Anticoagulation and Antiplatelet Therapy in Urological Practice: ICUD/AUA Review Paper

Comparative Analysis of Diagnostic Accuracy and Complication Rate of Transperineal Versus Transrectal Prostate Biopsy in Prostate Cancer Diagnosis

INTRODUCTION

Transperineal prostate (TP) biopsy has emerged as a substantial alternative to the conventional transrectal (TR) approach for prostate sampling by its ability to sample specific areas of the prostate more effectively. The objective of this review is to conduct a comparative analysis of the current literature regarding diagnostic accuracy, complication rate and clinical outcome of transrectal vs. transperineal approaches in prostate biopsy-naïve patients and in repeated biopsy scenarios.

MATERIALS AND METHODS

An extensive search of the literature in PubMed, Scopus, and Web of Science was conducted between September 2010 and September 2024. We utilized a robust and comprehensive retrieval strategy including phrasing the two approaches as follows: (perineal or transperineal) and (rectal or transrectal).

CONCLUSIONS

The transperineal and transrectal approaches show similar results in the detection of PCa in biopsy-naïve men, similar rates of infection, urinary retention and effectiveness managing biopsy-associated pain. However, in the rebiopsy scenario, the TP approach has demonstrated increased accuracy compared to the TR approach. This has significant implications in decision making and patient counselling.

Optimizing Pharmacotherapy During Implementation of Enhanced Recovery After Surgery (ERAS) in Ambulatory Urologic Oncology Surgery: Narrative Review

Adapting Enhanced Recovery After Surgery (ERAS) protocols to the ambulatory surgery setting is an ongoing need. While all surgical procedures necessitate the need for recovery protocols, urologists looking to perform outpatient surgical oncology procedures must be cognizant of the restrictive discharge criteria for an ambulatory procedure. Furthermore, a surgery being performed in the ambulatory setting should not imply that the procedure is without the risk of morbidity. With this in mind, ERAS protocols are paramount to ensuring optimal surgical outcomes. The individual components of such protocols encompass the perioperative period in its entirety. They include patient education, the stabilization of chronic medical conditions, perioperative nutrition, frailty mitigation, and the management of various postoperative sequalae. This review paper evaluates and summarizes the essential role of pharmacotherapy in ERAS protocols for ambulatory urologic oncology surgery.

Risk of postoperative bleeding and thromboembolic events in anticoagulated patients undergoing transurethral resection of bladder tumors

Background

Transurethral resection of the bladder (TURB) harbors a high-risk for postoperative bleeding, especially in patients requiring anticoagulation. Recently, direct oral anticoagulants (DOACs) have become a popular alternative to vitamin K antagonists (VKAs), though their impact on TURB complications remains unclear.

Objectives

To assess the postoperative complications of TURB from patients taking DOACs and VKAs.

Design

Retrospective cohort study.

Materials and methods

We retrospectively identified anticoagulated patients undergoing a TURB at our institution between 2012 and 2022 and divided them into two groups: whether they received VKA or DOAC. Follow-up of each patient was performed for 3 months. Occurrence and time to event of postoperative bleeding and thromboembolic events were recorded. A multivariable regression analysis was performed to assess risk differences.

Results

A total of 167 patients (11.7%) fulfilled the inclusion criteria, of which 102 patients (61.1%) received a DOAC and 65 patients (38.9%) a VKA. Postoperative bleeding led to re-catheterization in 13 (12.8%) DOAC and 6 (9.2%) VKA patients (p = 0.49) and re-intervention in 7 (6.9%) DOAC and 4 (6.2%) VKA patients (p = 0.86). Blood transfusions were administered to 3 DOAC patients (2.9%), none in the VKA group. No thromboembolic events were reported.

Conclusion

TURB carries low morbidity in anticoagulated patients. Thromboembolic events and the need for blood transfusion are infrequent. No substantial difference between the postoperative bleeding risk of patients receiving DOAC or VKA was found. All bleeding complications occurred within 2 weeks, marking it a potentially safe point in time to restart the OAC thereafter.

