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. 2006 May;88(3):280–283. doi: 10.1308/003588406X95084

The Management of Aspirin in Transurethral Prostatectomy: Current Practice in the UK

Mohamed Khalid Enver 1, Ivan Hoh 1, Frank I Chinegwundoh 1
PMCID: PMC1963700  PMID: 16719999

Abstract

INTRODUCTION

Stopping aspirin prior to transurethral prostatectomy (TURP) may minimise peri-operative blood loss, but it may also increase the risk of a significant cardiovascular event. There are no guidelines on the management of aspirin in TURP. This study sought to determine the variation in the peri-operative management of transurethral prostatectomy (TURP) patients that are taking aspirin.

MATERIALS AND METHODS

A questionnaire was sent to 444 consultant urologists in the UK from a list obtained from the British Association of Urologists. This resulted in 290 anonymous replies (65%), of which 287 were suitable for analysis.

RESULTS

Of these 287 urologists, 178 (62%) ask patients to stop aspirin prior to TURP. Aspirin is stopped 9.8 days (median, 10 days; range, 2–30 days) prior to surgery, and recommenced 8.8 days (median, 7 days; range, 1–42 days) after surgery. In those that stop aspirin, 62% will stop aspirin in all patients, regardless of the indication, and 40% will cancel a TURP if aspirin use has inadvertently continued. Of the 287 urologists, 109 (38%) do not stop aspirin.

CONCLUSIONS

There is a wide variation in the management of aspirin in TURP patients in the UK. Aspirin is being stopped in patients at high risk of serious cardiovascular disease, often for longer than necessary. There is a need for multidisciplinary guidelines to reduce variation in practice.

Keywords: Benign prostatic hypertrophy, TURP, Aspirin

Excessive operative blood loss in transurethral prostatectomy (TURP) makes the procedure technically more difficult, may necessitate blood transfusion, and occasionally re-operation. Many urologists attempt to minimise blood loss by stopping aspirin prior to TURP, thus avoiding aspirin-induced iatrogenic coagulopathy. However, stopping aspirin increases the patient's risk of serious cardiovascular disease. Up to 25% of men aged over 65 years take aspirin.1 There are no guidelines on the management of aspirin in TURP. In the UK, the duration for which aspirin is stopped and the type of patient in whom it is stopped are not known. It is also not known if urologists consider aspirin a contra-indication to TURP. This study sought to determine the management of aspirin in TURP by British urologists.

Materials and Methods

A questionnaire was sent to 444 consultant urologists from a list obtained from the British Association of Urologists. There were 290 anonymous replies (65%); 3 replies were not filled in (conducting own aspirin study; does not perform TURP; paediatric urologist). The results of 287 questionnaires were, therefore, analysed.

Results

Of the 287 urologists, 178 (62%) ask patients to stop aspirin prior to TURP. Aspirin is stopped 9.8 days (median, 10 days; range, 2–30 days) prior to surgery, and recommenced 8.8 days (median, 7 days; range, 1–42 days) after surgery. In those that stop aspirin, 62% will stop aspirin in all patients, regardless of the indication, and 40% will cancel a TURP if aspirin use has inadvertently continued (Figs 1–3).

Figure 1.

Figure 1

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Results from questionnaire.

Figure 3.

Figure 3

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Days after TURP that aspirin is restarted.

Figure 2.

Figure 2

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Days prior to TURP that aspirin is stopped.

Of the 287 urologists, 109 (38%) do not stop aspirin; 90% of these believe that the cardiovascular benefits of aspirin outweigh the urological risks. However, 58% of these urologists believe that aspirin does increases TURP blood loss.

Discussion

This study shows a wide variation in the management of aspirin in TURP. Aspirin protocols are made after considering its operative bleeding risks and its cardiovascular benefits.

The effect of aspirin on coagulation is to inhibit thromboxane 2 production irreversibly for the life of the platelet, thus reducing platelet aggregation.2,3

Aspirin's effects on coagulation may not necessarily lead to increased operative blood loss. The only randomised trial to investigate aspirin in TURP patients found that aspirin did not increase operative blood loss. There was a greater postoperative blood loss in those on aspirin, but this was not associated with an increase in blood transfusion requirements.4 Other non-randomised studies have produced conflicting results. One study found that aspirin did not increase blood loss in TURP, after correcting for size of prostate and operating time,5 but others have shown higher blood loss.6–8

It is difficult to identify those at high risk of surgical bleeding. The bleeding time is the only routine measure of platelet dysfunction. Although aspirin increases the bleeding time by a factor of 1.7,9–12 this represents an abnormal bleeding time in only 15–25% of patients.9 These are patients that have an exaggerated response to aspirin.13,14 However, measuring the bleeding time in pre-operative patients is of little benefit. The test is operator-dependent and difficult to perform.15 Studies in coronary bypass grafting have found that the bleeding time does not correlate with peri-operative blood loss.16 The College of American Pathologists do not recommend pre-operative measures of bleeding time, stating that it is not a useful predictor of the risk of haemorrhage associated with surgical procedures.17,18

