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  • Review Article
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Thromboprophylaxis and bleeding diathesis in minimally invasive stone surgery

Nature Reviews Urology volume 11, pages 51–58 (2014)Cite this article

Subjects

Key Points

  • Urologists frequently encounter patients with multiple and complex comorbidities who are on regular antiplatelet or anticoagulation medication or who have a chronic bleeding disorder

  • Decisions regarding perioperative and postoperative thromboprophylaxis in patients undergoing urological surgery, particularly stone surgery, are frequently met with confusion

  • Systematic thromboprophylaxis with low molecular weight heparin as a subcutaneous injection once daily, until complete mobilization, is recommended in high-risk patients and when lithotripsy is not day case surgery

  • Patients undergoing stone surgery should be stratified into groups according to the risk of bleeding and the risk of thromboembolic events for the respective intervention (high, intermediate and low risk)

  • Bridging therapy should be directed by the inherent risk of bleeding in individual patients, according to American College of Chest Physicians guidelines, as should perioperative treatment with antiplatelet agents

  • A decision algorithm for each lithotripsy modality according to antithrombotic medication used should help the operating surgeon achieve the fine balance required between patient safety and treatment effectiveness

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.

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Figure 1: Haemostasis involves two principle components, platelets and fibrin, acting in concert to generate a wound-sealing clot.

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Author information

Authors and Affiliations

  1. Endourology and Stones Services, Barts Health NHS Trust, 9th Floor, Royal London Hospital, London, E1 1BB, Whitechapel, UK

    Andreas Bourdoumis, Stefanos Kachrilas, Noor Buchholz & Junaid Masood

  2. Department of Urology, North Devon District Hospital NHS Trust, Barnstaple, EX31 4HX, North Devon, UK

    Theodora Stasinou

  3. 2nd Department of Urology, School of Medicine, University of Athens, Sismanoglio General Hospital, 1 Sismanogleiou Street, Athens, 14578, Greece

    Athanasios G. Papatsoris

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  1. Andreas Bourdoumis
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Contributions

A. Bourdoumis, T. Stasinou and S. Kachrilas researched the data for the article. A. Bourdoumis and T. Stasinou provided a substantial contribution to discussions of the content. A. Bourdoumis wrote the article. A. Bourdoumis, S. Kachrilas, A. G. Papatsoris, N. Buchholz and J. Masood contributed to review and/or editing of the manuscript before submission.

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Correspondence to Andreas Bourdoumis.

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Bourdoumis, A., Stasinou, T., Kachrilas, S. et al. Thromboprophylaxis and bleeding diathesis in minimally invasive stone surgery. Nat Rev Urol 11, 51–58 (2014). https://doi.org/10.1038/nrurol.2013.278

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