Defining the incidence and management of postoperative scrotal hematoma after primary and complex three-piece inflatable penile prosthesis surgery

Scrotal hematoma is a challenging complication of penile prosthesis surgery. We characterize the risk of hematoma formation with implementation of standardized techniques to mitigate hematomas and assess for any associated factors in a large multi-institutional penile implant cohort. This was a retrospective review from February 2018 to December 2020 of all patients who underwent inflatable penile prosthesis implantation at 2 high volume implant centers. Cases were defined as "complex" if they involved revision, salvage with removal/replacement, or were performed with concurrent penile, scrotal or intra-abdominal surgeries. The incidence of scrotal hematoma among primary and complex IPP recipients was measured and modifiable and innate risk factors associated with hematoma formation within the two cohorts were tracked. Of 246 men who underwent penile prosthesis surgery, 194 (78.9%) patients underwent primary implantation and 52 (21.1%) were complex. Although hematoma formers in the complex group had comparable drain outputs to primary patients on postoperative day 0 (66.8cc ± 32.5 vs 48.4 ± 27.7, p = 0.470) and postoperative day 1 (40.3cc ± 20.8vs 21.8 ± 11.3 p = 0.125), hematomas in the complex group had a higher propensity for OR evacuation (p = 0.03). Difference in duration of temporary device inflation between 2 (64, 26%) and 4 weeks (182, 74%) did not contribute to hematoma formation (p = 0.562). The incidence of postoperative hematoma formation in complex cases was 9.6% (5/52) and 3.6% in primary cases (7/194) (HR = 2.61, p = 0.072). Complex IPP surgery performed for revision or with ancillary procedures are more likely to result in clinically significant hematomas that require surgical management, suggesting a need for heightened caution in managing these individuals.

Comparison of perioperative bleeding risk between direct oral anticoagulants in transurethral resection of prostate

OBJECTIVES

To evaluate the perioperative morbidity and mortality associated with direct oral anticoagulants (DOACs) and warfarin for patients receiving transurethral resection of prostate (TURP).

PATIENTS AND METHODS

This was a single-centre, retrospective cohort analysis of patients who underwent TURP for benign prostate hyperplasia from April 2019 to December 2023. The primary objective was to evaluate the perioperative bleeding and thromboembolic risk between anticoagulated (AC) vs no-AC patients. The secondary objective was to evaluate perioperative bleeding and thromboembolic risk between different formulations of DOACs. Patient demographics, prior treatment, prostate size, baseline bleeding risk, and operative details were collected. Bleeding and thromboembolic-related morbidity were captured within a 3-month postoperative period. Perioperative management of AC therapy was recorded, and all patients had their AC therapy withheld. Cohort characteristic between the AC vs no-AC, and DOAC groups were analysed with two-sided t-test, and chi-square test. Further logistic regression analyses were carried out to identified significant variables between the groups. These significant variables were used for adjustment in inverse probability-weighted treatment effect analysis to evaluate bleeding risk.

RESULTS

There were 629 patients in the cohort, and 113 (18%) patients were receiving AC therapy. The AC patients were at 1.6 times statistically significant increased risk of acute bleeding, and 11 times increased risk of prolonged haematuria for >14 days. When compared to apixaban, patients on rivaroxaban conferred a statistically significant increased risk of acute bleeding by 2.21 times. Patients receiving AC therapy had a statistically significant increased risk of stroke in the perioperative setting (no-AC vs AC: 0.4% vs 2.7%, P = 0.01).

CONCLUSION

This is the first study to evaluate risk of bleeding for TURP patients receiving DOACs. The AC patients are more likely to experience haematuria and stroke in the perioperative period despite withholding therapy. Apixaban appears to cause less bleeding-related complications than rivaroxaban.

The efficacy and safety of ureteroscopic lithotripsy and flexible ureteroscopy with continuous anticoagulant or antiplatelet drugs: A multicenter retrospective real-world study

Objective

The objective of this study is to assess the effectiveness and safety of ureteroscopic lithotripsy and flexible ureteroscopy (fURS) for treating patients on anticoagulant (AC) or antiplatelet (AP) medications.

Patients and Methods

The study included 213 patients with urinary stones who underwent ureteroscopic lithotripsy or fURS between January 2019 and October 2022 at the Shanghai Municipal Hospital Urology Specialist Alliance. Among these patients, 15 received AC therapy, 193 received AP therapy, and 5 received both AC and AP therapy. Patients were divided into 3 groups based on the real-world management of antithrombotic drugs: the continuation group (n = 62), the discontinuation group (n = 91), and the discontinuation and bridge heparin group (n = 60). Intraoperative and postoperative outcomes were compared among the 3 groups.

Results

Age, sex, body mass index, stone location, stone size, stone side, and residual fragments were not different among the groups. None of the patients received blood transfusions or had thromboembolic events, emergencies for gross hematuria, significant bleeding-related complications, or unplanned secondary ureteroscopic surgery. The mean duration of hospital stay of the continuation group (3.97 days) was significantly lower than that of the discontinuation group (5.99 days) and the discontinuation and bridge heparin group (5.75 days) (p < 0.001).