The dose of aspirin taken does not predict bleeding risk. Patients taking the 75-mg low-dose aspirin have the same risk of bleeding as those on higher doses; increases in dose do not further increase the bleeding time.19,20 However, the presence of uraemia can potentiate the effect of aspirin on bleeding time.21

This study has found that concern regarding the effects of aspirin on bleeding has led to it being stopped by over 60% of urologists prior to TURP. Over half of these consider the bleeding risks severe enough to justify cancelling a TURP if its use has inadvertently continued, thus making aspirin an absolute contra-indication to TURP. Even half of the urologists that continue aspirin believe that it increases operative blood loss.

If anaesthetists request aspirin to be stopped pre-operatively, they should state if this is to minimise TURP bleeding or to reduce the risk of spinal haematoma. Guidelines from the Scottish Intercollegiate Guidelines Network22 found little or no evidence that aspirin increased the risk of spinal haematoma following epidural or spinal anaesthesia, and suggested that aspirin use continue pre-operatively. The incidence of spinal haematoma after spinal anaesthesia is reported as less than 1 in 220,000 spinal anaesthetics.23

The cardiovascular benefits of aspirin have been known since the 1950s.24 Aspirin reduces risk of death immediately after myocardial infarction, and long term in those at high risk of serious cardiovascular disease, e.g. previous transient ischaemic attack, stroke or angina.25 Aspirin use has recently increased greatly in two low cardiovascular risk groups in whom its benefits are not certain – in those with cardiac risk factors only (e.g. hypertension)26 and in healthy patients who purchase aspirin over-the-counter.27

The cardiovascular risks of stopping aspirin have not been measured, but there are anecdotal reports of patients suffering serious cardiovascular disease after stopping aspirin.28 The urologists that stop aspirin in all patients prior to TURP risk major morbidity in those at high-risk of serious cardiovascular disease. Almost all urologists that continue aspirin in TURP believe its cardiovascular benefits outweigh its urological risks.

It is, therefore, not surprising that this study has identified a large variation in the management of aspirin in TURP in the UK. There is conflicting evidence as to whether aspirin increases TURP blood loss, and an inability to identify those at highest risk of bleeding pre-operatively. The benefits of aspirin in high cardiovascular risk patients are clear, but the benefits in low-risk patients are minimal. The risks of stopping aspirin have not been measured.

If aspirin is to be stopped, it should be for the minimum length of time. Aspirin is stopped prior to TURP because of its irreversible effect on platelets, which lasts for the whole 14-day lifetime of a platelet. However, bleeding times return to previous levels within 48 h of stopping aspirin.9 This is the time taken for new platelets to reach sufficient numbers to compensate for aspirin-affected platelets that are still in circulation. This study found that urologists in the UK stop aspirin 7 days prior to TURP, which is longer than necessary.

Most urologists were found to restart aspirin 7 days after a TURP, which is usually long after postoperative bleeding has stopped and the patient has been discharged. This interval could be shortened, although care would need to be taken in the immediate postoperative period, as bleeding times become prolonged within 2 h of commencing aspirin.11

Local protocols should be produced which are written, rather than verbal. If aspirin is to be stopped, the protocol should state whether aspirin is to stop in all or selected patients. The duration for which it is to stop should be specified. The management of patients that inadvertently continue aspirin until the day of surgery should also be stated. Protocols that continue aspirin should describe if measures to reverse the anti-platelet effects, such as desmopressin,29 are to be considered. A single dose of desmopressin can return bleeding times to basal levels for 3 h in patients taking aspirin.

In our practice, aspirin is stopped 48 h prior to TURP, and recommenced postoperatively on trial without catheter. Aspirin is not stopped in patients with a history of serious cardiovascular disease. Surgery will proceed if aspirin use has continued inadvertently.

This study only addresses the management of aspirin in TURP, but drugs taken with aspirin can exacerbate bleeding risk. Particular care needs to be taken in patients receiving combined clopidrogel and aspirin therapy, as this can increase bleeding time 3-fold.31 Non-steroidal anti-inflammatory drugs, including aspirin, should not be given with low molecular weight heparins in patients receiving spinal anaesthesia, because of the risk of spinal haematoma.32

Conclusions

A wide variation in practice has been identified, which can only be resolved by multidisciplinary guidelines created by urologists, cardiologists, anaesthetists and haematologists. Until such guidelines are available, there is a need for local protocols to consider cardiovascular risk, and to review the duration for which aspirin is stopped.

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