Use new data to inform unique patient group

December 22, 2016

"Increasingly, urologists are faced with patients who cannot safely discontinue anticoagulation or antiplatelet medications, even in the face of an impending surgical procedure. This is a trend that is likely to continue into the foreseeable future," writes Brian R. Matlaga, MD, MPH.

Brian R. Matlaga, MD, MPHDr. Matlaga

 

Increasingly, urologists are faced with patients who cannot safely discontinue anticoagulation or antiplatelet medications, even in the face of an impending surgical procedure. This is a trend that is likely to continue into the foreseeable future.

Related: Anticoagulant use in URS patients ups bleeding risk

When it comes to stone management, such a situation eliminates certain treatment options-percutaneous nephrolithotomy and shock wave lithotripsy-as they cannot be safely performed on an anticoagulated patient. As a result, for the anticoagulated patient with a symptomatic stone requiring treatment, surgical therapy is limited to ureteroscopy (URS).

This approach is codified in the recently released AUA Surgical Management of Stones Guidelines, which specifically address the issue of stone management in patients who have a bleeding diathesis or require continuous anticoagulation or antiplatelet therapy. The guideline panel’s recommendation was that URS be considered first-line therapy for such patients.

Importantly, the panel recognized that there can be an increased risk of bleeding associated with URS in this situation; to that end, the guidelines suggest several maneuvers that the urologist may undertake to minimize such risk. These maneuvers include measures to minimize intra-renal pressures by utilizing an access sheath, employing non-pressurized irrigation, and keeping the bladder decompressed with a small catheter if an access sheath is not used.

The present study by Ingimarsson and colleagues advances our understanding of URS in an anticoagulated setting (see article here), and builds on a similar series reported by Elkoushy and associates (Int Braz J Urol 2012; 38:195-203). These findings are particularly important, as they provide a broader understanding of the increased risk encountered in this setting.

One of the most important things that we do as surgeons is to educate our patients on what to expect following a surgical procedure. In this case, we can leverage the findings reported in this study in order to provide more informed counsel to this unique group of patients.

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