Should aspirin be suspended prior to robot-assisted radical prostatectomy? A systematic review and meta-analysis

Impact of oral antithrombotic agents on urinary continence recovery following robot-assisted radical prostatectomy: a retrospective cohort study

BACKGROUND

Robot-assisted radical prostatectomy (RARP) is a preferred minimally invasive surgical treatment for prostate cancer. The number of elderly patients and those with cardiovascular and/or cerebrovascular issues undergoing surgery is increasing, and many of them are taking antithrombotic (AT) agents. However, the effect of AT agents on postoperative urinary recovery has not been adequately studied. In this study, we analyzed the differences in the postoperative recovery of urinary continence and oncological outcomes in patients undergoing RARP for localized prostate cancer between AT agent adherents and non-adherents.

METHODS

A total of 394 patients who underwent conventional anterior RARP between February 2015 and February 2021 were categorized into two groups: those taking oral AT agents (AT group) and the control group. Urinary continence recovery, complications, and oncological outcomes were compared between the groups. A Cox proportional hazards analysis was performed to identify clinical factors that affect urinary continence recovery.

RESULTS

The background data and bleeding complications did not differ significantly between the groups. The recovery of continence was significantly poorer in the AT group in terms of complete pad free (HR: 0.53 [95% CI: 0.39-0.71]) and use of ≤ 1 safety pad (HR: 0.74 [95% CI: 0.59-0.94]). The rate of anastomotic leakage on cystography was significantly higher in the AT group (20.9% vs. 6.7%). A univariate analysis revealed that taking antithrombotic agents, higher prostate-specific antigen levels, and a more advanced clinical stage were associated with a poor urinary continence recovery; a multivariate analysis showed that taking AT agents was an independent factor negatively associated with urinary continence recovery. There was no significant difference between the groups in the positive surgical margin rate (19.0% vs. 23.8%) or the biochemical-recurrence-free rate.

CONCLUSION

Taking oral AT agents may be associated with poor urinary continence recovery after RARP.

Safety and complications of continuation of aspirin therapy in patients undergoing robot-assisted laparoscopic simple prostatectomy

To evaluate the safety and feasibility of continued perioperative aspirin at the time of robotic assisted simple prostatectomy (RASP). We performed a retrospective review of our IRB approved institutional database of patients who underwent RASP between 2013 and 2022. Comparative groups included patients taking aspirin in the perioperative period and those not taking aspirin pre-operatively. The primary outcome was any post-operative bleeding related complication using the modified Clavien-Dindo classification. Secondary outcomes included the identification of risk factors for increased blood loss in the entire study population, operative time, and blood transfusion requirement. 143 patients underwent RASP of which 55 (38.5%) patients continued perioperative aspirin therapy and 88 (61.5%) patients did not. Baseline demographics were similar between groups. Patients taking perioperative aspirin had a higher rate of hypertension (74.5% vs 58.0%, p = 0.04) and other cardiovascular disease (30.9% vs 11.4%, p = 0.007). Postoperative complications were similar between the groups (Clavien-Dindo ≥ 3; p = 0.43). Median blood loss (150 cc vs 150 cc, p = 0.38), percentage drop in hemoglobin (13.4 vs 13.2, p = 0.94) and blood transfusion rate (3.6 vs 1.1, p = 0.56) were also similar between groups. The median blood loss was 150 ml for the whole study population. On regression analysis, neither aspirin nor any other variable was associated with increased blood loss (> 150 ml). Aspirin can be safely continued perioperatively in patients undergoing RASP without any risk of bleeding related complications, blood loss, or increased transfusion rate.

On the relationship between various anticoagulants and robot-assisted radical prostatectomy: a single-surgeon serial analysis

