Perioperative outcomes of ongoing antithrombotic therapy during endoscopic surgery for benign prostatic hyperplasia: a systematic review and meta-analysis of observational studies

Abstract

The management of antithrombotic therapy in patients undergoing endoscopic surgery for benign prostatic hyperplasia (BPH) remains challenging due to competing risks of thromboembolism and perioperative bleeding. This meta-analysis evaluated perioperative outcomes among patients undergoing endoscopic prostate procedures while continuing antiplatelet (APT) or anticoagulant (AC) therapy compared with patients not receiving antithrombotic treatment. Literature search was conducted on 17th September 2025 including PubMed, Medline, Embase, and Scopus database, to identify comparative studies evaluating perioperative outcomes of endoscopic prostate procedures in patients on versus off APT/AC therapy were identified. Data were pooled using random-effects models to estimate mean differences (MD) or odds ratios (OR) with 95% confidence intervals (CI). Fifteen studies comprising 6091 patients (1900 on APT/AC, 4191 controls) were included. Operative time, postoperative hemoglobin decrease, catheterization duration, and continuous bladder irrigation time were comparable between groups across all surgical modalities. However, bleeding-related complications were significantly more frequent among APT/AC users undergoing transurethral resection of the prostate (TURP) (OR 1.90, 95% CI 1.05–3.41, p = 0.03) and enucleation (OR 2.91, 95% CI 1.71–4.93, p < 0.0001), particularly in the AC subgroup (OR 4.80, p = 0.0002). Enucleation also carried higher odds of bleeding requiring surgical hemostasis (OR 3.69, 95% CI 1.73–7.84, p = 0.0007) and acute urinary retention (OR 1.36, 95% CI 1.04–1.77, p = 0.02) among antithrombotic users. Conversely, photoselective vaporization (PVP) demonstrated comparable rates of transfusion, hemostasis, and urinary complications regardless of APT/AC therapy. Hospital stay was marginally longer after TURP and PVP among APT/AC users (p < 0.05). Continuation of antithrombotic therapy during PVP appears safe, with perioperative outcomes comparable to those of non-antithrombotic patients. Conversely, its ongoing use—especially AC—significantly increases bleeding risks following TURP and enucleation. PVP may therefore represent the preferred modality for high-risk patients requiring uninterrupted antithrombotic therapy. Clinical decision-making should balance individual thromboembolic risk against anticipated bleeding risk, with multidisciplinary input when appropriate.