The new oral anticoagulants, do they change the benefit vs. risk for thromboprophylaxis in association to ambulatory surgery?

[New oral anticoagulants and prostate biopsy: Which usual precaution should we use?]

INTRODUCTION

In 2013, more than 30,000 prostate biopsies have been performed in France. Bleeding complications are not rare. It imposes meticulous perioperative management in order to avoid them. In a close future, new oral anticoagulants (NOAC) will probably substitute vitamin K antagonist in many indications. The management of these new drugs is not really familiar in urology. The authors have specified it by using a systematic literature search in association to guidelines analysis edited by learned society.

METHODS

This article is based on a systematic literature search by using Pubmed database and by consulting international learned society of urology, anesthesiology or cardiology and the French National Agency of Drugs Security.

RESULTS

There was no guidelines edited by urological learned society. A standardized protocol adapted to prostate biopsies has been suggested using French Anesthesiologist and Hemostasian guidelines. The authors recommended stopping the oral anticoagulant treatment 5 days prior the biopsy. A bridge, by using a curative dose of heparin, was required during the preoperative period in order to manage the bleeding risk. It must be stopped 12 hours or 24 hours before biopsy (standard or low molecular weight heparin). Contrary to vitamin K antagonist, the re-initiation of the oral should begin 6-8 hours after procedure. The treatment should not overlap with heparin. The NOAC anticoagulant effect is quickly effective after 2 to 4 hours. The treatment should be re-initiated directly after the biopsy, in the absence of bleeding complications.

CONCLUSIONS

The perioperative management of new oral anticoagulants seems to be more simple than vitamin K antagonist (VKA) during prostate biopsy. A standardized protocol should be recommended.