How long should aspirin (acetylsalicylic acid) be held before prostate surgery?

Management of Aspirin Before Prostate Surgery

For patients taking aspirin for cardiovascular protection, aspirin can be safely continued throughout the perioperative period for prostate surgery without significantly increasing the risk of major bleeding complications.

Aspirin Management Based on Cardiovascular Risk

High Cardiovascular Risk Patients

• Continue aspirin throughout the perioperative period for patients with:

  • Recent coronary stents (especially within 12 months of drug-eluting stent placement or within 3 months of bare metal stent placement)
  • Secondary stroke prevention
  • High risk for thrombotic events 1

• For patients with cardiac risk factors on low-dose aspirin alone, aspirin can be continued in the perioperative period without increased risk of major bleeding 1

Low Cardiovascular Risk Patients

• For patients taking low-dose aspirin without specific medical indications, aspirin may be discontinued until directed by the surgical team 1
• If discontinuation is deemed necessary, aspirin should be stopped 7-10 days before surgery to allow for complete restoration of platelet function 2

Prostate Surgery-Specific Considerations

Radical Prostatectomy

• Studies have shown that aspirin perioperatively did not result in increased intraoperative complications during robot-assisted radical prostatectomy 3
• In a study of robot-assisted radical prostatectomy, there were no significant differences in operative time, blood loss, or hospital stay between patients who continued aspirin and those who didn't 3

Transurethral Resection of Prostate (TURP)

• Anticoagulation/antiplatelet therapy in patients undergoing TURP is associated with an increased risk of bleeding 1
• However, the risk of cardiovascular complications from stopping aspirin may exceed the risk of perioperative bleeding in high-risk patients 3

Prostate Biopsy

• Prostate biopsy can be performed safely for patients on low-dose aspirin with only a minor risk of bleeding (approximately one-third higher than controls) 1, 4
• Continued use of aspirin does not increase the risk of moderate or severe hematuria after prostate biopsy 4

Practical Algorithm for Aspirin Management in Prostate Surgery

1. Assess cardiovascular risk:

   • High risk: Recent stents, stroke prevention, acute coronary syndrome
   • Moderate risk: Stable coronary artery disease, peripheral vascular disease
   • Low risk: Primary prevention without significant risk factors

2. Determine bleeding risk of specific prostate procedure:

   • High risk: Radical prostatectomy, TURP
   • Moderate risk: Open prostatectomy
   • Low risk: Prostate biopsy, minimally invasive procedures

3. Decision pathway:

   • High cardiovascular risk + any procedure: Continue aspirin throughout perioperative period
   • Moderate cardiovascular risk + high bleeding risk procedure: Consider cardiology consultation; generally continue aspirin
   • Low cardiovascular risk + high bleeding risk procedure: Discontinue aspirin 7-10 days before surgery
   • Any cardiovascular risk + low bleeding risk procedure: Continue aspirin

4. Resumption of aspirin:

   • Resume within 24-48 hours after surgery once adequate hemostasis is achieved 2

Common Pitfalls to Avoid

• Unnecessary discontinuation: Stopping aspirin in high cardiovascular risk patients can lead to serious thrombotic events
• Inconsistent timing: If aspirin must be discontinued, ensure proper timing (7-10 days before surgery)
• Failure to consult specialists: For patients with recent coronary stents or high cardiovascular risk, cardiology consultation is recommended before discontinuing antiplatelet therapy
• Inadequate risk assessment: Not properly weighing the relative risks of thrombotic events versus bleeding complications

Special Considerations

• For dual antiplatelet therapy (aspirin plus clopidogrel, prasugrel, or ticagrelor), withdrawal should not occur before urological procedures within 12 months of drug-eluting stent placement or within 3 months of bare metal stent placement 1
• A multidisciplinary approach involving cardiology expertise is essential when urgent urological procedures are required within these time frames 1

Remember that the risk of thrombotic events from discontinuing aspirin in high-risk patients often outweighs the risk of increased bleeding during prostate surgery, particularly with modern surgical techniques and careful hemostasis.