limit well the possible risk of thromboembolic events. However, we noted that this approach may prolong the duration of catheterization after the procedure which may necessitate necessary precautions.