Benign Prostatic Hyperplasia (BPH) is one of the most common urological diseases in elderly men. Associated lower urinary tract symptoms (LUTS) have been found to be the main cause of decreased health-related quality of life (QoL) in these cases.¹

Although several endoscopic surgical alternatives such as resection, ablation, incision, vaporization, and enucleation with mechanical morcellation have been described and applied in the relief of LUTS secondary to small-medium size BPH in patients refractory to medical treatment or those developing BPH-related complications, endoscopic management of large prostates (>100 ml) constituted a real challenge for the endourologists on this aspect. Especially, bleeding risk may limit the use of endoscopic treatment alternatives particularly in patients with large-volume prostates receiving antithrombotic (antiplatelet-anticoagulant) therapy.^{2, 3}

Historically, open prostatectomy (OP) has been considered to be the standard surgical treatment for large prostate. However, despite effective removal of the obstruction and successful outcomes, studies have shown that OP carries the risk of excessive bleeding, requiring transfusion during or after the procedure. Moreover, increased bleeding may necessitate continuous bladder irrigation, prolonged catheterization, and longer hospital stay.^{4, 5}

Accumulated data so far have shown that the incidence of use of antithrombotic agents have been increased in cases at older ages and these patients have multiple comorbidities which may increase the risk of a thromboembolic event (TE). Due to the high risk of TE events, antithrombotic therapy (AT) has always been continued during minor surgeries and also AT was advised to be continued as soon as bleeding control is achieved, if AT was planned to be discontinued. Related with this critical issue, guidelines state dual anti-platelet therapy should be initiated again in high-risk patients as soon as possible (within 48 hours if possible) after surgery. Similarly, coumadine should be restarted at 24 hours postoperatively in such patients (eg with prosthetic heart valves).⁶ However, due to the high risk of bleeding and related life-threatening complications both OP and TURP may not allow the initiation of AT in the early postoperative period.

HoLEP is a size-independent technique, enabling the complete removal of enlarged adenomas through a safe and anatomic dissection made between the adenoma(s) and surgical capsule associated with a lower risk of intraoperative bleeding. Published data on this aspect demonstrated that the HoLEP procedure could reveal similar or better post-operative clinical outcomes along with lower complication rates than TURP, OP, or other therapies. It has therefore become the new gold standard technique for the treatment of BPH/LUTS especially in large volume prostates.^{7, 8} Long-term data have been emerging to show that this enucleative procedure has durable results with lower retreatment rates.^{3, 9}

Last but not least, in the light of the evident risk of postoperative bleeding after the above-mentioned treatment alternatives coupled with the increased risk of TE events due to relatively longer cessation of AC therapy, HoLEP procedure may give the advantages of continuation of AP agents as well as immediate initiation of AC agents if stopped, due to the effective and safe tissue removal particularly in large-volume prostates.

In this present study, we aimed to evaluate the efficacy and safety of the HoLEP procedure in cases with large prostates with a social emphasis on the discontinuation as well as the early initiation of AC, AT agents respectively to limit the risk of associated TE events.