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Berger JH, DiPina T, Alshara L, Batagello C, Heiman J, Large T, Sivalingam S, Sur RL, Krambeck A, Bechis SK. The Effect of Pre-Stenting on Bleeding-Related Complications Following Ureteroscopy in Patients on Anticoagulation or Antiplatelet Therapy. J Endourol 2023; 37:1174-1178. [PMID: 37675902 DOI: 10.1089/end.2023.0300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
Introduction: The American Urological Association guidelines state that continuing anticoagulant (AC) and antiplatelet (AP) agents during ureteroscopy (URS) is safe. Through a multi-institutional retrospective study, we sought to determine whether pre-stenting in patients on AP or AC was associated with fewer URS bleeding-related complications. Methods: A series of 8614 URS procedures performed across three institutions (April 2010 to September 2017) was electronically reviewed for AC/AP use at time of URS. Records indicating AC or AP use at time of URS were then manually reviewed to characterize intraoperative and 30-day postoperative (intraoperative bleeding, postoperative hematuria, emergency department visits, hospital readmission, unplanned reoperation, phone calls, and other minor 30-day complications). Results: A total of 293 identified URS procedures were completed on patients on AC/AP therapy-112 cases were on AC only (38 were pre-stented), 158 on AP only (51 pre-stented), and 23 on both AP and AC (8 pre-stented). Patient characteristics and comorbidities were similar between the pre-stented and non-pre-stented groups. For AC and AP subjects, pre-stenting did not decrease the composite risk of bleeding complications (10.3% pre-stent vs 12.2% non-prestent, p = 0.6). Pre-stented patients did have a significantly lower likelihood of requiring an unplanned reoperation (1.0% vs 5.6%, p = 0.04). In the subgroup of patients on AP alone, pre-stented patients had significantly fewer episodes of intraoperative bleeding (0% vs 9%, p = 0.04), unplanned reoperations (0% vs 6.5%, p = 0.02), and 30-day complications (14% vs 27%, p = 0.05). In the subgroup of patients on AC alone, there were no significant differences in outcomes based on stent status. Conclusions: In this multi-institutional study, we found that pre-stenting before URS was not associated with fewer bleeding complications. However, pre-stenting appeared to be associated with improved outcomes for those patients on AP therapy. These results suggest a need for prospective studies to clarify the role of pre-stenting for URS.
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Affiliation(s)
- Jonathan H Berger
- Department of Urology, University of California, San Diego, San Diego, California, USA
| | - Thomas DiPina
- Department of Urology, University of California, San Diego, San Diego, California, USA
| | - Luay Alshara
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Carlos Batagello
- Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Joshua Heiman
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tim Large
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sri Sivalingam
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Roger L Sur
- Department of Urology, University of California, San Diego, San Diego, California, USA
| | - Amy Krambeck
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Seth K Bechis
- Department of Urology, University of California, San Diego, San Diego, California, USA
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Xu ZJ, Chen L, Li D, Xu CL, Chen FT, Tang QL, Shao Y. Ureteroscopic and flexible ureteroscopic lithotripsy: continuation or discontinuation of anticoagulant or antiplatelet drugs? A Chinese survey among urologists. Urolithiasis 2023; 51:39. [PMID: 36809516 DOI: 10.1007/s00240-023-01413-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 02/11/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE To evaluate the management of antithrombotic drugs made by different urologists before ureteroscopic lithotripsy and flexible ureteroscopy in stone patients undergoing active anticoagulant or antiplatelet therapy. METHODS A survey was distributed to 613 urologists in China, which included personal work information and views on the management of anticoagulants (AC) or antiplatelet (AP) drugs during the perioperative period of ureteroscopic lithotripsy (URL) and flexible ureteroscopy (fURS). RESULTS 20.5% of urologists believed that AP drugs could be continued and 14.7% believed that AC drugs could be continued. 26.1% of the urologists who participated in more than 100 ureteroscopic lithotripsy or flexible ureteroscopy surgeries each year believed that AP drugs could be continued and 19.1% believed that AC drugs could be continued, compared with 13.6% (P < 0.01) and 9.2% (P < 0.01) of the urologists who performed less than 100 surgeries. Among the urologists with more than 20 cases undergoing active AC or AP therapy per year, 25.9% thought that AP drugs could be continued and 19.7% thought that AC drugs could be continued, compared with 17.1% (P = 0.008) and 11.5% (P = 0.005) of the urologists with less than 20 cases. CONCLUSION The decision on the continuation of AC or AP drugs before ureteroscopic and flexible ureteroscopic lithotripsy should be individualized. The experience in URL and fURS surgeries and in dealing with patients under AC or AP therapy is the influencing factor.
