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Anticoagulation and antiplatelet therapy in urological practice: ICUD/AUA review paper
Daniel J Culkin1, Emilio J Exaire1, David Green2
1Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma.
Insights
Managing anticoagulant and antiplatelet medications during urologic procedures requires careful consideration. Consensus recommendations aim to balance bleeding and thrombotic risks for improved patient outcomes.
Area of Science:
- Urology
- Cardiology
- Hematology
Background:
- Lack of urology-specific guidelines for managing anticoagulant/antiplatelet therapy during procedures.
- Need for standardized recommendations to reduce morbidity and mortality associated with medication management.
Purpose of the Study:
- Develop consensus-based recommendations for the periprocedural management of anticoagulant and antiplatelet medications in urology.
- Provide guidance on when to stop prophylaxis, which procedures can be done without interruption, and strategies to balance bleeding and thrombotic risks.
Main Methods:
- Systematic literature review addressing key questions on medication management.
- Inclusion of hematology and cardiology guidelines.
- Selection and full-text review of 79 relevant articles.
Main Results:
- Multidisciplinary management is crucial for patients with thromboembolic events, mechanical valves, atrial fibrillation, or cardiac stents.
- Elective procedures with recent stents require interruption of dual antiplatelet therapy.
- Low bleeding risk for procedures like ureteroscopy, prostate biopsies, and percutaneous renal biopsy with continued aspirin.
- Open prostate and renal procedures can be safely performed on aspirin or with heparin bridging.
Conclusions:
- Evidence base established from 79 reviewed articles.
- Recommendations aim to reduce complications from improper medication management.
- Further research needed on optimal timing for resuming prophylaxis post-procedure.
Purpose:
Given the lack of urology specific directives for the periprocedural management of anticoagulant and antiplatelet medications, the AUA (American Urological Association) and ICUD (International Consultation on Urological Disease) named an international multidisciplinary panel to develop consensus based recommendations.
Materials And Methods:
A systematic literature review was queried by a methodologist for 3 questions. 1) When and in whom can anticoagulant/antiplatelet prophylaxis be stopped in preparation for surgery? 2) What procedures can be safely performed without discontinuing anticoagulant/antiplatelet prophylaxis? 3) What periprocedural strategies can adequately balance the risk of major surgical bleeding vs the risk of major thrombotic event? Hematology and cardiology guidelines, and 79 articles were selected for full review.
Results:
Multidisciplinary management of anticoagulant/antiplatelet medications for patients with recent thromboembolic events, mechanical cardiac valves, atrial fibrillation and cardiac stents would reduce the high morbidity and mortality of inexpertly discontinuing or modifying these lifesaving therapies. No elective procedures requiring interruption of dual antiplatelet therapies should be performed with a recent bare metal or drug eluting stent. The risk of significant bleeding complications is low for patients who require continuation of aspirin for ureteroscopy, transrectal prostate biopsies, laser prostate outlet procedures and percutaneous renal biopsy. Open extirpative prostate and renal procedures can be performed with a low risk of significant hemorrhage for patients on aspirin and those requiring heparin based bridging strategies. The current literature does not give direction on the timing of the resumption of anticoagulant/antiplatelet prophylaxis other than that it be resumed as soon as the risk of bleeding has decreased.
Conclusions:
A total of 2,674 nonredundant article abstracts were obtained and assessed for relevance to key questions outlined by the panel. Overall 106 articles were selected for full text review and accepted or rejected based on the relation to the topic, quality of information and key questions. A total of 79 articles were accepted. Reasons for rejection (27 articles) included abstract only (12), insufficient information or unrelated to topic (13) and redundancy (2). We extracted study design, patient population, followup period and results from accepted articles, which serve as the evidence base.
