To stop or not to stop. Endoscopic enucleation of the prostate in patients on blood thinners: outcomes, a real-life prospective multicenter study of 932 cases.

PURPOSE: To evaluate the safety of endoscopic enucleation of the prostate (EEP) in benign prostatic hyperplasia (BPH) patients maintained on blood thinners compared to those who discontinued therapy, and to identify independent predictors of postoperative bleeding complications.

METHODS

BPH patients on blood thinners planned for EEP were prospectively enrolled from 30 centers (December 2024-June 2025). Patients were divided into Group 1 (continued blood thinners, n = 329) and Group 2 (discontinued blood thinners, n = 603). Outcomes included bleeding complications, hospital stay, and functional results. Multivariable logistic regression identified predictors of postoperative bleeding (blood transfusion, need for restarting of continuous bladder washout, clot retention, surgical control of post-operative bleeding).

RESULTS

The overall population had a median age of 70.0 years and prostate volume of 81.0 ml. Group 1 patients had higher comorbidity rates. Group 1 demonstrated significantly longer median operative times (87.0 vs. 70.0 min, p < 0.001) and increased bleeding-related complications, including continuous bladder washout restart (14.3% vs. 2.5%, p < 0.001), blood transfusion requirements (1.5% vs. 0.5%, p < 0.001), and hospital readmissions (10.0% vs. 4.1%, p < 0.001). Rates of surgical hemostasis intervention were similar (1.8% in Group 1 vs. 2.0% in Group 2, p = 0.92). No major thrombotic events occurred. Independent predictors of bleeding included longer operative time (OR 1.01, p < 0.001) and combination antiplatelet/anticoagulant therapy (OR 2.47, p = 0.04), while tranexamic acid was associated with lower odds (OR 0.18, p < 0.001).

CONCLUSION

EEP can be safely performed in patients on blood thinners with acceptable morbidity, though bleeding complications are higher. Combination therapy carries the highest risk, while tranexamic acid reduces bleeding complications.