Conclusions

Ureteroscopic lithotripsy and fURS can be performed safely and effectively in patients on AC or AP drugs, resulting in reduced duration of hospital stay.

Thromboelastography in Long-Term Antiplatelet Therapy for Patients Diagnosed with Benign Prostate Hyperplasia Undergoing Holmium Laser Enucleation of the Prostate: A Retrospective Study

Objective

To compare low- vs high-power HoLEP effects on coagulation in patients on antiplatelet (AP) therapy via thromboelastography (TEG).

Methods

210 patients was retrospectively analyzed and stratificated into three discrete groups, specifically: Group A (AP therapy, high-power HoLEP, n = 72); Group B (AP therapy, low-power HoLEP, n=73); Group C (no AP therapy, low-power HoLEP, n = 65). Baseline characteristics and coagulation profiles via TEG were compared. Univariate and multivariate analyses were conducted to identify independent risk factors associated with hematuria. Furthermore, parameters such as IPSS, Qmax, post-void residual volume V2 and PSA levels were recorded during 1year follow-up.

Results

No differences in terms of baseline characteristics across all groups. Significant differences were observed in the duration of enucleation, morcellation, bladder irrigation, post-operative catheterization, length of hospital stay and the extent of hemoglobin reduction (F = 54.06, 8.54, 6.68, 9.24, 17.06, 5.97, p < 0.05). No differences were noted in postoperative hematuria, urine retention, transfusion rates, and SUI (x1 2 = 1.082 ; x2 2 = 0.197,; x3 2 = 3.981;x4 2 = 0.816, p > 0.05). Univariate and multivariate analyses revealed that prostate volume emerged as an independent risk factor for hematuria (OR 1.080, 95% CI: 1.007-1.158, p = 0.031). Clinical outcomes including Qmax, IPSS, V2, and PSA demonstrated significant enhancement during 1 year follow-up.

Conclusion

Compared to HP-HoLEP, LP-HoLEP effectively reduces surgical and subsequent processing times, decreases hospital stay duration, and diminishes hemoglobin decline, offering a viable option without discontinuing AP therapy.

Effects of thienopyridine class antiplatelets on bleeding outcomes following robot-assisted radical prostatectomy

This study aimed to assess the effects of thienopyridine-class antiplatelet agents (including ticlopidine, clopidogrel, and prasugrel) on bleeding complications in patients who underwent robot-assisted radical prostatectomy. This cohort study used a database for robot-assisted radical prostatectomy at 23 tertiary centers nationwide between 2011 and 2022. Patients who received thienopyridines (thienopyridine group) were compared with those who received aspirin monotherapy (aspirin group). The primary outcome was the incidence of bleeding complications. High-grade complications were defined as Clavien-Dindo grade III or higher. The risks of these outcomes were evaluated using inverse probability of treatment weighted regression models. The study results demonstrated that thienopyridine therapy was associated with a higher risk of overall bleeding complications (OR: 3.62, 95%CI 1.54-8.49). The increased risks of the thienopyridine group were detected for low-grade bleeding complications (OR: 3.20, 95%CI 1.23-8.30) but not for high-grade bleeding complications (OR: 5.23, 95%CI 0.78-34.9). The increased risk of bleeding complications was not observed when thienopyridine was discontinued (OR: 2.52, 95%CI 0.83-7.70); however, it became apparent when it was continued perioperatively (OR: 4.35, 95%CI 1.14-16.61). In conclusion, thienopyridine increased the incidence of bleeding complications, particularly low-grade bleeding complications, following robot-assisted radical prostatectomy. These bleeding effects emerged when thienopyridine was continued perioperatively.

Is it Safe to Continue Aspirin in Patients Undergoing Percutaneous Nephrolithotomy?

OBJECTIVE

To evaluate peri-operative outcomes in patients on chronic aspirin therapy undergoing percutaneous nephrolithotomy (PCNL), with and without discontinuation of aspirin. Anti-coagulation and anti-platelet therapy are contraindications for PCNL per American Urological Association guidelines due to bleeding risk. However, there is potentially increased cardiovascular risk with peri-procedural aspirin withdrawal.

METHODS

Patients on chronic aspirin undergoing PCNL between January 2014 and May 2019 were retrospectively reviewed and stratified by continued or discontinued aspirin >5 days preoperatively. Hematologic complications, transfusions, and thrombotic complications were assessed with logistic regression model.

