Antiplatelet and Anticoagulative Medication During Shockwave Lithotripsy

International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy

Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.

The Urological Association of Asia clinical guideline for urinary stone disease

The Urological Association of Asia, consisting of 25 member associations and one affiliated member since its foundation in 1990, has planned to develop Asian guidelines for all urological fields. The field of stone diseases is the third of its guideline projects. Because of the different climates, and social, economic and ethnic environments, the clinical practice for urinary stone diseases widely varies among the Asian countries. The committee members of the Urological Association of Asia on the clinical guidelines for urinary stone disease carried out a surveillance study to better understand the diversity of the treatment strategy among different regions and subsequent systematic literature review through PubMed and MEDLINE database between 1966 and 2017. Levels of evidence and grades of recommendation for each management were decided according to the relevant strategy. Each clinical question and answer were thoroughly reviewed and discussed by all committee members and their colleagues, with suggestions from expert representatives of the American Urological Association and European Association of Urology. However, we focused on the pragmatic care of patients and our own evidence throughout Asia, which included recent surgical trends, such as miniaturized percutaneous nephrolithotomy and endoscopic combined intrarenal surgery. This guideline covers all fields of stone diseases, from etiology to recurrence prevention. Here, we present a short summary of the first version of the guideline - consisting 43 clinical questions - and overview its key practical issues.

Assessing Cost-Effectiveness of New Technologies in Stone Management

Diagnosis, treatment, and follow-up are all influential in determining the overall cost to the health care system for kidney stones. New innovations in the field of nephrolithiasis have been abundant, including disposable ureteroscopes, ultrasound-guided approaches to percutaneous nephrolithotomy, and advanced laser lithotripters. Identifying cost-effective treatment strategies encourages practitioners to be thoughtful about providing value-based high-quality care and remains on important principle in the treatment of urinary stone disease.

The New/Novel Oral Anticoagulants and Their Impact on Patients Being Considered for Shockwave Lithotripsy: The Findings of an International Survey of the Endourological Society

INTRODUCTION

Although general guidelines exist directing the management of new/novel oral anticoagulants (NOACs) in the perioperative period for open/endoscopic procedures, no consensus exists for those patients being considered for shockwave lithotripsy (SWL). To gauge current practice, we administered a survey to the international endourologic community.

METHODS

A web-based survey was sent to current Endourological Society members. Respondents were asked whether they would consider SWL in patients receiving NOACs, and if they used SWL how these agents were managed perioperatively. Respondents were also asked which physicians in the patients' circle of care managed the discontinuation and reinstitution of the drugs.

RESULTS

There were 165 respondents from 27 countries. Approximately 92.7% of urologists had access to SWL but only 53.4% indicated they would offer SWL to patients receiving NOACs. Among these urologists, 63.3% relied on internal medicine/hematology/cardiology colleagues to counsel patients on the discontinuation of NOACs pretreatment, whereas the majority (64%) handled the resumption guidance themselves. There was wide variability in the management of NOACs before lithotripsy, with discontinuation varying from 2 to 7 days. Resumption was more consistent, ranging from 1 to 2 days or when hematuria resolved. None of the respondents reported knowledge of adverse effects such as perinephric hematomas or cardiovascular morbidity.

CONCLUSIONS

A large percentage of globally surveyed endourologists do not offer SWL to patients who are taking NOACs. Among those that do offer SWL, there seems to be a absence of consensus on optimal duration of discontinuation, suggesting a need to establish evidence-based guidance to optimize patient outcomes.

Influence of acetylsalicylic acid and low-molecular weight heparins on the formation of renal hematoma after shock wave lithotripsy

PURPOSE

To investigate the risk of renal hematoma (RHT) after shock wave lithotripsy (SWL) among patients on acetylsalicylic acid (ASA) or low-molecular-weight heparin (LMWH).

PATIENTS AND METHODS

Retrospective analysis of 434 patients treated with SWL for nephrolithiasis and ureterolithiasis of the proximal ureter. Primary endpoint was detection of RHT by ultrasound the day after SWL. Secondary outcome variables included transfusion of erythrocyte concentrate(s), interventions, hospital readmission or death due to RHT within 30 days of SWL. Binary logistic regression analysis was used including a post hoc one-way analysis.

RESULTS

Of 434 patients, 33 (7.6%) and 67 (15.4%) patients were medicated with ASA and LMWH, respectively. RHT was detected in 20 of 434 (4.6%) patients. Of those, 3 (20%) were on ASA, 6 (35%) were on LMWH, 1 (5%) was on ASA and LMWH, and 10 (50%) had no anticoagulation. Univariate analysis showed a statistically significant higher risk for RHT among patients on ASA (p = 0.04) and LWMH (p = 0.02) with an untreated urinary tract infection (UTI) (p = 0.008) and history of cardiovascular disease (p = 0.028). On multivariate analysis, ASA medication, untreated UTI (OR 4.4, 95% CI 1.31-14.75, p = 0.016 and OR 5.79, 95% CI 1.65-20.32, p = 0.03) and a therapeutic dose of LMWH (OR 10.4, 95% CI 1.74-62.27, p = 0.01) were independent predictors for RHT.

