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Goktas C et al, 2016: Does Transient Cessation of Antiplatelet Medication Prior to Shock Wave Lithotripsy Have Any Safety Concern: Evaluation of the Short Term Safety Results.

Goktas C, Sahin C, Cetinel AC, Turkoglu O, Buz A, Erbay E, Eryildirim B, Sarica K.
Department of Urology, Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey.

Abstract

OBJECTIVE: The study aimed to evaluate the true safety of transient cessation of the antiplatelet medication before extracorporeal shock wave lithotripsy (SWL) on bleeding-related complications.
PATIENTS AND METHODS: Forty cases undergoing SWL for renal pelvic stones were included and depending on the use of antiplatelet medication they were divided into 2 groups namely: group 1, cases under antiplatelet medication in whom the medication was stopped before ESWL; and group 2, cases without any antiplatelet medication. Comparative evaluation of patient, stone and treatment-related parameters were done in both groups.
RESULTS: Although microscopic hematuria was present in all cases, the incidence of macroscopic hematuria was higher in cases undergoing antiplatelet medication when compared with the other cases. Regarding the microscopic hematuria again, the mean number erythrocytes per field of analysis was significantly higher in group 1 cases. The mean value of the hematoma size was similar in both groups.
CONCLUSION: Our findings indicate that SWL can be applied safely in patients under antiplatelet therapy following the cessation of medication for a certain period of time. However, among the cases treated with this concept in our study, we clearly observed that the incidence of procedure-related hematoma formation and macroscopic hematuria were more common in such cases than in the normal ones. 

Urol Int. 2016 Jun 14. [Epub ahead of print]

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Comments 1

Hans-Göran Tiselius on Sunday, 11 September 2016 10:14

his report deals with the interesting and highly important issue on how patients with anti-platelet medication should be managed when SWL is planned. The conclusion is that with cessation of anti-platelet treatment “for a limited period of time based on well-established consultation with the responsible physician…”, SWL can be carried out safely. It is further mentioned that this “period of time” without platelet therapy is 7 days. This period is also in line with international recommendation for patients undergoing surgery.

With this information in mind it is of note that compared with patients without anti-platelet medication, the occurrence of macroscopic haematuria was more pronounced and the number of erythrocytes in urine larger in the anti-platelet group. The sizes of the haematoma, at least expressed as surface areas were similar, but in the Group 2 (not previously treated with anti-platelet drugs) only 4 had developed haematoma compared with 11 in Group 1.

It needs, however, to be particularly observed that one patient in Group 1 died as a result of “renal fragmentation”! This serious complication is not mentioned in the Abstract and was obviously considered to be without relevance for the final conclusion. Such an outcome is extremely rare and I have personally not encountered this complication despite an experience of >20 000 SWL-treatments. It is of course difficult to say that this complication was the consequence of increased risk of bleeding, but attention really needs to be paid to this outcome.

In view of the reported findings, the question that should be raised is if cessation of anti-platelet treatment 7 days before SWL is safe enough? I have personally followed the rule of pausing anti-platelet medication 10 days before SWL, based on the assumption that this is a period required for renewal of most thrombocytes. Mortality of 1/20 (5%) gives rise to serious concerns about the safety limit of 7 days.

There are, however, also other aspects (not covered in this report) that need careful evaluation:

Is there any risk of pausing anti-platelet treatment in patients with cardiovascular disease and if so, how can we identify patients at risk?

How can we measure, in a standardized and accurate way, the risk of bleeding in order to find patients at specific risk of bleeding complications during SWL.

his report deals with the interesting and highly important issue on how patients with anti-platelet medication should be managed when SWL is planned. The conclusion is that with cessation of anti-platelet treatment “for a limited period of time based on well-established consultation with the responsible physician…”, SWL can be carried out safely. It is further mentioned that this “period of time” without platelet therapy is 7 days. This period is also in line with international recommendation for patients undergoing surgery. With this information in mind it is of note that compared with patients without anti-platelet medication, the occurrence of macroscopic haematuria was more pronounced and the number of erythrocytes in urine larger in the anti-platelet group. The sizes of the haematoma, at least expressed as surface areas were similar, but in the Group 2 (not previously treated with anti-platelet drugs) only 4 had developed haematoma compared with 11 in Group 1. It needs, however, to be particularly observed that one patient in Group 1 died as a result of “renal fragmentation”! This serious complication is not mentioned in the Abstract and was obviously considered to be without relevance for the final conclusion. Such an outcome is extremely rare and I have personally not encountered this complication despite an experience of >20 000 SWL-treatments. It is of course difficult to say that this complication was the consequence of increased risk of bleeding, but attention really needs to be paid to this outcome. In view of the reported findings, the question that should be raised is if cessation of anti-platelet treatment 7 days before SWL is safe enough? I have personally followed the rule of pausing anti-platelet medication 10 days before SWL, based on the assumption that this is a period required for renewal of most thrombocytes. Mortality of 1/20 (5%) gives rise to serious concerns about the safety limit of 7 days. There are, however, also other aspects (not covered in this report) that need careful evaluation: Is there any risk of pausing anti-platelet treatment in patients with cardiovascular disease and if so, how can we identify patients at risk? How can we measure, in a standardized and accurate way, the risk of bleeding in order to find patients at specific risk of bleeding complications during SWL.
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