RESULTS

Three hundred twenty-five patients on chronic aspirin therapy underwent PCNL-85 continued and 240 discontinued aspirin. There were no significant differences in hemoglobin change, estimated blood loss, transfusions, creatinine change, thrombotic complications, 30-days re-admissions, complications, or 30-day emergency department visits. Patients who continued aspirin had longer length of stay (1.6 vs 1.9 days, P = .03). American Society of Anesthesiologists (ASA) score of 3 (OR 3.2, P = .02, 95% confidence intervals (CI) [1.2-8.4]), ASA score of 4 (OR 4.0, P = .02, 95% CI [1.2-13.1]), Black race, and previous smoking (OR 2.1, P = .02, 95% CI [1.1-3.9]) was associated with continued aspirin. Body mass index ≥30 was associated with aspirin discontinuation (OR 0.9, P = .004, 95% CI [0.9-1.0]). Increased postoperative hematologic complications were associated with additional anticoagulation medication (OR 2.9, P = .04, 95% CI [1.0-4.4]).

CONCLUSION

Continued aspirin use did not increase in postoperative complications in patients undergoing PCNL. Patients who are on additional anticoagulation medication are at risk of hematologic complications.

The Effect of Pre-Stenting on Bleeding-Related Complications Following Ureteroscopy in Patients on Anticoagulation or Antiplatelet Therapy

Introduction: The American Urological Association guidelines state that continuing anticoagulant (AC) and antiplatelet (AP) agents during ureteroscopy (URS) is safe. Through a multi-institutional retrospective study, we sought to determine whether pre-stenting in patients on AP or AC was associated with fewer URS bleeding-related complications. Methods: A series of 8614 URS procedures performed across three institutions (April 2010 to September 2017) was electronically reviewed for AC/AP use at time of URS. Records indicating AC or AP use at time of URS were then manually reviewed to characterize intraoperative and 30-day postoperative (intraoperative bleeding, postoperative hematuria, emergency department visits, hospital readmission, unplanned reoperation, phone calls, and other minor 30-day complications). Results: A total of 293 identified URS procedures were completed on patients on AC/AP therapy-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-prestent, p = 0.6). Pre-stented patients did have a significantly lower likelihood of requiring an unplanned reoperation (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 based on stent status. Conclusions: In this multi-institutional study, we found that pre-stenting before URS was not associated with fewer bleeding complications. However, pre-stenting appeared to be associated with improved outcomes for those patients on AP therapy. These results suggest a need for prospective studies to clarify the role of pre-stenting for URS.

[Prostate Biopsy: General Consideration and Systematic Biopsy]

Korea is rapidly entering into an aging society, and an increasing socioeconomic burden related to prostate cancer is inevitable. Therefore, the need for early detection and accurate diagnosis of prostate cancer is becoming increasingly critical. Ideally, a biopsy should accurately detect cancers using a minimum number of cores. However, as prostate cancer is often indistinguishable on imaging, image-guided targeted biopsies alone are insufficient for diagnosis. After decades of trial and error, the diagnosis of prostate cancer relies heavily on systematic biopsy, which is characterized by random and repetitive core acquisition throughout the gland. This review will provide an overview of the historical aspects of prostate cancer diagnosis. Moreover, the review will also address the general considerations involved in prostate biopsy, and discuss the periprocedural management of the patients.

Bleeding risk in female patients undergoing intravesical injection of onabotulinumtoxinA for overactive bladder: a Danish retrospective cohort study

INTRODUCTION AND HYPOTHESIS

We aimed to examine the risk of bleeding in female patients undergoing intravesical onabotulinumtoxinA (BTX-A) treatments and provide clinical recommendations for the perioperative management of patients on antithrombotic therapy prior to BTX-A treatments.

METHODS

This was a retrospective cohort of Danish female patients, who had their first BTX-A treatment because of an overactive bladder at the Department of Gynecology and Obstetrics, Herlev and Gentofte University Hospital, between January 2015 and December 2020. Data extraction was from an electronic medical journal system. BTX-A, Botox® Allergan was injected in the detrusor at 10-20 sites. Significant bleeding during or after a BTX-A treatment was defined as persistent macroscopic hematuria. Bleeding reporting was based on information obtained from journal notes.

RESULTS

We included 400 female patients, who had a total of 1,059 BTX-A treatments. Median age at first BTX-A treatment was 70 years (IQR 21), and median number of BTX-A treatments was 2 (range 1-11). In total, 27.8% (n=111) received antithrombotic therapy. Within this group, 30.6% and 69.4% were on anticoagulant and antiplatelet therapy. No cases of hematuria were reported in our cohort. We found that no patients stopped their antithrombotic therapy, were bridged, or monitored by International Normalized Ration (INR) levels.

