Aspirin Management Before Prostate Biopsy
Aspirin does not need to be stopped before prostate biopsy, as continuing aspirin therapy is safe and does not increase clinically significant bleeding complications. 1
Primary Recommendation
Prostate biopsy can be performed safely in patients on low-dose aspirin without discontinuation. 1 The 2014 ICUD/AUA guidelines explicitly state that prostate biopsy can be performed safely for patients on low-dose aspirin, with only a minor increase in bleeding risk (approximately one-third higher than controls), but these complications are self-limiting and not clinically significant. 1
Evidence Supporting Continuation of Aspirin
The urological literature consistently demonstrates that aspirin continuation is safe:
Multiple meta-analyses and prospective studies involving over 3,000 patients show no increase in severe bleeding complications. 2, 3 The most recent 2021 meta-analysis of 3,373 patients found no significant difference in hematuria (RR=1.02) or hematospermia (RR=0.93) between aspirin and non-aspirin groups. 3
Minor hematuria may be slightly more frequent (OR 1.36) but is self-limiting and does not require intervention. 2 A 2012 study of 930 consecutive patients found no severe bleeding complications in those continuing aspirin or warfarin. 4
Rectal bleeding risk is minimally increased (RR=1.27) but remains minor and self-limiting. 3 The 2014 guidelines note that perioperative continuation of aspirin may be associated with minor bleeding risk, but transfusion rates are not increased and complications are generally not Clavien grade III or higher. 1
When Aspirin Might Be Stopped (Alternative Approach)
If you choose to stop aspirin despite the evidence supporting continuation, the timeframe varies by source:
7-10 days before biopsy was the traditional recommendation from older urological practice. 1 The 2005 Mayo Clinic guidelines stated that NSAIDs should be avoided for 7-10 days before biopsy due to increased bleeding risk. 1
3 days before biopsy is suggested by extrapolation from liver biopsy guidelines. 1 The 2020 British Society of Gastroenterology guidelines recommend stopping aspirin 3 days prior to percutaneous biopsy when time allows, though they acknowledge this decision depends on the indication for aspirin and urgency of the procedure. 1
Critical Considerations
The decision to stop aspirin must weigh the thrombotic risk against minimal bleeding risk. 1 For patients with recent coronary stents or high cardiovascular risk, continuing aspirin is strongly preferred as the thrombotic risk far outweighs the minor bleeding risk. 1
Cardiology consultation should be obtained for patients at high thrombotic risk if considering aspirin cessation. 1 Patients with recent percutaneous coronary intervention or stents require particular caution. 1
Common Pitfalls to Avoid
Do not routinely stop aspirin based on outdated protocols. The most current urological guidelines support continuation. 1
Do not confuse aspirin management with P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor), which have different bleeding profiles and typically require 7-10 days cessation. 1
Do not stop aspirin without assessing cardiovascular risk. Halting aspirin in patients with moderate to high thromboembolic risk cannot be recommended. 1