The prevalence of BPH increases with age and in the aging population, cardiovascular disease is a common comorbidity representing the leading cause of death in the United States. A cornerstone of treatment for the prevention of ischemic heart disease and to reduce thrombosis of coronary artery stents is AP therapy, commonly aspirin combined with a P2Y12 inhibitor such as clopidogrel. In addition to AP therapy, many cardiac patients suffer from atrial fibrillation which puts them at risk for embolic stroke or venous thromboembolism. Traditionally, warfarin was utilized as an AC in these patients; however, direct oral anticoagulants (DOACs) were introduced in 2010 and are more commonly prescribed due to fewer side effects and drug interactions, shorter reversal time, and ease of monitoring. Examples of these medications include dabigatran, rivaroxaban, apixaban, and edoxaban. As the population ages, we are seeing an increasing number of men with BPH who are on AP and/or AC therapy which poses a significant challenge when considering surgical intervention.  Laser treatments for BPH (i.e., HoLEP, ThuLEP, PVP) are associated with a lower rate of blood transfusion when compared to TURP.313-317, 333, 462, 463 The hemostatic properties of lasers relate to their delivery of high density energy into the prostate which effectively coagulates blood vessels and surrounding tissue with minimal tissue depth penetration. While the depth of tissue penetration depends on the wavelength of the laser, the rapid hemostasis and superficial areas of ischemia created, make lasers favorable for use in patients on AC/AP therapy.464 HoLEP, ThuLEP, and PVP have all been utilized as surgical treatments for BPH in patients on AC/AP therapy.464-475 A study by El Tayeb et al. evaluated 1,558 patients who underwent HoLEP and identified 116 patients who were on AC/AP therapy including 325 mg of aspirin, clopidogrel, aspirin/dipyridamole, dabigatran, enoxaparin, or warfarin in the perioperative period (86 on intermittent AC/AP; 30 on continuous AC/AP).467 The patients who were on AC/AP therapy had a longer length of stay by 3.8 hours and longer duration of continuous bladder irrigation by 1.5 hours; however, there was no difference in the rate of blood transfusion or the need for clot evacuation even in patients on continuous AC/AP therapy.  Multiple studies have reported the use of PVP utilizing the LBO laser in patients on AC/AP therapy.465, 474-477 The 532 nm wavelength of this laser is selectively absorbed by hemoglobin giving it hemostatic properties that can be an advantage in patients on AC/AP therapy. Meskawi et al. examined the complications and functional outcomes of PVP with a 180 W, 532 nm wavelength laser in high-risk patients with cardiovascular disease who were on AC/AP therapy and compared them to a control group who were not on AC/AP therapy.465 The patients on AC/AP therapy were older with more comorbidities and had a higher rate of postoperative hematuria (Clavien 1 events), higher readmission rate, and longer length of stay and catheterization time. However, on multivariable analysis, AC/AP therapy was not a predictor of serious bleeding events after surgery.  Traditionally, clearance is obtained to hold AC/AP therapy in patients undergoing BPH surgery.  There are clinical scenarios in which holding AC/AP therapy can pose significant health risks such as recent thromboembolic event, prosthetic heart valves, hypercoagulable state, or recent cardiac stent. The dilemma for the clinician is in determining which poses greater risk: holding AC/AP therapy or continuing it. In a recent study, Xu et al. evaluated the question of whether to hold or continue AC/AP therapy in patients undergoing HoLEP for BPH.478 They identified 139 patients on AC/AP therapy of which 82 held the medication and 57 continued the medication (38 on clopidogrel [21 held]; 20 on warfarin [11 held]; 57 on apixaban [34 held]; 24 on rivaroxaban [16 held]). Overall, there were no significant differences in IPSS, PVR, rate of same day discharge, complication rates, emergency room visits, readmission rates, or hospital length of stay. However, on subgroup analysis controlling for age and prostate volume, patients who held clopidogrel had shorter length of stay (11.3 hours versus 27.3 hours; p=0.016), higher likelihood for same day catheter removal (90.5% versus 47.1%; p=0.002), and higher likelihood of same day discharge (90.5% versus 35.3%; p=0.002). Patients who held warfarin had shorter procedure times (61.3 minutes versus 92.2 minutes; p=0.025) and morcellation times (7.36 minutes versus 18 minutes; p=0.048). The rate of blood transfusion was not different between the groups (5.8% versus 4.8%; p=1.0). Patients who continued rivaroxaban had a higher 90-day readmission rate (42.9% versus 0%; p=0.036). Two patients who held AC/AP therapy suffered postoperative stroke requiring neurologic intervention. This study demonstrates the feasibility of continuing AC/AP therapy during HoLEP; however, the decision to hold or continue these medications must be made on an individual case basis with the expertise and guidance of the prescribing practitioner (e.g., cardiologist, primary care provider, hematologist).478 Despite the favorable characteristics of the lasers discussed, patients should be counseled about the increased risk of bleeding with BPH procedures whether the AC/AP is held or continued. PAE can also be considered for treatment of LUTS/BPH in patients at high risk of bleeding or requiring AC/AP medications. Since this treatment is performed via an endovascular route rather than a transurethral approach, typically AC/AP therapy can be continued peri-procedurally or held for a short duration (24-48 hours) to decrease the risk of puncture site hematomas.479 PAE has demonstrated efficacy in elderly, frail patients with medical comorbidities who are more likely to be on AC/AP therapy.480