CONCLUSIONS

We suggest that BTX-A treatments might be classified as low-risk procedures. Discontinuation of antithrombotic therapy is not required in the perioperative management of this patient group.

Hemorrhagic Shock After Transrectal Ultrasound-Guided Prostate Biopsy Successfully Treated With Endoscopic Therapy

Prostate cancer is the second cause of cancer-related deaths among men in the United States. Transrectal ultrasound-guided prostate biopsy is the gold standard for diagnosis of prostate cancer. This is a relatively safe procedure, yet bears the small risk of hemorrhage. In rare instances, the bleeding may require emergent endoscopic or radiologic therapy. However, scarce literature exists depicting the appearance of the bleeding lesions and the successful endoscopic therapies used to treat them. In this report, we present a case of a 64-year-old man who developed massive bleeding after transrectal ultrasound-guided prostate biopsy that was successfully treated with epinephrine injection and endoscopic hemoclipping.

Ureteroscopic and flexible ureteroscopic lithotripsy: continuation or discontinuation of anticoagulant or antiplatelet drugs? A Chinese survey among urologists

PURPOSE

To evaluate the management of antithrombotic drugs made by different urologists before ureteroscopic lithotripsy and flexible ureteroscopy in stone patients undergoing active anticoagulant or antiplatelet therapy.

METHODS

A survey was distributed to 613 urologists in China, which included personal work information and views on the management of anticoagulants (AC) or antiplatelet (AP) drugs during the perioperative period of ureteroscopic lithotripsy (URL) and flexible ureteroscopy (fURS).

RESULTS

20.5% of urologists believed that AP drugs could be continued and 14.7% believed that AC drugs could be continued. 26.1% of the urologists who participated in more than 100 ureteroscopic lithotripsy or flexible ureteroscopy surgeries each year believed that AP drugs could be continued and 19.1% believed that AC drugs could be continued, compared with 13.6% (P < 0.01) and 9.2% (P < 0.01) of the urologists who performed less than 100 surgeries. Among the urologists with more than 20 cases undergoing active AC or AP therapy per year, 25.9% thought that AP drugs could be continued and 19.7% thought that AC drugs could be continued, compared with 17.1% (P = 0.008) and 11.5% (P = 0.005) of the urologists with less than 20 cases.

CONCLUSION

The decision on the continuation of AC or AP drugs before ureteroscopic and flexible ureteroscopic lithotripsy should be individualized. The experience in URL and fURS surgeries and in dealing with patients under AC or AP therapy is the influencing factor.

Pro-Con Debate: Are Patients With Coronary Stents Suitable for Free-Standing Ambulatory Surgery Centers?

With increasing implantation of coronary artery stents over the past 2 decades, it is inevitable that anesthesiologists practicing in the outpatient setting will need to determine whether these patients are suitable for procedures at a free-standing ambulatory surgery center (ASC). Appropriate selection of patients with coronary artery stents for a procedure in an ASC requires consideration of factors that affect the balance between the risk of stent thrombosis due to interruption of antiplatelet therapy and the thrombogenic effects of surgery, and the risk of perioperative bleeding complications that may occur if antiplatelet therapy is continued. Thus, periprocedure care of these patients presents unique challenges, particularly for extensive surgical procedures that are increasingly scheduled for free-standing ASCs, where consultation and ancillary services, as well as access to percutaneous cardiac interventions, may not be readily available. Therefore, the suitability of the ambulatory setting for this patient population remains highly controversial. In this Pro-Con commentary, we discuss the arguments for and against scheduling patients with coronary artery stents in free-standing ASCs.

International Alliance of Urolithiasis guideline on retrograde intrarenal surgery

OBJECTIVES

To set out the second in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis that concerns retrograde intrarenal surgery (RIRS), with the aim of providing a clinical framework for urologists performing RIRS.

MATERIALS AND METHODS

After a comprehensive search of RIRS-related literature published between 1 January 1964 and 1 October 2021 from the PubMed database, systematic review and assessment were performed to inform a series of recommendations, which were graded using modified GRADE methodology. Additionally, quality of evidence was classified using a modification of the Oxford Centre for Evidence-Based Medicine Levels of Evidence system. Finally, related comments were provided.

RESULTS

A total of 36 recommendations were developed and graded that covered the following topics: indications and contraindications; preoperative imaging; preoperative ureteric stenting; preoperative medications; peri-operative antibiotics; management of antithrombotic therapy; anaesthesia; patient positioning; equipment; lithotripsy; exit strategy; and complications.

