Introduction
Benign Prostatic Hyperplasia (BPH) causing bladder outlet obstruction presents significant management challenges in patients with high cardiac risk who are receiving ongoing antiplatelet therapy. Bipolar Transurethral Resection of the Prostate (TURP) offers a surgical option with reduced bleeding risk in such situations.
Case Presentation
A 70-year-old male presented with:
- Hesitancy
- Intermittent urinary stream
- Frequency
- Urgency
- Urge incontinence for 2 years
Symptoms remained uncontrolled despite oral alpha-blockers and significantly affected quality of life.
Investigations
Ultrasound Findings:
- Enlarged prostate
- Incomplete bladder emptying
- Pre-void volume: 187 cc
- Post-void volume: 148 cc
Uroflowmetry:
- Average flow (Qavg): 2 mL/s
- Maximum flow (Qmax): 10 mL/s
Findings suggested severe bladder outlet obstruction with threatened urinary retention.
The patient was planned for Transurethral Plasma Kinetic Bipolar Resection of Prostate (Bipolar TURP) due to its advantages over conventional TURP:
- Better haemostasis
- Faster resection
- Lower TUR syndrome risk
Clinical Challenges
The patient had significant coronary artery disease (CAD):
- Ex-smoker (quit in 2009)
- PTCA in 2009 – RCA stent
- PTCA in 2017 – 3 stents in LCA
- Complex PTCA in 2018 – 4 stents
- ECG: Poor R-wave progression to V3 with T-wave inversions
Stopping antiplatelet therapy posed a high risk of stent thrombosis, while proceeding with surgery on antiplatelets increased the risk of severe bleeding.
Following multidisciplinary discussion with Dr. Haresh Mehta (Cardiology) and team, a bridging strategy using alternative antiplatelet therapy was adopted.
Clinical Challenges
The patient had significant coronary artery disease (CAD):
- Ex-smoker (quit in 2009)
- PTCA in 2009 – RCA stent
- PTCA in 2017 – 3 stents in LCA
- Complex PTCA in 2018 – 4 stents
- ECG: Poor R-wave progression to V3 with T-wave inversions
Stopping antiplatelet therapy posed a high risk of stent thrombosis, while proceeding with surgery on antiplatelets increased the risk of severe bleeding.
Following multidisciplinary discussion with Dr. Haresh Mehta (Cardiology) and team, a bridging strategy using alternative antiplatelet therapy was adopted.
Preoperative Management
Treatment Protocol
- Aspirin stopped 48 hours before surgery
- Inj. Cangrelor initiated
- Dose: 0.75 mcg/kg/min
- Preparation: 50 mg in 250 mL NS
- Infusion rate: 17 mL/hr
- Infusion discontinued 6 hours prior to surgery
- Otis urethrotomy performed
Procedure Details
Anaesthesia: Spinal + Epidural
(Dr. Vaibhavi Baxi and team)
Cystoscopy Findings
- Performed using 26 Fr resectoscope
- Enlarged median and lateral lobes
- Obstructed bladder neck
Postoperative Course
- ICU observation for 1 day
- Bipolar TURP performed successfully with adequate haemostasis
- Preoperative blood pressure maintained to minimise postoperative bleeding
- Cangrelor restarted 5 hours postoperatively
- Improved urinary flow
- Better quality of life
- Foley catheter removed and patient discharged on Day 5 while continuing Aspirin therapy
Discussion
Cangrelor is the only direct parenteral P2Y12 inhibitor with rapid onset and offset, unlike oral agents such as:
It functions as a bridging agent in patients with recent coronary stenting requiring surgery.
Following multidisciplinary evaluation and counselling, surgery was preferred because prolonged catheterisation carries long-term risks including:
- Prostate abscess
- Epididymo-orchitis
- Haematuria
- Recurrent blockage
- UTIs
- Catheter discomfort
Conclusion
Bipolar TURP can be safely considered in high cardiovascular-risk patients using a bridging antiplatelet strategy such as Cangrelor.
Key Benefits
- Improved quality of life
- Reduced catheter-related complications
- Safe surgical intervention in appropriately selected patients where benefits outweigh risks