Prostate cancer patients often have other health conditions and take anticoagulants. It was believed that surgery under anticoagulants could worsen surgical results. This study aims to explore the safety of robot-assisted prostatectomy in anticoagulated patients, without any exclusion criteria. The study included 500 patients who underwent RARP by a single surgeon between April 2019 and August 2022. Patients were divided into two groups: Group 1, consisting of 376 men (75.2%), did not receive any anticoagulation, while Group 2, with 124 patients (24.8%), received different forms of anticoagulation. Then, the anticoagulation group was divided into 4 subgroups according to their definite anticoagulation: the aspirin 15.6%, new oral anticoagulants (NOAC) 5.4%, Vitamin K antagonist (VKA) 2%, and dual-antiplatelet therapy (DAPT) 1.8% subgroup. Postoperative complications and readmission rates were compared between the two study groups and subgroups. Patients in the combined group 2 were older and they also carried more comorbidities compared to men in group 1 (p = 0.03, p = 0.001).The study groups had similar oncological results, with 40.4% of patients having locally advanced cancers. Catheter days were longer in the anticoagulation group (4.5 vs 4 days, p = 0.001). No significant differences were observed between study groups for overall, minor, and major complications (p = 0.160, 0.100, and 0.915, respectively). In addition, readmissions were low (5.6%) and similar between the study groups (p = 0.635). Under cautious management, RARP under diverse anticoagulation regimes is safe and has comparable results to men with no medications. Further prospective studies must be conducted to confirm our findings.

Effects of thienopyridine class antiplatelets on bleeding outcomes following robot-assisted radical prostatectomy

This study aimed to assess the effects of thienopyridine-class antiplatelet agents (including ticlopidine, clopidogrel, and prasugrel) on bleeding complications in patients who underwent robot-assisted radical prostatectomy. This cohort study used a database for robot-assisted radical prostatectomy at 23 tertiary centers nationwide between 2011 and 2022. Patients who received thienopyridines (thienopyridine group) were compared with those who received aspirin monotherapy (aspirin group). The primary outcome was the incidence of bleeding complications. High-grade complications were defined as Clavien-Dindo grade III or higher. The risks of these outcomes were evaluated using inverse probability of treatment weighted regression models. The study results demonstrated that thienopyridine therapy was associated with a higher risk of overall bleeding complications (OR: 3.62, 95%CI 1.54-8.49). The increased risks of the thienopyridine group were detected for low-grade bleeding complications (OR: 3.20, 95%CI 1.23-8.30) but not for high-grade bleeding complications (OR: 5.23, 95%CI 0.78-34.9). The increased risk of bleeding complications was not observed when thienopyridine was discontinued (OR: 2.52, 95%CI 0.83-7.70); however, it became apparent when it was continued perioperatively (OR: 4.35, 95%CI 1.14-16.61). In conclusion, thienopyridine increased the incidence of bleeding complications, particularly low-grade bleeding complications, following robot-assisted radical prostatectomy. These bleeding effects emerged when thienopyridine was continued perioperatively.

Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy: an update

The anesthetic concerns of patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) are primarily related to the use of pneumoperitoneum in the steep Trendelenburg position. This combination will affect cerebrovascular, ocular, respiratory, and hemodynamic homeostasis. Possible non-surgical complications range from mild subcutaneous emphysema to devastating ischemic optic neuropathy. The anesthetic management of RALP patients involves a thorough preoperative evaluation, careful positioning on the operative table, managing ventilation issues, and appropriate fluid management. Close coordination between the anesthesia and surgical teams is required for a successful surgery. This updated review will discuss the anesthetic concerns and perioperative management of patients presenting for RALP.

Does the continuation of low-dose acetylsalicylic acid during the perioperative period of thyroidectomy increase the risk of cervical haematoma? A 1-year experience of two Italian centers

BACKGROUND

A growing number of patients taking antiplatelet drugs, mainly low-dose acetylsalicylic acid (ASA) (75-150 mg/day), for primary or secondary prevention of thrombotic events, are encountered in every field of surgery. While the bleeding risk due to the continuation of these medications during the perioperative period has been adequately investigated in several surgical specialties, in thyroid surgery it still needs to be clarified. The main aim of this study was to assess the occurrence of cervical haematoma in patients receiving low-dose acetylsalicylic acid, specifically ASA 100 mg/day, during the perioperative period of thyroidectomy.

METHODS

Patients undergoing thyroidectomy in two high-volume thyroid surgery centers in Italy, between January 2021 and December 2021, were retrospectively analysed. Enrolled patients were divided into two groups: those not taking ASA were included in Group A, while those receiving this drug in Group B. Univariate analysis was performed to compare these two groups. Moreover, multivariate analysis was employed to evaluate the use of low-dose ASA as independent risk factor for cervical haematoma.