CONCLUSION

The series of recommendations regarding RIRS, along with the related commentary and supporting documentation, offered here should help provide safe and effective performance of RIRS.

Effect of continued perioperative antithrombotic therapy on bleeding outcomes following laparoscopic nephrectomy and nephroureterectomy

INTRODUCTION

In this study, we aimed to assess the impact of perioperative continuation of antithrombotic therapy on bleeding and complications in patients undergoing laparoscopic radical nephrectomy (LRN) and nephroureterectomy (LNU).

METHODS

This was a retrospective observational study. Patients who underwent LRN and LNU between January 2017 and July 2019 at our institution were recruited. All patients taking antithrombotic agents continued taking them during the perioperative phase (AA group). Surgical outcomes of patients in the AA group were compared with those of patients who were not taking antithrombotic agents (NA group). The primary outcome was the rate of bleeding complications. Secondary outcomes included intraoperative estimated blood loss, transfusion rate, and complications for up to 90 days.

RESULTS

A total of 100 patients were included in the analysis, with 36 and 64 patients assigned to the AA and NA groups, respectively. Patients in the AA group were found to have more severe comorbidities than those in the NA group, with a Charlson Comorbidity Index ≥5, totaling 14 (39%) and 12 (19%), respectively (P = .03). According to surgical outcomes, none of the patients in the AA group required secondary procedures for bleeding complications. Moreover, there were no significant differences between the groups in intraoperative blood loss, hemoglobin deficit, rate of perioperative transfusion, readmission rate, or high-grade complications.

DISCUSSION

These results indicate that perioperative use of antithrombotic agents does not increase the risk of bleeding and can be considered safe during LRN and LNU.

Perioperative Safety of Bladder Hydrodistention in Patients on Antithrombotic Therapy

IMPORTANCE

Bladder hydrodistention (BH) is commonly used to diagnose and treat patients with interstitial cystitis/bladder pain syndrome (IC/BPS), but the overall assessment of bleeding complications for patients taking antithrombotics is lacking.

OBJECTIVES

The study aimed to investigate if perioperative complications were more common in patients with IC/BPS receiving antithrombotic therapy after BH.

STUDY DESIGN

We retrospectively reviewed patients with IC/BPS who underwent hydrodistention during January 2010 and May 2021. Patients with and without antithrombotic drugs were identified and grouped, and their medical records were reviewed. Perioperative data and symptom scores were assessed. The rates of complications in the 2 groups were recorded at 3 months and at the last visit postoperatively.

RESULTS

A total of 387 patients were eventually included. Among them, 29 (7.5%) patients were receiving systemic antithrombotic therapy and 358 (92.5%) were not. Compared with the non-antithrombotic group, patients receiving antithrombotic therapy demonstrated a longer hospital stay (P = 0.033) and a longer catheterization time (P = 0.034). Moreover, the patients with antithrombotic drugs had increased odds of bladder tamponade (odds ratio, 6.76; P = 0.019) and urinary retention (odds ratio, 5.79; P = 0.033) both 3 months postoperatively and last follow-up, but this is not statistically different between patients with and without Hunner lesions. No thromboembolic events were identified during the study period.

CONCLUSIONS

Although a small number of patients with IC/BPS needed anticoagulants, longer hospital stays, longer catheterization time, and increased odds of bladder tamponade and urinary retention were observed in patients receiving antithrombotic therapy. Still, a comprehensive management scheme to balance bleeding complications and antithrombotic agents is needed for individuals.

International Alliance of Urolithiasis (IAU) Guideline on percutaneous nephrolithotomy

The International Alliance of Urolithiasis (IAU) would like to release the latest guideline on percutaneous nephrolithotomy (PCNL) and to provide a clinical framework for surgeons performing PCNLs. These recommendations were collected and appraised from a systematic review and assessment of the literature covering all aspects of PCNLs from the PubMed database between January 1, 1976, and July 31, 2021. Each generated recommendation was graded using a modified GRADE methodology. The quality of the evidence was graded using a classification system modified from the Oxford Center for Evidence-Based Medicine Levels of Evidence. Forty-seven recommendations were summarized and graded, which covered the following issues, indications and contraindications, stone complexity evaluation, preoperative imaging, antibiotic strategy, management of antithrombotic therapy, anesthesia, position, puncture, tracts, dilation, lithotripsy, intraoperative evaluation of residual stones, exit strategy, postoperative imaging and stone-free status evaluation, complications. The present guideline on PCNL was the first in the IAU series of urolithiasis management guidelines. The recommendations, tips and tricks across the PCNL procedures would provide adequate guidance for urologists performing PCNLs to ensure safety and efficiency in PCNLs.

