LAUSR

Considering the progressive ageing of the haemophilia population, it is surprising that diseases of the prostate and their medical and surgical management received so far relatively little attention in the literature and guidelines.1 Prostate cancer is the second most common type of cancer in men after skin cancer, with approximately one million cases diagnosed worldwide each year.2 It is estimated that one every 10 men will be diagnosed with this tumour during their lifetime, particularly after the age of 60 years.2 Much more frequent than malignancy is benign prostatic hyperplasia, that affects the majority of older men with a variable degree of urinary symptoms and is managed with drugs such as alpha-blockers and alpha-reductase inhibitors or, in cases with unsatisfactory pharmacological control, with such a moderately invasive surgical procedure as transurethral prostate resection (TURP). Notwithstanding the fact that prostate cancer is the sixth leading cause of cancer death in men, it is well treatable in the early stages, thus emphasizing the key role of primary prevention through the control of such modifiable risk factors as smoking, alcohol, being sedentary and overweight, as well as the judicial use of prostate-specific antigen (PSA) testing. When this serum marker and/or clinical symptoms point toward a suspicion of prostate cancer, magnetic resonance imaging followed by ultrasound-guided transrectal biopsy of the gland is the onlyway to establishwith certainty a diagnosis of cancer. A major surgical procedure such as radical prostatectomy is the mainstay of management of localized cancer in patients with a good life expectancy and is carried out laparoscopically or by means of robot-assisted techniques, the latter having the advantages of shorter hospitalization and less blood loss and transfusion requirement. Persons with haemophilia (PWH) are not exempt from prostate illness, being males and reaching more and more frequently older age.3 The European Haemophilia Safety Surveillance System (EUHASS) has been collecting data since2008on thediagnosis of newmalignancies in patients with bleeding disorder from 92 treatment centres in 26 European countries.4 During the period 2008–2021 the EUHASS participating centres cared for 20,414 personswith haemophilia A and B. The total number of reported malignancies in these individuals was 436 and 53 of them were prostate cancers, confirming that PWH are not exempt from these problems (unpublished information). The paper by Gautier and colleagues from 14 French haemophilia centres describing in the current issue of Haemophilia their questionnaire-based survey is timely.5 It reports the management of 86 PWHundergoing prostate biopsies and that of cancer in 50 older individuals between 2003 and 2018 (age range 56–87), 28 of them treatedwith surgery and the remaining 22with othermodalities.What are the main general messages that can be drawn from this report, cognizant of the limitations of a questionnaire survey, the relatively small number of cases, and the long 15-year period covered by the survey? Regarding prostate biopsy, it appears that the authors originally regarded it as a minor surgical procedure, because they planned replacement therapy (with desmopressin in patients with mild disease and with factor replacement in those severely affected) for relatively short time periods, spanning from two to four days depending on the severity and type of haemophilia. Bleeding complications occurred in 14 of 86 procedures (16%), usually with a delayed onset at a mean of seven post-operative days when prophylactic replacement therapy was already stopped. Even though bleeding episodes were generally mild and only one needed transfusion, these observations indicate that prostate biopsy should be managed with longer periods of short-term prophylaxis, because it is a closed procedure that makes it difficult to secure local hemostasis. The prostate and urinary tract are organs rich in fibrinolytic activity,6 so that it is wise, as suggested and done in a few cases by the French authors,5 to use an adjuvant such as tranexamic acid during the perioperative and postoperative periods. The authors reported no case treated with TURP for benign hyperplasia, but we