Indian Journal of Urology
EVIDENCE BASED UROLOGY
Year
: 2006  |  Volume : 22  |  Issue : 1  |  Page : 59--60

Should the aspirin (acetyl salicylic acid) be stopped before trans-urethral surgery?


Siva Prasad Gourabathini, Nitin S Kekre 
 Department of Urology, Christian Medical College, Vellore, India

Correspondence Address:
Siva Prasad Gourabathini
Department of Urology Christian Medical College Vellore
India




How to cite this article:
Gourabathini SP, Kekre NS. Should the aspirin (acetyl salicylic acid) be stopped before trans-urethral surgery?.Indian J Urol 2006;22:59-60


How to cite this URL:
Gourabathini SP, Kekre NS. Should the aspirin (acetyl salicylic acid) be stopped before trans-urethral surgery?. Indian J Urol [serial online] 2006 [cited 2020 Oct 20 ];22:59-60
Available from: https://www.indianjurol.com/text.asp?2006/22/1/59/24658


Full Text

Antiplatelet agents inhibit platelet function, in particular platelet activation and aggregation. It is a common practice among urologists to advise their patients to discontinue antiplatelet agents at least 10 days prior to transurethral surgery. The main concern is increased risk of bleeding during surgery. The risk of bleeding with antiplatelet agents varies and depends on the surgical procedure. The German Urological society states that aspirin withdrawal is not mandatory before surgery. An expert committee of the French society of anesthesiology[2] presented a detail review on peri-operative use of antiplatelet agents. They found that there was no way to assess the efficacy and bleeding risk among aspirin users. Bleeding time and Platelet function analyser were not useful. Platelet aggregation and flow cytometry were cumbersome to use routinely. They concluded, for transurethral surgery only level II evidence is available on risk of peri-operative hemorrhage. The Level I evidence of risk of hemorrhage is available for hip surgery only.[2] In addition, aspirin could be stopped in patients with bleeding diathesis and in those undergoing neurosurgery.[3]

In a recent review and meta analysis by Burger et al[9] on secondary cardiovascular risks on peri-operative withdrawal versus bleeding on continuation of aspirin, reported an odds ratio of 2.7 for increase in bleeding in aspirin users. They suggested that aspirin might increase the frequency of post procedural bleeding in prostatectomy. But the clinical studies which they included should be critically reviewed. The study by Nielsen et al[6] from Denmark is the only available prospective, randomised double blind placebo-controlled study on effect of low dose aspirin on bleeding after TURP. They showed that there was significant increase only in post operative blood loss among aspirin users (mean 150 ml). However, the intra-operative blood loss, transfusion requirement, time to catheter removal and hospital stay were not different. In this study, over all blood transfusion rate itself was very high and its indication was not mentioned. There were 2 cardiovascular events out of a total 53 patients. At the end inspite of these short comings, authors of the only randomised study[6] gave their opinion regarding peri-operative withdrawal of aspirin before TURP. There were even reports of 2 deaths following prostatectomy among aspirin users in early 1990's, due to increased bleeding. Contrary to the existing belief in 1990's that antiplatelets increase risk of bleeding, Ala-Opas etal[4]1995 in a case control study on blood loss in long term users of aspirin undergoing TURP showed that blood loss was not enhanced by aspirin use and avoidance of aspirin before surgery was unnecessary. In a retrospective analysis, Wierod et al[5] reported that patients on aspirin and NSAIDS undergoing TURP required more blood transfusions, but the groups were not identically matched. In a survey[10] conducted in 1998 among British radiologists and urologists with regard to practice of withdrawal of aspirin before prostatic biopsy, 52% radiologists stopped aspirin for an average of 4.6 days and while only 27% urologists withdrew aspirin for an average of 8 days. In another recently reported prospective study of morbidity of transrectal ultrasound guided biopsy on patients with low dose aspirin, Z mann et al[7] showed that there was no statistically significant difference in the incidence of haematuria or overall bleeding after biopsy.

Single low dose aspirin on long term is protective in preventing occlusive vascular events like acute MI, ischemic stroke, unstable or stable angina.[1] Addition of second antiplatelet drug may produce some additional benefit. Majority of patients undergoing transurethral surgery are elderly, they are likely to be placed on one of the antiplatelet drugs for various reasons. Transurethral surgery itself involves risk of peri-operative vascular events such as deep vein thrombosis, pulmonary embolism, myocardial infarction and stroke. Infact, there is potential hazard of stopping aspirin before transurethral procedure. The reported rates of cardiovascular events after withdrawal of aspirin range from 1.1 to 1.4 per 1000 patients per week. There can be precipitation of an acute vascular event in the peri-operative period.[8] The newer antiplatelet agents like clopidogrel are not studied with respect to peri-operative bleeding in transurethral surgery. There is no reason to believe that they would behave any different from aspirin. Currently, there is not enough evidence available to guide us either to withdraw or continue aspirin before transurethral surgery. However, if one decides to stop antiplatelet drugs before surgery, he should weigh benefits against the risks of stopping. High risk of acute coronary syndrome and risk of acute stent thrombosis especially in 1st month of stenting should be kept in mind. Aspirin should be restarted as soon as possible since there is cumulative risk involved with respect to time duration of discontinuation.[2] In case one decides to perform TURP with out withdrawing aspirin, they should have an infrastructure for blood product replacements if required for support including platelet concentrate. Final verdict on discontinuation of antiplatelet drug should be taken only after discussion of each case on its merit with the cardiovascular colleague and the patient.

References

1Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction and stroke in high risk patients. BMJ 2002;324:71-86.
2Samama CM, Bastien O, Forestier F, Denninger MH, Isetta C, Juliard JM, et al . French Society of Anesthesiology and Intensive Care. Antiplatelet agents in the peri-operative period: expert recommendations of the French Society of Anesthesiology and Intensive Care (SFAR) 2001-summary statement. Can J Anaesth 2002;49:S26-35.
3Fijnheer R, Urbanus RT, Nieuwenhuis HK. Withdrawing the use of acetylsalicyclic acid prior to an operation usually not necessary. Ned Tijdschr Geneeskd 2003;147:21-5
4Ala-Opas MY, Gronlund SS. Blood loss in long-term aspirin users undergoing transurethral prostatectomy. Scand J Urol Nephrol 1996;30:203-6.
5Wierod FS, Frandsen NJ, Jacobsen JD, Hartvigsen A, Olsen PR. Risk of haemorrhage from transurethral prostatectomy in acetylsalicylic acid and NSAID-treated patients. Scand J Urol Nephrol 1998;32:120-2.
6Nielsen JD, Holm-Nielsen A, Jespersen J, Vinther CC, Settgast IW, Gram J. The effect of low-dose acetylsalicylic acid on bleeding after transurethral prostatectomy-a prospective, randomized, double-blind, placebo-controlled study. Scand J Urol Nephrol 2000;34:194-8.
7Maan Z, Cutting CW, Patel U, Kerry S, Pietrzak P, Perry MJ, et al . Morbidity of transrectal ultrasonography-guided prostate biopsies in patients after the continued use of low-dose aspirin. BJU Int 2003;91:798-800.
8Mitchell SM, Sethia KK. Hazards of aspirin withdrawal before transurethral prostatectomy. BJU Int 1999;84:530.
9Burger W, Chemnitius JM, Kneissl GD, Rucker G. Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis. J Intern Med 2005;257:399-414.
10Connor SE, Wingate JP. Management of patients treated with aspirin or warfarin and evaluation of haemostasis prior to prostatic biopsy: a survey of current practice amongst radiologists and urologists. Clin Radiol 1999;54:598-603.