Anticoagulant but not antiplatelet use is associated with haematuria complications after bladder outflow surgery

Objective:

The evidence on the safety of peri-procedural management of more novel antithrombotic medication in the context of a wider option of bladder outflow obstruction (BOO) procedures is limited. We aimed to assess the risk of delayed discharge or readmission (specifically due to haematuria) for all patients undergoing BOO surgery.

Patients and methods:

Prospective identification of all patients undergoing any type of BOO procedure at a single centre between April and December 2019 was performed. Clinical information was obtained from electronic patient records to scrutinise medications, procedure, delayed discharge and readmission within 30 days of surgery due to haematuria.

Results:

Two hundred forty patients were identified. In all, 78.6% (22/28) of patients on anticoagulants were on novel agents. The delayed discharge rate due to haematuria was 0.58% (1/171) in the no antithrombotic group and 7.14% (2/28) in the anticoagulant-only group. Increased age and perioperative anticoagulant therapy predicated delayed discharge. Readmissions due to haematuria were statistically significant with 1.16% (2/171) readmitted with no antithombotics, compared with 14.3% (4/28) of those on anticoagulants ( p ⩽ 0.01).

Conclusion:

Perioperative anticoagulant use is associated with an increased risk of readmission following BOO surgery. Further work is required to help stratify and lower risk, especially with evolving surgical and medical technologies.

Level of evidence:

3b

The International Penile Prosthesis Implant Consensus Forum: clinical recommendations and surgical principles on the inflatable 3-piece penile prosthesis implant

Despite significant scientific advances in the modern three-piece inflatable penile prosthesis implant surgery, it is not without surgical risks and can carry additional cosmetic and psychosocial consequences in poorly selected and consented individuals. To address this problem, an international group of key opinion leaders and high-volume prosthetic surgeons reviewed the current guidelines and clinical evidence, discussed their experiences, and formed a consensus regarding inflatable penile prosthesis surgery. The findings of this consensus panel were presented at the 17th biennial Asia Pacific Society of Sexual Medicine scientific meeting. The experts concluded that proper patient selection, informed consent and strict adherence to safe surgical principles are important to optimize clinical outcomes. Furthermore, most intraoperative complications, if recognized, can be addressed intraoperatively to enable placement of the device at the time of initial surgery. Men with significant corporal fibrosis due to Peyronie's disease, prior prosthesis explantation and priapism, and men who have undergone construction of a neophallus, as well as men who receive concurrent continence surgery, are complex cases requiring additional care and advanced techniques to obtain optimal surgical outcomes. Variability in patient care - in terms of postoperative antibiotic use, pain management, scrotal care, and cycling of the penile prosthesis implant - must be reduced to enable optimization and assessment of outcomes across patient groups.

Imaging of clinically silent rectoprostatic hematoma in MRI guided in-bore prostate biopsy

MR imaging provides awareness for rectoprostatic hematomas as a complication in prostate biopsy. We evaluated the frequency and size of clinically silent bleeding after in-bore MRI-guided prostate biopsy according to documentation in MRI. From 2007 until 2020 in-bore MRI-guided prostate biopsy was performed in 283 consecutive patients with suspected prostate cancer. Interventional image documentation was reviewed for rectoprostatic hematomas and rectal blood collections in this retrospective observational single-center study. Correlation to patient characteristics was analyzed using a multivariable logistic regression model. 283 consecutive patients with a mean age of 66 ± 8 years were included. We diagnosed bleeding complications in 41 (14.5%) of the patients. Significant rectoprostatic hematomas were found in 24 patients. Intra-rectal blood collections were observed in 16 patients and one patient showed bleeding in the urinary bladder. The volume of rectoprostatic hematomas was determined with a median of 7.5 ml (range 2–40 ml, IQR 11.25). We found no correlation between the presence of a rectoprostatic hematoma and malignant findings, patient position in biopsy, number of cores, age, prostate volume nor PSA density (p > 0.05). Rectoprostatic hematomas and rectal blood collections are rare complications after in-bore MR-guided prostate biopsy. MR imaging provides benefits not only for lesion detection in prostate biopsy but also for the control of bleeding complications, which can be overlooked in standard TRUS biopsy. Their significance in pain, erectile dysfunction, and urinary retention remains to be investigated.