RESULTS

A total of 412 patients underwent thyroidectomy during the study period. Among them, 29 (7.04%) were taking ASA. Based on the inclusion criteria, 351 patients were enrolled: 322 were included in Group A and 29 in Group B. In Group A, there were 4 (1.24%) cervical haematomas not requiring surgical revision of haemostasis and 4 (1.24%) cervical haematomas requiring surgical revision of haemostasis. In Group B, there was 1 (3.45%) cervical haematoma requiring surgical revision of haemostasis. At univariate analysis, no statistically significant difference was found between the two groups in terms of occurrence of cervical haematoma, nor of the other early complications of thyroidectomy. At multivariate analysis, the use of low-dose ASA did not prove to be an independent risk factor for cervical haematoma.

CONCLUSIONS

Based on our findings, we believe that in patients receiving this drug, either for primary or secondary prevention of thrombotic events, its discontinuation during the perioperative period of thyroidectomy is not necessary.

Perioperative Considerations for Antithrombotic Therapy in Oculofacial Surgery: A Review of Current Evidence and Practice Guidelines

PURPOSE

Recent survey studies have demonstrated wide variability in practice patterns regarding the management of antithrombotic medications in oculofacial plastic surgery. Current evidence and consensus guidelines are reviewed to guide perioperative management of antithrombotic medications.

METHODS

Comprehensive literature review of PubMed database on perioperative use of antithrombotic medication.

RESULTS/CONCLUSIONS

Perioperative antithrombotic management is largely guided by retrospective studies, consensus recommendations, and trials in other surgical fields due to the limited number of studies in oculoplastic surgery. This review summarizes evidence-based recommendations from related medical specialties and provides context for surgeons to tailor antithrombotic medication management based on patient's individual risk. The decision to continue or cease antithrombotic medications prior to surgery requires a careful understanding of risk: risk of intraoperative or postoperative bleeding versus risk of a perioperative thromboembolic event. Cessation and resumption of antithrombotic medications after surgery should always be individualized based on the patient's thrombotic risk, surgical and postoperative risk of bleeding, and the particular drugs involved, in conjunction with the prescribing doctors. In general, we recommend that high thromboembolic risk patients undergoing high bleeding risk procedures (orbital or lacrimal surgery) may stop antiplatelet agents, direct oral anticoagulants, and warfarin including bridging warfarin with low-molecular weight heparin. Low-risk patients, regardless of type of procedure performed, may stop all agents. Decision on perioperative management of antithrombotic medications should be made in conjunction with patient's internist, cardiologist, hematologist, or other involved physicians which may limit the role of guidelines depending on patient risk and should be used on a case-by-case basis. Further studies are needed to provide oculofacial-specific evidence-based guidelines.

Safety of not withholding clopidogrel therapy during the immediate several days pre- and post-trans-urethral resection of prostate (TURP): a retrospective cohort study

BACKGROUND AND AIM

Benign prostatic hypertrophy or hyperplasia (BPH) is a frequent urological complain particularly in old-aged individuals. Those patients usually have other risk factors (such as ischemic cardiovascular diseases) for which they might be treated with anti-thrombotic agents chronically. These medicines may induce blood thinning and raise the incidence of hemorrhage. Thus, if those patients needed operative treatment for BPH, they may be at high risk of hemorrhage or its related adverse effects with the usage of anti-thrombotic drugs during the peri-operative time. On the other hand, dis-continuation of these agents can lead to ischemic events in susceptible individuals. Therefore, this research aims to assess the safety of the continuation of using anti-thrombotic agents throughout the peri-operative duration in patients with prostate surgery in form of Transurethral Resection of Prostate (TURP) only for Benign Prostatic Hypertrophy (BPH).

METHODS

Patients' notes were reviewed retrospectively. The entire participants were categorized into two categories. First category was on clopidogrel therapy (CTC) for prolong time and the usage of these agents was carried on throughout the peri-operative period. The second category was not on clopidogrel therapy at all (NCTC). Both of these categories had Transurethral Resection of Prostate (TURP) for Benign Prostatic Hypertrophy (BPH). A comparison had been conducted between the two categories with regards to: (i) the amount of blood lost intra-operatively (ii) the duration of operation (iii) hematocrit concentration per-operatively (iv) transfused packed red blood cells (PRBC) if needed (v) clearance of hematuria postoperatively (vi) secondary hemorrhage and clot retention after discharge. Pearson Chi-square test, Independent sample t test and test for numeric variables were used as appropriate.

