Alathel AH. et al., 2019: The New/Novel Oral Anticoagulants and Their Impact on Patients Being Considered for Shock Wave Lithotripsy: The Findings of an International Survey of the Endourological Society
Alathel AH, Nott L, Bjazevic J, Chew BH, Pace KT, Razvi H.
Division of Urology, Department of Surgery, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.
King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
Division of Urology, Department of Surgery, Western University, London, Canada.
Department of Urological Sciences, University of British Columbia, Vancouver, Canada.
Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada.
INTRODUCTION: Although general guidelines exist directing the management of new/novel oral anticoagulants (NOACs) in the perioperative period for open/endoscopic procedures, no consensus exists for those patients being considered for shock wave lithotripsy (SWL). In order to gauge current practice, we administered a survey to the international endourological community. METHODS: A web-based survey was sent to current Endourological Society members. Respondents were asked whether they would consider SWL in patients receiving NOACs; and if they used SWL how these agents were managed perioperatively. Respondents were also asked which physicians in the patients' circle of care managed the discontinuation and reinstitution of the drugs. RESULTS: There were 165 respondents from 27 countries. 92.7% of urologists had access to SWL but only 53.4% indicated they would offer SWL to patients receiving NOACs. Among these urologists, 63.3% relied on internal medicine/hematology/cardiology colleagues to counsel patients on the discontinuation of NOACs pre-treatment, while the majority (36,7 %) handled the resumption guidance themselves. There was wide variability in the management of NOACs pre-lithotripsy, with discontinuation varying from 2-7 days. Resumption was more consistent, ranging from 1-2 days or when hematuria resolved. None of the respondents reported knowledge of adverse effects such as perinephric hematomas or cardiovascular morbidity. CONCLUSIONS: A large percentage of globally surveyed endourologists do not offer SWL to patients who are taking NOACs. Among those that do offer SWL, there appears to be a lack of consensus on optimal duration of discontinuation, suggesting a need to establish evidence-based guidance to optimize patient outcomes.
J Endourol. 2019 Feb 22. doi: 10.1089/end.2019.0057. [Epub ahead of print]
“Unfortunately, the literature related to SWL and the risks of bleeding associated with antiplatelet/anticoagulants in general has been considered low quality due to retrospective and non-standardized study designs. Moreover, no publications specifically address SWL and the periprocedural management of NOACs. In fact, despite the absence of specific data, SWL has been classified as a high-risk bleeding procedure.”
The authors are right to state: “Future efforts should focus on establishing specific guidelines regarding the perioperative management of NOAC medications for patients undergoing SWL using the highest level of evidence available.” However unfortunately there is and will be no evidence as no RCTs will be done to find out. “In theory there is no difference between theory and practice. In practice there is.” (Yogi Berra)