Category: Clinical Stones: Ureteroscopy

MP29-2 - The effect of pre-stenting on complications after ureteroscopy in patients on anticoagulation or antiplatelet therapy.

Sun, Sep 23
2:00 PM - 4:00 PM

Introduction & Objective :

The American Urological Association guidelines state that continuing anticoagulation (AC) and antiplatelet (AP) agents during ureteroscopy (URS) is safe. However, a single institution study has suggested that pre-placement of a ureteral stent (pre-stenting) may decrease bleeding-related complications (1). Therefore, using a multi-institutional retrospective study, we sought to determine whether pre-stenting in patients on AP or AC reduced URS bleeding-related complications.


Methods :

We identified 8614 URS procedures performed across three institutions from April 2010 through September 2017. Records were retrospectively reviewed to identify AC and/or AP use and characterize intraoperative and 30-day postoperative complications. A total of 293 patients were identified who were taking AC (warfarin, dabigatran, apixaban, rivaroxaban, any bridging with enoxaprin or heparin) or AP (aspirin, clopidogrel, aspirin and ticagrelor) or both. Complications included intraoperative bleeding (poor visualization leading to prolonged operative time or termination of the case), postoperative hematuria, Emergency Department visit, hospital readmission, unplanned reoperation, phone calls, and other 30-day complications (including infections, flank pain, urinary retention).


Results :

Of the 293 identified procedures, 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-pre-stent, p=0.6).  Pre-stented patients did have a significantly lower likelihood of requiring an unplanned reoperation for stone removal (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 between patients who were pre-stented versus non-pre-stented.


Conclusions : In this multi-institutional study we found that pre-stenting before URS does not reduce overall (composite) risk of bleeding complications.  However, pre-stenting appeared to benefit patients on AP therapy. This data appears to contradict prior literature and necessitates prospective studies to clarify the role of pre-stenting for URS.

References:
1. Westerman ME, Scales JA, Sharma V, et al. Urology. 2017;100:45-52.

Seth K. Bechis

Assistant Professor
UC San Diego Department of Urology
San Diego, California

Seth Bechis, MD, MS, is a urologist who cares for patients with diseases of the urinary tract, including kidney stones, benign prostatic hyperplasia (BPH) or enlarged prostate, and men’s health issues. As member of the comprehensive Kidney Stone Center at UC San Diego Health, he has a special interest in advanced surgical treatment, medical prevention and research on kidney stone disease. He also performs advanced procedures for BPH as well as robotic surgery.

Dr. Bechis completed fellowship training in laparoscopy/robotics and endourology at UC San Diego School of Medicine, and residency training at Harvard Medical School, Massachusetts General Hospital. He earned his medical degree from the University of California, San Francisco School of Medicine and holds additional Master of Science training in biomedical research, also from UCSF. Biomedical research (or experimental medicine) focuses on ways to prevent and treat diseases. It is a key component of the Kidney Stone Center, which offers patients access to clinical trials that examine newly developed therapies and procedures.

Prior to joining UC San Diego Health, Dr. Bechis worked at Massachusetts General Hospital and Harvard Medical School.

Thomas DiPina

Research Associate
UC San Diego Department of Urology
San Diego, California

Luay Alshara

Cleveland, Ohio

Carlos Batagello

Research Fellow
Cleveland Clinic
Cleveland, Ohio

Joshua Heiman

Medical Student
Indiana University School of Medicine
Indianapolis, Indiana

Tim Large

Endourology Fellow
Indiana University School of Medicine
Indianapolis, Indiana

Name: Tim Large MD
Title: Endourology Fellow - Indiana University School of Medicine
Affiliation: IU-Methodist Hospital

I am currently in the second year of fellowship with Drs. Lingeman and Krambeck at Indiana University in Indianapolis, Indiana. We focus on the management of stones and symptomatic benign prostate hyperplasia.

Sri Sivalingam

Staff Urologist
Cleveland Clinic Foundation
Cleveland, Ohio

Sri Sivalingam MD, MSc, FRCSC, is assistant professor of surgery at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. He is Director of the Center for Endourology and Stone Disease at Cleveland Clinic’s Hillcrest Hospital. Originally from Canada, he earned his Bachelors, Masters, and Medical degrees at the University of Toronto, and subsequently completed his urology residency at the University of Manitoba. He then completed a two-year fellowship in advanced Endourology and Minimally Invasive Surgery with a strong focus on urinary stone disease at the University of Wisconsin. He is board certified by both the American Board of Urology and the Royal College of Physicians and Surgeons of Canada.

Dr. Sivalingam's primary surgical, clinical, research and teaching interests include the treatment and prevention of urinary stone disease with several peer reviewed publications in this area. He is the co-director of the endourology research group and the fellowship program in stone disease at the Cleveland Clinic.

Roger L. Sur

Professor of Urology
UC San Diego Department of Urology
San Diego, California

Amy E. Krambeck

Professor
Indiana University School of Medicine
Indianapolis, Indiana