RESULTS

The study identified 329 patients. One hundred and sixty five participants in the CTC (clopidogrel therapy category) and 164 in the NCTC (non-clopidogrel therapy category). It had been revealed that there was no statistically significant difference between the CTC and NCTC regarding: (i) the amount of blood lost intra-operatively (ii) the duration of operation (iii) hematocrit concentration per-operatively (iv) transfused packed red blood cells (packed RBC) if needed (v) clearance of hematuria postoperatively (vi) secondary hemorrhage and clot retention after discharge (P > 0.65).

CONCLUSION

The continuation of usage of anti-thrombotic therapy (clopidogrel) during peri-operative period in patients with TURP for BPH is a safe practice. It is not associated with high probability of hemorrhage or PRBC transfusion or other adverse effects.

A comparative study of anticoagulant/antiplatelet therapy among men undergoing robot-assisted radical prostatectomy: a prospective single institution study

The present study aimed to assess the safety and efficacy of robot-assisted radical prostatectomy (RARP) in patients with prostate cancer (PCa) under anticoagulant (AC) and/or antiplatelet (AP) therapy, as compared to a control group, and to establish possible differences in postoperative-related morbidity. Data of all consecutive patients submitted to elective RARP for PCa from June 2017 to May 2020 at our institution were prospectively collected. Patients were divided according to the use of AC/AP therapy at surgery. The primary endpoint was to determine differences in 90-day postoperative complication rate, while secondary endpoints included differences in transfusion rate, readmission rate and postoperative oncological outcomes between the two groups. Sub-groups analysis was separately performed for patients undergoing pelvic lymphadenectomy and nerve-sparing procedures. Overall, 822 patients were included in the study and divided in 704 control-group patients (group A) and 118 patients under AC/AP therapy at surgery (group B). Despite the higher estimated blood loss between AC/AP takers and the control group, we did not find a significant difference in terms of 90-day postoperative complication rate, transfusion rate, readmission rate and postoperative oncological outcomes (all p > 0.05). In the cohort of patients undergoing nerve-sparing prostatectomy, a higher rate of complications and transfusions were found. At multivariate analysis, ASA score and ongoing medications were independently associated with complication in this sub-group. RARP can be safely and effectively performed in patients with PCa and ongoing AC/AP agents. Attention has to be paid in candidates for nerve-sparing procedures.

The multiple effects of aspirin in prostate cancer patients

Aspirin is a commonly used medication with anti-inflammatory and analgesic properties, and it is widely used to reduce the risk of ischaemic heart disease-related events and/or cerebrovascular accidents. However, there is also evidence from epidemiological and interventional studies to suggest that regular aspirin use can reduce the risk of prostate cancer development and progression, and can reduce the risk of disease recurrence following anti-prostate cancer therapy. Aspirin use in African-American men is associated with a reduced incidence of advanced PCa and reduced disease recurrence, and there is evidence from other studies of an association between regular aspirin use and decreased PCa-related mortality. The cyclooxygenase-2 enzyme inhibited by Aspirin and other NSAIDs, and which catalyses prostaglandin synthesis and mediates inflammation, is overexpressed in prostate cancer, therefore inhibition of cyclooxygenase-2 may have direct, and indirect, therapeutic effects. This review explores the evidence suggesting that aspirin use can modify prostate cancer biology and disease characteristics, and explores the potential mechanisms underpinning the observed associations between aspirin use and modification of prostate cancer risk. It also summarises the potential for adjuvant aspirin use to combine with other therapeutic approaches such as radical surgery and radiotherapy.

Effect of Continued Perioperative Anticoagulant Therapy on Bleeding Outcomes Following Robot-assisted Radical Prostatectomy

OBJECTIVE

To assess the impact of continued perioperative anticoagulant drug administration on bleeding and complications in patients undergoing robot-assisted radical prostatectomy.