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Affiliation(s)
- Zi-Jie Xu
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Chen
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Deng Li
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chao-Liang Xu
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fei-Teng Chen
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi-Lin Tang
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Shao
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai Municipal Alliance in Urology, Shanghai, China.
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Ureteroscopy in Patients Taking Anticoagulant or Antiplatelet Therapy: Practice Patterns and Outcomes in a Surgical Collaborative. J Urol 2020; 205:833-840. [PMID: 33035142 DOI: 10.1097/ju.0000000000001416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE AUA guidelines recommend ureteroscopy as first line therapy for patients on anticoagulant or antiplatelet therapy and advocate using a ureteral access sheath. We examined practice patterns and unplanned health care use for these patients in Michigan. MATERIALS AND METHODS Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) clinical registry we identified ureteroscopy cases from 2016 to 2019. We assessed outcomes and adherence to guidelines based on therapy at time of ureteroscopy: 1) anticoagulant: continuous warfarin or novel oral agent therapy; 2) antiplatelet: continuous clopidogrel or aspirin therapy; 3) control: not on anticoagulant/antiplatelet therapy. We fit multivariate models to assess anticoagulant or antiplatelet therapy association with emergency department visits, hospitalization and ureteral access sheath use. RESULTS In total, 9,982 ureteroscopies were performed across 31 practices with 3.1% and 7.8% on anticoagulant and antiplatelet therapy, respectively. There were practice (0% to 21%) and surgeon (0% to 35%) variations in performing ureteroscopy on patients on anticoagulant/antiplatelet therapy regardless of volume. After adjusting for risk factors, anticoagulant or antiplatelet therapy was not associated with emergency department visits. Hospitalization rates in anticoagulant, antiplatelet and control groups were 4.3%, 5.5% and 3.2%, respectively, and significantly increased with antiplatelet therapy (OR 1.48, 95% CI 1.02-2.14). Practice-level ureteral access sheath use varied (23% to 100%) and was not associated with anticoagulant/antiplatelet therapy. Limitations include inability to risk stratify between type/dosage of anticoagulant/antiplatelet therapy. CONCLUSIONS We found practice-level and surgeon-level variation in performing ureteroscopy while on anticoagulant/antiplatelet therapy. Ureteroscopy on anticoagulant is safe. However, antiplatelet therapy increases the risk of hospitalization. Despite guideline recommendations, ureteral access sheath use is not associated with anticoagulant/antiplatelet therapy.