CONCLUSIONS

Before SWL, a patient risk profile should be evaluated. If feasible, LMWH in therapeutic dosing should be avoided, and ASA should be discontinued. UTI should be treated before SWL in any case.

TRIAL REGISTRATION

http://www.clinicaltrials.gov ; Identifier NCT02875717.

[S2k guidelines on diagnostics, therapy and metaphylaxis of urolithiasis (AWMF 043/025) : Compendium]

Every tenth German citizen will suffer from at least one urinary calculus during the lifetime. The diagnostics, treatment and follow-up treatment of urolithiasis are, therefore, part of the daily routine practice for all urologists in hospitals and private practices as well as in many other disciplines, such as general practitioners, internists, nephrologists and pediatricians. Although the diagnostics and therapy have experienced substantial alterations over the last 10 years, the possibilities of metabolic diagnostics and secondary prevention for patients at risk are, unfortunately and unjustly, in many places very poorly represented. The present S2k guidelines, which for the first time were established in an interdisciplinary consensus process, represent the current practical recommendations and, whenever possible, use tables and algorithms in order to facilitate easy reference in the routine daily work. Last but not least, this greatly simplifies the measures for metaphylaxis.

Does Transient Cessation of Antiplatelet Medication Prior to Shock Wave Lithotripsy Have Any Safety Concern: Evaluation of the Short Term Safety Results

OBJECTIVE

The study aimed to evaluate the true safety of transient cessation of the antiplatelet medication before extracorporeal shock wave lithotripsy (SWL) on bleeding-related complications.

PATIENTS AND METHODS

Forty cases undergoing SWL for renal pelvic stones were included and depending on the use of antiplatelet medication they were divided into 2 groups namely: group 1, cases under antiplatelet medication in whom the medication was stopped before ESWL; and group 2, cases without any antiplatelet medication. Comparative evaluation of patient, stone and treatment-related parameters were done in both groups.

RESULTS

Although microscopic hematuria was present in all cases, the incidence of macroscopic hematuria was higher in cases undergoing antiplatelet medication when compared with the other cases. Regarding the microscopic hematuria again, the mean number erythrocytes per field of analysis was significantly higher in group 1 cases. The mean value of the hematoma size was similar in both groups.

CONCLUSION

Our findings indicate that SWL can be applied safely in patients under antiplatelet therapy following the cessation of medication for a certain period of time. However, among the cases treated with this concept in our study, we clearly observed that the incidence of procedure-related hematoma formation and macroscopic hematuria were more common in such cases than in the normal ones.

Shock-wave lithotripsy: variance within UK practice

The objectives of this study are to determine the current treatment policies of UK shock-wave lithotripsy centres. Fixed-site lithotripter centres in the UK were identified via the national Therapeutic Interventions for Stones of the Ureter (TISU) study (n = 25). Questionnaires were completed regarding current SWL protocols for each centre, including management of anticoagulation, use of antibiotics and analgesia, urine testing, pacemakers, and arterial aneurysms. Data were collected regarding service delivery. Responses were obtained for 21 centres. Most centres use the Storz Modulith (85.7 %). Wide variation was observed in clinical contraindications to SWL, with 47.6 % centres performing SWL in patients with an abdominal aortic aneurysm, 66.7 % performing SWL in patients with a pacemaker, and 66.7 % of centres not performing SWL in asymptomatic patients with a urine dipstick positive for nitrites and leucocytes. The management of anticoagulation pre- and post-SWL showed wide variation, with the omission of anticoagulation ranging from 0 to 10 days pre-SWL. Seventeen distinct analgesia regimens were reported and prophylactic antibiotics are routinely administered in 25.0 % of centres. Tamsulosin is prescribed to all patients in 20.0 % of centres and a further 15.0 % of centres routinely prescribe tamsulosin post-SWL of ureteric stones. The included centres undertake SWL a median of 4 days per week and treat a median of six patients per list. Emergency SWL is unavailable in 30.0 % of centres. This observational real-life study has identified a significant disparity in the delivery of SWL throughout the UK, despite high numbers of patients with renal and ureteric stones being treated with this modality. Further studies should address the key areas of controversy, including an assessment of technical training, and facilitate the development of national guidelines to ensure a high level of standardized care for SWL patients.