METHODS

Between January 2014 and January 2020, 620 patients with prostate cancer underwent robot-assisted radical prostatectomies and were retrospectively reviewed. Fourteen patients who discontinued antithrombotic therapy were excluded. Among the 606 included patients, 31 continued anticoagulant therapy during the perioperative phase (anticoagulant group). The anticoagulant group outcomes were compared with those of patients who continued clopidogrel and prasugrel (thienopyridine group = 13), aspirin monotherapy (aspirin group = 61), and no chronic antithrombotic agent (control group = 501). The primary outcome was the incidence of bleeding complications requiring transfusion, additional intervention, or readmission. Secondary outcomes were the incidence of thrombotic complications, estimated blood loss, and overall complication rates.

RESULTS

Among the 31 patients in the anticoagulant group, 20 (65%) used directed oral anticoagulants, 11 (35%) used warfarin, and 5 used combined aspirin. Only 1 (3%) patient in the anticoagulant group required postoperative transfusion, and none required additional interventions or readmission. No significant differences were detected between the anticoagulant and other groups (anticoagulant vs thienopyridine, aspirin, and control groups) regarding bleeding complications (3% vs 8%, P = .51; 0%, P = .34; 0.4%, P = .17, respectively), thrombotic complications (3% vs 0%, P = .70; 2%, P = .56; 0.2%, P = .11, respectively), estimated blood loss (200 vs 100 mL, P = .63; 175 mL, P = .64; 165 mL, P = .74, respectively), or other high-grade complications (6% vs 0%, P = .49; 2%, P = .26; 3%, P = .24, respectively).

CONCLUSION

Perioperative continuation of anticoagulant use is feasible for patients undergoing robot-assisted radical prostatectomy.

Risks and complications of robot-assisted radical prostatectomy (RARP) in patients receiving antiplatelet and/or anticoagulant therapy: a retrospective cohort study in a single institute

The objective of the study was to evaluate the risk of bleeding complications in patients undergoing robot-assisted radical prostatectomy (RARP) while taking antiplatelet (AP) and/or anticoagulant (AC) agents. We analyzed the data of 334 patients undergoing RARP from May 2015 to May 2019. Patients were categorized into AP, AC, and control groups; the bleeding complications were compared among them. The end points were the estimated blood loss, decrease in hemoglobin level, and bleeding complications. The patient characteristics did not differ significantly among groups, with the exception of ASA scores, which were significantly higher in the AP and AC groups vs. the control group. The estimated blood loss and hemoglobin decrease were not significantly different between the AP and AC groups and the control group. The frequency of bleeding complications did not differ significantly between the AP and the control groups, but was significantly higher in the AC vs. the control group (4.3% in the AP and 23.5% in the AC group vs. 3.7% in the control group; P = 0.63 and P < 0.01, respectively). There was no significant difference in bleeding complications between the AP continuation (continuation of a single AP) and the AP interruption group or between the heparin bridging and the AC interruption group. All bleeding complications observed in the AC group occurred after resuming AC therapy. RARP can be performed safely with continuation of a single AP, and in patients taking ACs by interrupting these agents or via heparin bridging, without increasing intraoperative bleeding, whereas postoperative bleeding complications may increase after resuming ACs.

Perioperative management of antiplatelet therapy in noncardiac surgery

PURPOSE OF REVIEW

Perioperative management of antiplatelet agents (APAs) in the setting of noncardiac surgery is a controversial topic of balancing bleeding versus thrombotic risks.

RECENT FINDINGS

Recent data do not support a clear association between continuation or discontinuation of APAs and rates of ischemic events, bleeding complications, and mortality up to 6 months after surgery. Clinical factors, such as indication and urgency of the operation, time since stent placement, invasiveness of the procedure, preoperative cardiac optimization, underlying functional status, as well as perioperative control of supply-demand mismatch and bleeding may be more responsible for adverse outcome than antiplatelet management.

SUMMARY

Perioperative management of antiplatelet therapy (APT) should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic/thrombotic and bleeding risks. Where possible, surgery should be delayed for a minimum of 1 month but ideally for 3-6 months from the index cardiac event. If bleeding risk is acceptable, dual APT (DAPT) should be continued perioperatively; otherwise P2Y12 inhibitor therapy should be discontinued for the minimum amount of time possible and aspirin monotherapy continued. If bleeding risk is prohibitive, both aspirin and P2Y12 inhibitor therapy should be interrupted and bridging therapy may be considered in patients with high thrombotic risk.