Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today, we're highlighting HoLEP outcomes with blood thinners, a retrospective analysis. Joining me today is Dr. Perry Xu. He's an Assistant Professor of Urology at Northwestern Medicine.

Dr. Xu, it's such a pleasure to have you join us today. Can you provide us a brief introduction of your paper titled "To Hold or Continue Blood Thinners? A Retrospective Analysis on Outcomes of Holium Laser Enucleation of the Prostate in Patients Who Either Held or Continued Blood Thinner Therapy"?

Dr. Perry Xu: Thank you so much, Melanie, and thanks for having me on this podcast. Just talk about the paper. Holium laser enucleation of the prostate, or HoLEP, is a guideline-indicated surgery for benign prostatic hyperplasia. And specifically, it's for a size-independent glands, and you can use it for even patients on blood thinners. And that's part of our guidelines, because of the hemostatic nature of our high-powered holmium laser that we use to dissect our planes and actually perform the surgery.

So, what kind of motivated this study is that we don't really know whether or not It was better or worse to hold or continue blood thinners through the surgery. As with many surgeries, you have to really entertain and understand whether or not to hold the blood thinners before surgery. For most surgeries, you do have to hold them, but our HoLEP surgery, we can actually perform the surgery while continuing the blood thinner. So, we really didn't know whether or not it was better or worse to continue or hold it. So, that's kind of why we did what we did. And we did a retrospective analysis and looked at 139 of our patients. Eighty-two patients held their blood thinner, as is traditional through surgery, and then 57 of them continued. So, that's what we really looked at, and we want to look at the outcomes of the patients.

Melanie Cole, MS: Why don't you have to hold blood thinners with HoLEP?

Dr. Perry Xu: So, it really has to do with our high-powered holmium laser that we use to dissect during our surgery. And also, you know, as part of the nature of the Holmium laser enucleation of the prostate, we're traversing between the transition zone and the peripheral zone, which is a natural plane of the prostate, which has fewer blood vessels and less bleeding. So by the nature of our surgery and also using our energy modality, we're able to have better hemostasis throughout.

Melanie Cole, MS: That's so interesting, Dr. Xu. So, the common indications for blood thinner therapy in patients who underwent HoLEP, what was the commonality there?

Dr. Perry Xu: As with many patients out there, as you get older, you have more and more comorbidities, and you have to take more and more medications for whatever reason. And paralleling that, men who have large prostates, it's age-related as well. So, you have these two patient populations coinciding. So, very often the people who are taking blood thinners are taking it for coronary artery disease, atrial fibrillation, having had blood clots in their legs or in their lungs, or having had a cerebrovascular accident or any sort of TIA. So, those would all be common indications for blood thinners.

Melanie Cole, MS: Well, certainly, so many people, as you say, for AFib and various coronary artery diseases are on blood thinners, but when you're talking about HOLEP, which is prostate involved, did you observe any differences in intraoperative outcomes?

Dr. Perry Xu: There were no intraoperative outcome differences when you look at the indications for the blood thinners. But when we looked at our retrospective analysis, and we looked at all of our patients who are continuing or holding their blood thinners, there was no intraoperative difference whether or not they continued or held their blood thinner medication outside of one thing.

So when we do our HoLEP procedure, we enucleate the prostate, and then we push the enucleated tissue into the bladder, and then we perform a second part of the surgery, which is morcellating the tissue. We identified that patients who held their warfarin, if they were on warfarin, had a faster morcellation time during surgery. But that's just a little bit, minor difference. There was a significant difference when we analyzed. But ultimately, it doesn't really translate to any clinical difference, I think. It just is a technical difference for perhaps just urologists to know.

Melanie Cole, MS: And so, there was no extra bleeding intraoperatively.

Dr. Perry Xu: There was no extra bleeding. There was no intraoperative transfusions, whether or not they were held or they continued their blood thinner. And I think that's mainly attributed to the technical aspects of the HoLEP procedure as well as the laser that we employ.

Melanie Cole, MS: Certainly true. That's a good point. Now, did they have any impact on postoperative outcomes?

Dr. Perry Xu: So, that's a great question. So postoperatively, we proved that even if patients are on blood thinners, that the surgery is efficacious. Everybody had resolution of their symptoms, which we measured using certain surveys. And then, we also examined other postoperative outcomes such as complication rates. And we actually did identify that, unsurprisingly, this patient population, which has a lot of comorbidities, does experience higher rates of complication than your average HOLEP patient. So, their complication rates were as high as 30% for both arms, whether or not the blood thinner was held or continued. That was something to bring to light out of this paper, and something we wanted to emphasize and bring home.

