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The Effect of Pre-Stenting on Bleeding-Related Complications Following Ureteroscopy in Patients on Anticoagulation or
Jonathan H Berger1, Thomas DiPina1, Luay Alshara2
1Department of Urology, University of California, San Diego, San Diego, California, USA.
Insights
Pre-stenting before ureteroscopy (URS) did not reduce bleeding complications for patients on anticoagulant (AC) or antiplatelet (AP) therapy. However, pre-stenting showed improved outcomes for patients on AP therapy, suggesting further research is needed.
Area of Science:
- Urology
- Nephrology
- Surgical Complications
Background:
- American Urological Association guidelines suggest continuing anticoagulant (AC) and antiplatelet (AP) agents during ureteroscopy (URS) is safe.
- The role of pre-stenting in mitigating bleeding complications for patients on AC/AP therapy during URS remains unclear.
Purpose of the Study:
- To investigate whether pre-stenting is associated with fewer URS bleeding-related complications in patients on AC or AP therapy.
- To analyze the impact of pre-stenting on intraoperative and postoperative complications in patients undergoing URS while on AC/AP agents.
Main Methods:
- Multi-institutional retrospective study involving 8614 URS procedures from April 2010 to September 2017.
- Electronic review identified patients on AC/AP therapy at the time of URS.
- Manual review characterized intraoperative and 30-day postoperative bleeding-related complications, comparing pre-stented versus non-pre-stented groups.
Main Results:
- Pre-stenting did not decrease the composite risk of bleeding complications for patients on AC and AP therapy combined (10.3% vs. 12.2%, p=0.6).
- Pre-stented patients had a significantly lower likelihood of requiring unplanned reoperation (1.0% vs. 5.6%, p=0.04).
- In the subgroup on AP alone, pre-stenting was associated with significantly fewer intraoperative bleeding episodes (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).
Conclusions:
- Pre-stenting before URS is not associated with reduced bleeding complications in patients on AC/AP therapy.
- Pre-stenting may offer improved outcomes, particularly reduced reoperations and complications, for patients on antiplatelet therapy alone.
- Prospective studies are warranted to further clarify the specific role of pre-stenting in URS for patients on antithrombotic agents.
Abstract:
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. 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). 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. 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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