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Alathel A, Bjazevic J, Chew BH, Pace KT, Razvi H. 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. J Endourol 2019; 33:319-324. [PMID: 30793937 DOI: 10.1089/end.2019.0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Abdulaziz Alathel
- 1 Division of Urology, Department of Surgery, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- 2 King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- 3 King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Jennifer Bjazevic
- 4 Division of Urology, Department of Surgery, Western University, London, Canada
| | - Ben H Chew
- 5 Department of Urological Sciences, University of British Columbia, Vancouver, Canada
| | - Kenneth T Pace
- 6 Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Hassan Razvi
- 4 Division of Urology, Department of Surgery, Western University, London, Canada
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Sharaf A, Amer T, Somani BK, Aboumarzouk OM. Ureteroscopy in Patients with Bleeding Diatheses, Anticoagulated, and on Anti-Platelet Agents: A Systematic Review and Meta-Analysis of the Literature. J Endourol 2018; 31:1217-1225. [PMID: 29048211 DOI: 10.1089/end.2017.0253] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Ureteroscopy (URS) is the most common surgical treatment of urolithiasis and can be problematic in patients with a bleeding diathesis. The intent of this review is to systematically review the literature to assess the safety and efficacy of ureteroscopic procedures in these groups of patients. METHODS The systematic review was performed according to the Cochrane diagnostic accuracy review guidelines. The search strategy was conducted to perform a comprehensive database search (1990-2017). A cumulative analysis was done and where applicable a comparative analysis between bleeding diathesis patients and those without. RESULTS Eight studies included were all published between 1998 and 2016 with the total number of participants with bleeding diatheses being 1109 with an age range of 18-97. Overall stone-free rate across the studies was 90.8% vs 86.2% in the control group. There was no significant difference in complications between the bleeding diathesis group and control group (N = 12,757, p = 0.07, 95% confidence interval [CI] 0.92, 6.02, I2 = 78%). Pooled analysis for bleeding-related complications shows a statistically significant difference favoring the control arm (N = 12,757, p ≤ 0.0001, 95% CI 1.81, 5.73, I2 = 0%). Pooled analysis for thrombosis shows no statistically significant difference between the bleeding diathesis group and the control arm (N = 118, p = 0.67, 95% CI 0.23, 9.86, I2 = 48%). CONCLUSION The use of URS with or without the holmium laser is a safe and efficient modality for treating patients with urolithiasis who also have a bleeding diathesis or are anticoagulated or on antiplatelet agents. However, this review would suggest that the increased risk of procedure related bleeding is not insignificant and a patient-centered approach should be taken with regards to continuing these agents or not correcting bleeding diatheses.
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Affiliation(s)
- Alaa Sharaf
- 1 Department of Urology, Queen Elizabeth University Hospital , NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Tarik Amer
- 1 Department of Urology, Queen Elizabeth University Hospital , NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Bhaskar K Somani
- 2 Department of Urology, University Hospital of Southampton NHS Foundation Trust , Southampton, United Kingdom
| | - Omar M Aboumarzouk
- 1 Department of Urology, Queen Elizabeth University Hospital , NHS Greater Glasgow and Clyde, Glasgow, United Kingdom .,3 EAU Young Academic Urologists-Endourology and Urolithiasis Working Group, European Assocication of Urology.,4 School of Medicine, Dentistry and Nursing, University of Glasgow , Glasgow, United Kingdom
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Ordon M, Andonian S, Blew B, Schuler T, Chew B, Pace KT. CUA Guideline: Management of ureteral calculi. Can Urol Assoc J 2015; 9:E837-51. [PMID: 26788233 DOI: 10.5489/cuaj.3483] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The focus of this guideline is the management of ureteral stones. Specifically, the topics covered include: conservative management, medical expulsive therapy, active intervention with either shockwave lithotripsy (SWL) or ureteroscopy (URS), factors affecting SWL treatment success, optimizing success, and special considerations (e.g., pregnancy, urinary diversion). By performing extensive literature reviews for each topic evaluated, we have generated an evidence-based consensus on the management of ureteral stones. The objective of this guideline is to help standardize the treatment of ureteral stones to optimize treatment outcomes.
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Affiliation(s)
- Michael Ordon
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
| | - Sero Andonian
- Division of Urology, Department of Surgery, McGill University, Montreal, QC
| | - Brian Blew
- Division of Urology, Department of Surgery, University of Ottawa, Ottawa, ON
| | - Trevor Schuler
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB
| | - Ben Chew
- Department of Urology, University of British Columbia, Vancouver, BC
| | - Kenneth T Pace
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
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Giusti G, Proietti S, Peschechera R, Taverna G, Sortino G, Cindolo L, Graziotti P. Sky is no limit for ureteroscopy: extending the indications and special circumstances. World J Urol 2014; 33:257-73. [DOI: 10.1007/s00345-014-1345-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 05/14/2014] [Indexed: 12/19/2022] Open
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