Melanie Cole, MS: What kinds of complications are we talking about?

Dr. Perry Xu: So, the most common complication was basically not being able to urinate on the same day, and possibly due to blood in the urine. And that was the case for 15% of the patients on both sides of what we were looking at. So whether or not you held or you continued your blood thinners, there was still a 15% chance of not being able to urinate after the surgery because of blood in the urine and requiring a catheter replacement, irrigation, and continuous bladder irrigation. That was just on the same day kind of perspective when we were able to ultimately remove the catheter and have patients urinate. But it was just a little hiccup in the road, if you will.

Melanie Cole, MS: I imagine other urologists and even other primary care providers would not think that this would be the case and right away would say if you're going to go in for HoLEP, you know, hold your blood thinners. What do you see, Dr. Xu, as the clinical implications of your study findings in patients undergoing HoLEP bench to bedside here? Tell us what you think are the implications.

Dr. Perry Xu: So, we thought so originally as well. But through some experience, just anecdotally, we found that patients who held their blood thinner, did great in the immediate postoperative period, but as soon as they started their blood thinner, we noticed there was an increased re-bleed situation. So, the theory was that if patients continued their blood thinner throughout the holmium laser enucleation of the prostate surgery, then we would be able to more identify the bleeders during the surgery and then use the laser at that time to achieve hemostasis. So, that was kind of the anecdotal inspiration for this study. And then, ultimately, we found that the complication arrays were similar, whether or not they continued or held their blood thinner. So, the long-term takeaway though was the complication rate being higher in both arms. So, what we do nowadays is we're more inclined to keep patients overnight with a catheter and less inclined to remove the catheter the same day so as to prevent and avoid complications.

Melanie Cole, MS: It sounds to me like the stopping and starting was more of an issue than continuing straight through. So based on your study findings, can you conclude for other providers that HoLEP is safe and effective in patients on blood thinners?

Dr. Perry Xu: Yes, definitely HoLEP is safe and effective in patients on blood thinners. Whether or not patients need to continue or hold their blood thinners throughout the surgery still needs some investigation because this is a retrospective analysis and kind of lays the groundwork and foundations for a prospective randomized controlled trial, which would be the ultimate goal moving forward to truly answer this question. But at least from our current retrospective analysis, we're able to show that HoLEP is safe and effective, even in a fragile comorbid patient population that are taking blood thinners.

Melanie Cole, MS: Well, I would love for you to come back, Dr. Xu, when you do those clinical trials and let us know how that works out because this is a fascinating subject. As we get ready to wrap up, are there any findings in the study that would be worth mentioning to other urologists or future research directions, where you would like to see this happen, what you would like to see happen in this field?

Dr. Perry Xu: So, here at Northwestern Medicine, we are doing a lot of pioneering work with the holmium laser enucleation of the prostate. And more and more people are learning how to do the HoLEP procedure. I think from our study here, it's really important to emphasize that the technical aspects of a HoLEP need to be perfect to achieve these results.

Because of the nature and the technicality of this surgery, it's not the easiest to do. I guess my point is that more and more people are learning how to do HoLEP, and I don't know that urologists who are just starting out and just starting to learn how to do HoLEP should do it in this patient population. But as more and more people learn the skill, and more and more patients have access to this skill, then perhaps that'll change.

Melanie Cole, MS: That's certainly a great point about the experience of the physician because I would imagine that that would make a big difference as far as experience and technical. Do you have anything else you'd like to add, Dr. Xu, as we wrap up? Any key takeaways for other providers.

Dr. Perry Xu: The key takeaway what we've mentioned, which is really that HoLEP can be done in patients who are on blood thinners should not be restricted or prohibitive from lifestyle-improving surgeries such as the holmium laser enucleation of the prostate. Some of my most appreciative and happy patients are patients who are urinating without a catheter and feeling great and we all take peeing for granted and it's always great when we can give that back. And it doesn't matter if the patients are on blood thinners, they can have that result and that quality of life improvement.

Melanie Cole, MS: Thank you so much, Dr. Xu, for joining us today. What an enlightening discussion this was. And to refer your patient or for more information, head over to our website at breakthroughsforphysicians.nm.org/urology to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.