Schnabel MJ et al, 2014: Antiplatelet and anticoagulative medication during shock wave lithotripsy.
Schnabel MJ, Gierth M, Bruendl J, Chaussy CG, Burger M, Fritsche HM
Department of Urology, Caritas St. Josef Medical Center, University of Regensburg , Regensburg, Germany
Introduction: Shock wave lithotripsy (SWL) is the gold standard treatment of most renal and proximal ureter calculi. Severe bleeding complications in SWL are extremely rare. Uncorrected bleeding diathesis might increase the risk and is considered to be an absolute contraindication for SWL. Objective: Perioperative management of anticoagulative and antiplatelet therapy has changed in the recent past. In
particular, low-dose acetylsalicylic acid (ASA) is no longer a contraindication for many surgical procedures. Methods: A systematic Medline/Pubmed literature search of peer-reviewed scientific articles in urology and cardiovascular medicine was performed concerning the management of anticoagulative and antiplatelet medication during SWL. Results: The literature on medically acquired and pathological bleeding diathesis and SWL in general is rare, retrospective, non-standardized and of low quality. Routine cessation of obligatory indicated anticoagulative or antiplatelet medication implies a significant risk for cardiovascular adverse events (CAE). Ureterorenoscopy is recommended in patients with uncorrected bleeding diathesis although this is not based on high level evidence. Conclusion: In patients with obligatory intake of anticoagulative or antiplatelet medication the risk for CAE must be balanced against the SWL-induced bleeding risk. In patients with low-dose
ASA-intake, SWL should be considered as an option instead of being disregarded as an absolute contraindication. Prospective randomized trials designed to define the optimal management of anticoagulants and antiplatelets during SWL are warranted.
J Endourol. 2014 May 23. [Epub ahead of print]
This article should be read and kept in mind by everyone doing SWL therapy to be able to councel patients with antiplatelet or anticoagulation therapy before a therapeutic decision is made.
Knowing this article I would find it extremely difficult to defend an urologist in court in case of a bleeding complication or a cardiovascular complication after SWL with ongoing antiplatelet or anticoagulative medication or any kind of bridging.
In light of this literature survey I do not think that we will ever have “Prospective randomized trials designed to define the optimal management of anticoagulants and antiplatelets during SWL”
I assume that even British urologists will not give an answer to the questions, despite results of a recent study in the UK quoted in this article: “Asked regarding their management of patients taking Clopidogrel, 54 of 297 British urologists (18.2%) indicated that they would perform SWL without suspending administration of the drug. Only 4 (1.6%) reported RHT after SWL (Mukerji G, Munasinghe I, Raza A. 2009. A survey of the peri-operative management of urological patients on clopidogrel. Ann R Coll Surg Engl, 91 (4):313-320).
A carefully done URS - which also carries a renal hematoma risk of 0,4% !! according to the references - seems to be the best option.