[Critical haematuria after prostate biopsies with RIVAROXABAN. Case report]

[Rivaroxaban, dabigatran and apixaban: new anticoagulants in operative urology]

The periprocedural management of patients receiving long-term oral anticoagulant therapy is a common but complex clinical problem. It is well established that maintaining oral anticoagulation is associated with an increased risk of bleeding in the periprocedural period while discontinuing anticoagulant therapy postoperatively leads to an elevated risk for thromboembolic events, especially in high risk patients. Nowadays there is growing evidence to maintain antiplatelet therapy with acetylsalicylic acid (ASS, Aspirin®) perioperatively in a setting of secondary prophylaxis. Beyond that the increasing routine clinical use of novel oral anticoagulants (NOACs), such as the direct factor IIa inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban and apixaban, presents a challenge for urological surgeons. These agents are approved in patients with nonvalvular atrial fibrillation (rivaroxaban, dabigatran and apixaban) and in patients after deep vein thrombosis and pulmonary embolism (rivaroxaban). Due to their relatively short elimination half-lives and rapid onset of action, these new drugs have the potential to simplify periprocedural anticoagulant management making heparin bridging therapy redundant. Critical consideration is necessary regarding potential pitfalls, such as impaired renal function, insufficient possibility of laboratory monitoring and lack of antidotes in cases of postoperative hemorrhage. Although periprocedural protocols for the use of NOACs are emerging, robust clinical data are still scarce. This article provides a practical, clinician-focused approach to periprocedural management of NOACs.