--- title: He cannot stop his blood thinners. That is not a reason to rule out prostate surgery publication: Medical Insights Korea section: columns category: Prostate canonical_url: https://medicalinsightskorea.com/columns/urology/bph-surgery-when-the-blood-thinners-cannot-be-stopped author: Chang Ki Lee, Specialist in Urology author_type: contributing clinician, not editorial staff author_practice: Goldman Urology Clinic, Incheon author_credential_issued_by: Ministry of Health and Welfare, Republic of Korea author_profile: https://medicalinsightskorea.com/authors/chang-ki-lee editorial_note: Signed opinion by the named clinician. Written by them, edited and translated by Medical Insights Korea. Not a reported article, and not a clinical review of this publication's reporting. published: 2026-09-08T17:17:43+09:00 modified: 2026-09-08T17:17:43+09:00 content_type: opinion license: Quotation permitted with attribution to Medical Insights Korea and a link to the canonical URL. --- # He cannot stop his blood thinners. That is not a reason to rule out prostate surgery The operation that removes the most tissue is the one recommended when the bleeding risk is highest. A urologist on why that is not a contradiction, and on what the guidelines actually name. ## Answer Men on anticoagulant or antiplatelet therapy are often told, or assume, that surgery for benign prostatic enlargement is closed to them, but current guidelines point the other way: the American Urological Association states that HoLEP, photoselective vaporisation and thulium laser enucleation should be considered in patients at higher risk of bleeding including those on anticoagulants, and the European Association of Urology's 2026 algorithm routes patients who cannot stop antithrombotic therapy to laser enucleation, laser vaporisation or a prostatic urethral lift rather than out of surgery altogether — because enucleation follows the plane between the adenoma and the prostatic capsule, where bleeding vessels become visible and can be controlled one at a time, instead of cutting across them at scattered points as resection does. ## Key takeaways - Being unable to stop an anticoagulant or antiplatelet drug is not, on its own, a reason to rule out surgery for benign prostatic enlargement. - The AUA guideline states that HoLEP, photoselective vaporisation and thulium laser enucleation should be considered in patients at higher risk of bleeding, such as those on anticoagulant drugs. - The EAU's 2026 recommendations naming antithrombotic therapy specifically name Tm:YAG laser enucleation and KTP or LBO laser vaporisation, both graded Weak; its treatment algorithm sends patients who cannot stop these drugs to laser enucleation, laser vaporisation or a prostatic urethral lift. - Enucleation works along the plane between the adenoma and the capsule, so vessels are exposed and controlled individually rather than divided at scattered points as in resection. - The choice of anaesthesia is part of the same decision. Spinal anaesthesia involves a needle in the back, and impaired clotting has to be weighed against that route. - Outcomes are not identical for the same named operation. Prostate size and the surgeon's technique both change what happens, and they matter more, not less, in a patient who cannot come off the drug. ## Full article The operation that removes the most tissue is the one recommended for patients whose bleeding risk is highest. That sounds backwards, and for a long time practice ran the other way: the assumption was that pushing the tissue aside or reducing its bulk would be gentler on a patient who bleeds easily than cutting the enlarged tissue out. The reason this matters is a question I hear in clinic often enough to recognise it before it is finished. “I take a blood thinner for my heart rhythm — so I can't have the operation, can I?” It comes from men whose urine flow has become difficult because of an enlarged prostate. Anticoagulants suppress clotting, so bleeding during or after surgery can be harder to stop, blood loss greater, and recovery slower. ### Why the drug is there in the first place These drugs are usually prescribed for the heart or the blood vessels. An irregular heartbeat — atrial fibrillation — a prosthetic heart valve, or a stent placed in a narrowed coronary artery are the common reasons. Stopping the drug on one's own raises the risk of a clot, and after a coronary stent there is often a period during which it has to be continued without interruption. Add a urinary problem to that and the decision becomes difficult. Have the operation, and the question of stopping the drug is in the way; postpone it, and the difficulty passing urine continues. Some men give up on surgery because the drug cannot be stopped, and arrive in clinic months later still carrying a catheter. One patient who came with his son opened not by asking whether the operation would go well, but whether he