Anticoagulant use in URS patients ups bleeding risk

Patients undergoing ureteroscopy while remaining on anticoagulant therapy may be at increased risk for bleeding complications, including significant bleeding events and unplanned returns to the operating room, according to a retrospective study from Mayo Clinic, Rochester, MN.

Commentary: Use new data to inform unique patient group

The authors were prompted to analyze the safety of continuing anticoagulation when performing ureteroscopy because anecdotally, their experience seemed to conflict with the published recommendation from the AUA/International Consultation on Urological Diseases (AUA/ICUD) stating that “Ureteroscopy can be performed with continuing oral anticoagulation and antiplatelet therapy” (J Urol 2014; 192:1026-34). They presented their findings at the 2016 World Congress of Endourology in Cape Town, South Africa.

“The AUA/IUCD statement is based on a systematic review of the literature that identified only three small retrospective series that reported no increase in bleeding-related complications in patients on anticoagulation or antiplatelet therapy undergoing utereroscopy. We thought the evidence, however, was insufficient to support such a conclusive statement,” said presenting author Jóhann P. Ingimarsson, MD.

“Further studies are needed to validate our findings, and we are not advocating against stopping anticoagulation in all patients undergoing ureteroscopy. Rather, the decision should be individualized taking into account the risks associated with procedural-related bleeding versus a thromboembolic event. However, we believe our study provides information that should be used for preoperative planning and patient counseling while also underscoring the need for practice recommendations to be evidence-based.”

Dr. Ingimarsson was involved in the study when he was a minimally invasive urologic surgery fellow at Mayo Clinic. He is currently attending surgeon, Maine Medical Center, South Portland.

To investigate the risk of bleeding complications when patients undergoing ureteroscopy continued on anticoagulation, the authors undertook a chart review covering the period from June 2009 to February 2016. They identified 4,799 ureteroscopic procedures, of which 528 involved patients on anticoagulation within 90 days prior to the procedure. After excluding patients on concomitant antiplatelet therapy, whose anticoagulant therapy could not be verified, and those who had another surgery concomitant with ureteroscopy, 272 patients remained in the study population.

Overall, the patients had a mean age of 70 years. The surgical technique included both semirigid and flexible ureteroscopy procedures and routine stent placement.

Bleeding-related complication rates were analyzed with the 272 patients divided into three groups according to whether the anticoagulation was continued (n=26), bridged with enoxaparin (n=53), or held (n=193). The patients who continued on anticoagulation were further stratified by whether they were on warfarin (n=17) or a non-vitamin K antagonist (n=9).

Next: Nearly 6% overall bleeding rate

Nearly 6% overall bleeding rate

Overall, 5.9% of patients had a significant bleeding-related event, which included emergency department visits for hematuria, re-admission for hematuria management, or return to the operating room for ongoing bleeding. Compared with the rate in the group that held anticoagulation, the rate of a significant bleeding-related event was about fivefold higher in the group that continued anticoagulation and about threefold higher in the bridged group (15% and 9% vs. 3%; p=.014).

Among the patients who continued anticoagulation, rates of all bleeding-related complication endpoints were higher in the subgroup on non-vitamin K antagonists compared with those on warfarin, although none of the differences achieved statistical significance.

“Our study may have been underpowered to detect statistically significant differences for these comparisons, but the higher rate of bleeding-related complications among patients on non-vitamin K antagonists is noteworthy considering these agents are being increasingly prescribed for anticoagulation compared with warfarin,” Dr. Ingimarsson said.

There were some significant differences between the three study groups in their baseline and operative characteristics. Patients on bridged anticoagulation had the highest mean Charlson Comorbidity Index and mean ASA score, and no patients who continued anticoagulation had ureteral dilation performed. In addition, some baseline and operative characteristics were associated with a significantly higher rate of various bleeding outcomes. Due to the small number of events overall, however, it was not possible to conduct a multivariate analysis to control for potential confounders and determine whether continuing anticoagulation or any of the other factors independently predicted bleeding risk.

“However, the group that continued on anticoagulation was very similar compared with the held anticoagulation group other than for the fact that ureteral dilation was not performed in any patients continuing on anticoagulation. We expect surgeons chose not to perform ureteral dilation in the patients continuing on anticoagulation as a matter of caution, and that probably limited the bleeding complication rate,” Dr. Ingimarsson told Urology Times.

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