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This is an interesting small study that examined the outcomes ofpatients who were candidates for transurethral resection of theprostate and who were receiving chronic oral anticoagulative ther-apy. The subjects were switched to low molecular weight heparinbefore surgery and outcomes were evaluated. Generally, outcomeswere acceptable. All subjects were voiding after transurethral resec-tion of the prostate, catheterization and hospitalization were some-what longer than usual (3.2 and 4.2 days, respectively) and 4 (20%)patients required transfusion. No thromboembolic events occurred inthis group of patients.
While initial review would suggest this to be a reasonable ap-proach, we have some reservations. When treating a patient who ischronically anticoagulated with significant obstructive symptomsrefractory to pharmacological therapy, there are 2 more traditionalapproaches to treatment. First, the question should be asked as towhether the anticoagulation can be discontinued before resection. Inthe example of atrial fibrillation, while the risk of ischemic stroke isreduced by anticoagulation, without treatment the risk is approxi-mately 2% to 5% a year.1–4 Thus, the risk of such an event resultingfrom discontinuation of anticoagulation for 1 to 3 weeks is probablyin the 0.05% to 0.3% range. Similarly, depending on the type of heartvalve, if a high flow valve many experts will allow discontinuation ofcoumadin during the operative period due to a low risk of thrombosis.Thus, for some of the patients in this study we would simply offerdiscontinuation of anticoagulation as a safe alternative to heparin.The second approach to this type of case is to use a minimallyinvasive treatment. Laser or transurethral needle ablation is fre-quently used in patients who are anticoagulated without the need fordiscontinuation of the anticoagulation therapy. The advantage ofthis approach is that these treatments have reasonable efficacy andanticoagulation can be continued.
In this group of 20 patients we would preferentially use 1 of these2 approaches rather than that of the authors, at least initially. Weare not convinced of the proven efficacy of heparin for atrial fibril-lation and cardiac valvular disease. A 20-patient sample is inade-quate to conclude that the lack of embolic events would be general-izable. We are also concerned about the bleeding complications inthis series as well as the potential for delayed bleeding. Certainly, a20% transfusion rate for transurethral resection of the prostate inmy practice would be unacceptable. Beyond the perioperative bleed-ing risk, we would be concerned about delayed bleeding, most oftenseen 3 weeks postoperatively.
The data are intriguing, suggesting that transurethral resection ofthe prostate can be performed in patients receiving heparin. Wewould prefer that this be the conclusion of the article rather than
that a patient with urinary retention or severe obstructive symptomswho is anticoagulated is best treated with transurethral resection ofthe prostate during a heparin “window.” The availability of otherlower risk therapies would be our personal choice for such a patient.
Stephen Kraus and Ian ThompsonDivision of UrologyUniversity of Texas Health Science Center at San AntonioSan Antonio, Texas
1. Fisher, C. M.: Reducing risks of cerebral embolism. Geriatrics,34: 59, 1979
2. Wolf, P. A., Dawber, T. R. and Thomas, H. E.: Epidemiologicassessment of chronic atrial fibrillation and risk of stroke: theFramingham study. Neurology, 28: 973, 1983
3. Flegel, K. M., Shipley, M. J. and Rose, G.: Risk of stroke innon-rheumatic atrial fibrillation. Lancet, 1: 526, 1987
4. Kopecky, S. I., Gersh, B. J., McGoon, M. D., Whisnant, J. P.,Holmes, D. R., Jr., Ilstrup, D. M. et al: The natural history oflone atrial fibrillation. N Engl J Med, 317: 669, 1987
REPLY BY AUTHORS
We agree that it is preferable to operate following discontinuationof any chronic anticoagulant therapy, which has also been our policyfor many years. However, under certain circumstances, such as inpatients with a history of intracardiac thrombus, transient ischemicattack, amaurosis fugax or stroke, the recommendation in the cur-rent literature is to avoid discontinuation of anticoagulant thera-py.1, 2 Thus, our series represents a highly select group of patients inwhom, following a preoperative cardiological assessment, anticoag-ulation was not to be discontinued.
The issue of minimally invasive techniques for tissue ablation,such as laser surgery, is discussed in the article. It should be notedthat despite its reported advantages, it is still hard to define itsefficacy as more than “reasonable” (at the most). Therefore, we stillregard transurethral resection, which is usually a 1-stage techniquewith definitive and durable results, as the procedure of choice forprostate ablation.
1. Ansell, J., Hirsh, J., Dalen, J., Bussey, H., Anderson, D., Poller,L. et al: Managing oral anticoagulant therapy. Chest, suppl.,119: 22S, 2001
2. Heit, J. A.: Perioperative management of the chronically antico-agulated patient. J Thromb Thrombolysis, 12: 81, 2001
LOW MOLECULAR WEIGHT HEPARIN PROPHYLAXIS IN PATIENTS UNDERGOING PROSTATECTOMY614