could have it at all while taking an anticoagulant. Being unable to stop the drug is not a reason to abandon the operation. ### Why removing more tissue can bleed less Transurethral resection shaves the inside of the prostate away in pieces, and in doing so divides the vessels running between the tissue at many points at once. Small bleeding points appear scattered across the field, and finding and sealing them one by one is not easy. Enucleation with a holmium laser works differently. It peels the enlarged tissue off whole, starting at the outer shell, and travels along the boundary between the adenoma and the prostatic capsule. When that plane separates cleanly the vessels come into view, so each can be sealed before moving on. The field stays visible during the operation, and the blood in the urine afterwards tends to clear comparatively quickly. > **What the guidelines name, precisely** > The AUA states that HoLEP, photoselective vaporisation and thulium laser enucleation should be considered in patients at higher risk of bleeding, such as those on anticoagulant drugs, and its 2026 revision adds prostatic artery embolisation for larger glands. The EAU's 2026 recommendations that name antithrombotic therapy specifically name Tm:YAG enucleation and KTP or LBO vaporisation, both graded Weak; holmium enucleation carries a Strong recommendation, but as a general alternative to resection and open surgery rather than one conditioned on bleeding risk. Its treatment algorithm, which does define laser enucleation as including holmium and thulium, routes patients who cannot stop these drugs to laser enucleation, laser vaporisation or a prostatic urethral lift. The point that holds across both is the one worth carrying: several routes remain open, and being on the drug is not the end of the conversation. ### The anaesthetic is part of the same decision Spinal anaesthesia is given through a needle in the back, so if clotting is impaired the possibility of bleeding along that route has to be weighed. That is why general anaesthesia is chosen for some patients who cannot stop their medication. Which is appropriate depends on cardiac and pulmonary function and on the drugs being taken, and is settled in discussion with the anaesthetic team — which is why the operation and the anaesthetic cannot be decided separately. ### The same operation is not the same result Bleeding can occur if the enlarged tissue is not correctly identified, and the course differs with technique. A prostate that has grown well beyond the usual range leaves more tissue to remove and a correspondingly heavier operation. The harder it is for a patient to stop the drug, the more the technique matters. ### What to establish in the urology clinic 1. Whether the cardiology or cardiovascular team has been consulted about continuing or stopping the medication. 2. Whether the operation under consideration has been matched to the size of the prostate and to how the bladder is functioning. 3. Whether the anaesthetic approach has been explained. If the urinary difficulty has been going on for a long time, it is better to find out what treatment is possible in the present circumstances than to conclude in advance that surgery is out of reach. **A different condition, often confused with this one** - [Should a Korean man have a PSA test?](https://medicalinsightskorea.com/faq/should-a-korean-man-have-a-psa-test) — Benign enlargement is not prostate cancer. This covers the test people meet first. ## Sources - Goueli R, Badlani GH, Welliver C, Anderson PD, Bauer SR, Dana T, Donalisio da Silva R, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline (2026) Part III: Procedural/Surgical Management. The Journal of Urology 2026;216(2):161-170. doi:10.1097/JU.0000000000005099. PMID:42095468. https://doi.org/10.1097/JU.0000000000005099 - European Association of Urology Guidelines Panel. EAU Guidelines on the Management of Non-neurogenic Male LUTS, 2026 edition — recommendations for enucleation and vaporisation of the prostate. European Association of Urology 2026 edition, pocket guidelines. https://uroweb.org/guidelines/management-of-non-neurogenic-male-luts - Romero-Otero J, García-Gómez B, García-González L, García-Rojo E, Abad-López P, Justo-Quintas J, et al. Critical analysis of a multicentric experience with holmium laser enucleation of the prostate for benign prostatic hyperplasia: outcomes and complications of 10 years of routine clinical practice. BJU International 2020;126(1):177-182. doi:10.1111/bju.15028. PMID:32020749. https://doi.org/10.1111/bju.15028 ## Citation Chang Ki Lee (2026). "He cannot stop his blood thinners. That is not a reason to rule out prostate surgery". Medical Insights Korea. https://medicalinsightskorea.com/columns/urology/bph-surgery-when-the-blood-thinners-cannot-be-stopped Retrieved from https://medicalinsightskorea.com/columns/urology/bph-surgery-when-the-blood-thinners-cannot-be-stopped