Thromboprophylaxis and bleeding diathesis in minimally invasive stone surgery

Abstract

With populations ageing and active treatment of urinary stones increasingly in demand, more patients with stones are presenting with an underlying bleeding disorder or need for regular thromboprophylaxis, by means of antiplatelet and other medication. A practical guide to thromboprophylaxis in the treatment of urinary tract lithiasis has not yet been established. Patients can be stratified according to levels of risk of arterial and venous thromboembolism, which influence the requirements for antiplatelet and anticoagulant medications, respectively. Patients should also be stratified according to their risk of bleeding. Consideration of the combined risks of bleeding and thromboembolism should determine the perioperative thromboprophylactic strategy. The choice of shockwave lithotripsy, percutaneous nephrolithotomy or ureteroscopy with laser lithotripsy for treatment of lithiasis should be determined with regard to these risks. Although ureteroscopy is the preferred method in high-risk patients, shockwave lithotripsy and percutaneous nephrolithotomy can be chosen when indicated, if appropriate guidelines are strictly followed.

How can and should we optimize extracorporeal shockwave lithotripsy?

“…For patients treated with acetylsalicylate preparations (ASA, for instance, aspirin; however, there are today numerous pharmacological agents containing ASA), the medication should be deferred to allow for new thrombocytes to form. Various recommendations are given in the literature, and the current advice is to withhold the treatment for a period of 7 days before SWL [ 58 – 60 ]. Zanetti and co-workers stopped ASA for 8 days and the EAU guidelines previously recommended 10 days [ 61 ], corresponding to the time required for renewal of thrombocytes.…”

Fatal cardiac thromboembolism in a patient with a pacemaker during ureteroscopic lithotripsy for ureter stone: a case report

“…Minimal invasive surgical procedures, such as shockwave lithotripsy and ureteroscopy, exhibit a low risk of thromboembolism, and do not typically require pharmacological antithrombotic therapy [ 6 ]. Preoperative anticoagulation can be considered for patients with an implanted pacemaker with high-risk diseases such as atrial fibrillation (AF) or mechanical heart valves [ 7 ].…”

Ureteroscopy for stone disease: expanding roles in the modern era

“…Reversal of anti-coagulation is advised where appropriate, but in certain circumstances where this is not possible, SWL and PCNL are contraindicated due to the high risk of bleeding [6, 7, 22]. Evidence suggests URS and laser stone fragmentation provides a good SFR of 87.7% and a complication rate of 11% [23].…”