ASPIRIN USE AND TRANSRECTAL ULTRASONOGRAPHY-GUIDED PROSTATE BIOPSY: A NATIONAL SURVEY

Authors


Junaid Masood, Department of Urology, Harold Wood Hospital, Romford, Essex, RM3 0BE, UK.
e-mail: junaido@aol.com

INTRODUCTION

There is sparse and conflicting published evidence about the management of aspirin before prostatic biopsy [1,2]. There is also no consensus on the period before the procedure for which aspirin should be stopped. Stopping aspirin before TRUS-guided prostate biopsy might minimize peri-operative blood loss, but might also increase the risk of a significant cardiovascular event. Aspirin induces an irreversible inactivation of cyclooxygenase in blood platelets, which lasts for the entire period that the platelets remain within circulation (7–10 days).

In one study, 52% of radiologists and 27% of urologists terminated aspirin before prostatic biopsy, although the urologists stopped aspirin for a longer period [2]. There are also few published studies assessing the use of aspirin before TURP. Again the data are conflicting, with some investigators suggesting that peri-operative use of aspirin does not increase blood loss [3], whilst others found that long-term low-dose aspirin therapy is associated with a significant increase in blood loss after TURP [4], and that aspirin therapy should be withdrawn 10 days before TURP [4]. A recent survey of current practice amongst urologists, assessing the use of aspirin and TURP, showed wide practice variations not only in the withdrawal of aspirin before surgery but also in the period that aspirin is withheld before and restarted after surgery [5]

There is also evidence of a lack of standardized practice in the peri-operative management of aspirin in other surgical specialities. One multi-study analysis stated that aspirin use caused no clinically relevant bleeding complications in cardiovascular, vascular and orthopaedic surgery, and during epidural anaesthesia [6]. Most of these studies reported an increase in clinically irrelevant bleeding induced by aspirin. A meta-analysis incorporating almost 50 000 patients (14 981 of these on aspirin) found that although aspirin increased the rate of bleeding complications by 1.5 times, it did not lead to greater severity of bleeding complications, except for intracranial surgery and possibly TURP [7]. In cardiac surgical procedures, patients who stop taking aspirin for ≤2 days before surgery have increased allogeneic red blood cell transfusion requirements during and after surgery. Patients who stop taking aspirin 3–7 days before surgery have little or no increase in the risk of transfusion [8].

There are no guidelines on the management of aspirin before taking prostate biopsies. TRUS-guided prostate biopsy, used to diagnose prostate cancer, is likely to be more common in future. Cancelling the procedure for inadvertent aspirin use has implications for staff time, cost and waiting lists. However, as noted, aspirin use might result in a greater risk of bleeding and hospitalization after biopsy, but stopping it might increase the risk of thromboembolic events. With so many conflicting results we assessed how UK urologists manage patients taking aspirin and attending for TRUS-guided prostate biopsies.

A 10-point questionnaire (Appendix 1) was mailed to 450 consultant urological surgeons in the UK, with the aim of establishing practices and protocols for managing aspirin or aspirin-like drugs before prostate biopsy. There was a 66% response rate (297 replies) to the questionnaire. Only 44% of urology departments have protocols in place relating to aspirin use before prostate biopsy. Of those who replied, 65% (193) do not routinely stop aspirin before prostate biopsy; 35% (104) stop aspirin before prostate biopsies, 52% of these 1 week before, 41% 2 weeks and 6% >2 weeks before. A third of the urologists feel that aspirin increases bleeding complications; 6% did not comment on this point, and 59% stated that the cerebrovascular risks of stopping aspirin outweigh the benefit of stopping aspirin for bleeding. Only four consultants reported cerebrovascular side-effects of stopping aspirin. For those who routinely stop aspirin, the median (range) time for restarting aspirin after biopsy was 2 (0–10) days.

It is clear from our results that urologists in the UK have no uniform approach to managing aspirin use before prostate biopsy. Not only is there wide variation in the practice of stopping aspirin, there is also a lack of consensus on the period for which aspirin is withdrawn before prostate biopsy. There appears to be no strong scientific evidence for the withdrawal of aspirin in all patients undergoing prostate biopsy. The best available evidence seems to suggest that only if low-dose aspirin causes bleeding risks, with increased mortality or complications comparable with the observed cardiovascular risks after aspirin withdrawal, should it be discontinued before an intended operation or procedure [7]. However, more than a third of the respondents stated that they would routinely stop aspirin and would cancel a procedure if the patient had inadvertently not stopped aspirin or aspirin-like drugs. We recommend randomized controlled studies to establish evidence-based guidelines to ensure standardized practice.

Appendix

APPENDIX 1

1. Are TRUS-guided prostate biopsies taken in your unit? Yes, No

2. If so, by whom? (answer Yes or No)

Urology consultant

Urology SpR/Staff grade

Radiologist

Other (please state)

3. Do you have a protocol in place concerning the management of aspirin before prostate biopsy? Yes, No

4. Do you stop aspirin/aspirin like drugs before prostate biopsy? Yes, No

5. If Yes to Q4 when is the aspirin stopped? (please tick)

0–7 days, 7–14 days, >14 days, Other (days)

6. Would you take a prostate biopsy in a patient who has inadvertently continued to use aspirin even if your policy is to routinely stop aspirin before the procedure, to avoid cancellation? Yes, No

7. Do you feel aspirin use before prostate biopsy increases bleeding complications during and after the procedure? Yes, No

8. Do you feel that the cardiovascular risks of stopping aspirin outweigh the urological benefits of continuing with the procedure on aspirin? Yes, No

9. If you routinely stop aspirin have you found any significant morbidity in your patients? Yes, No

If yes was it:

Transient ischaemic attack/cardiovascular accident

Peripheral vascular event

Cardiac event

Other (please state)

10. If you stop aspirin for prostate biopsy, how soon after the procedure do you advise patients to re-commence it? Please state. . . .

Ancillary