Comparison of surgical outcomes after robot-assisted laparoscopic partial nephrectomy between patients continuing and discontinuing aspirin therapy: a Japanese single-centre study

Purpose

To investigate the feasibility of continuing aspirin therapy in patients with renal tumours undergoing robot-assisted laparoscopic partial nephrectomy.

Methods

This retrospective, single-centre study included 106 patients receiving aspirin therapy who underwent robot-assisted laparoscopic partial nephrectomy. The patients were divided into two groups, including those continuing and discontinuing aspirin therapy, and their surgical outcomes were compared. To minimise potential bias, variables including patient and tumour characteristics were adjusted using 1:1 propensity score matching.

Results

Aspirin therapy was used for ischaemic heart disease in 38 patients (36%), cerebrovascular disease in 21 (20%) and others in 47 (44%). Of the 106 patients, 49 were classified to the continuing group and 57 to the discontinuing group. After matching, 24 patients were included in each group. The surgical outcomes, such as changes in the estimated glomerular filtration rate, estimated blood loss, and surgical margin positivity rate, were not significantly different between the groups. In addition, no significant difference was observed in haemoglobin level changes during surgery (continuing: −2.3 g/dl; discontinuing: −1.7 g/dl, P = 0.0676) and haemorrhagic complications (continuing: 8%; discontinuing: 4%, P = 0.500). Multivariate analysis of predictors for haemoglobin level decrease &gt;2 g/dl or haemorrhagic complications showed that, whereas tumour complexity was an independent predictor, continuation or discontinuation of aspirin therapy was not.

Conclusion

The surgical outcomes of robot-assisted laparoscopic partial nephrectomy between patients continuing and discontinuing aspirin therapy were not significantly different, thus suggesting the feasibility of continuing aspirin therapy in selected Japanese patients.

A comparative study of anticoagulant/antiplatelet therapy among men undergoing robot-assisted radical prostatectomy: a prospective single institution study

The present study aimed to assess the safety and efficacy of robot-assisted radical prostatectomy (RARP) in patients with prostate cancer (PCa) under anticoagulant (AC) and/or antiplatelet (AP) therapy, as compared to a control group, and to establish possible differences in postoperative-related morbidity. Data of all consecutive patients submitted to elective RARP for PCa from June 2017 to May 2020 at our institution were prospectively collected. Patients were divided according to the use of AC/AP therapy at surgery. The primary endpoint was to determine differences in 90-day postoperative complication rate, while secondary endpoints included differences in transfusion rate, readmission rate and postoperative oncological outcomes between the two groups. Sub-groups analysis was separately performed for patients undergoing pelvic lymphadenectomy and nerve-sparing procedures. Overall, 822 patients were included in the study and divided in 704 control-group patients (group A) and 118 patients under AC/AP therapy at surgery (group B). Despite the higher estimated blood loss between AC/AP takers and the control group, we did not find a significant difference in terms of 90-day postoperative complication rate, transfusion rate, readmission rate and postoperative oncological outcomes (all p > 0.05). In the cohort of patients undergoing nerve-sparing prostatectomy, a higher rate of complications and transfusions were found. At multivariate analysis, ASA score and ongoing medications were independently associated with complication in this sub-group. RARP can be safely and effectively performed in patients with PCa and ongoing AC/AP agents. Attention has to be paid in candidates for nerve-sparing procedures.

Safety of transrectal ultrasound-guided prostate biopsy in patients receiving aspirin: An update meta-analysis including 3373 patients

BACKGROUND

The management of aspirin before transrectal prostate puncture-guided biopsy continues to be controversial. The conclusions in newly published studies differ from the published guideline. Therefore, an updated meta-analysis was performed to assess the safety of continuing to take aspirin when undergoing a transrectal ultrasound-guided prostate biopsy (TRUS-PB).

METHODS

We searched the following databases for relevant literature from their inception to October 30, 2020: PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Medline, Web of Science, Sinomed, Chinese National Knowledge Internet, and WANGFANG. Studies that compared the bleeding rates between aspirin that took aspirin and non-aspirin groups were included. The quality of all included studies was evaluated using the Newcastle-Ottawa Scale. Revman Manger version 5.2 software was employed to complete the meta-analysis to assess the risk of hematuria, hematospermia, and rectal bleeding.

RESULTS

Six articles involving 3373 patients were included in this meta-analysis. Our study revealed that compared with the non-aspirin group, those taking aspirin exhibited a higher risk of rectal bleeding after TRUS-PB (risk ratio [RR] = 1.27, 95% confidence interval [CI] [1.09-1.49], P = .002). Also, the meta-analysis results did not reveal any significant difference between the 2 groups for the risk of hematuria (RR = 1.02, 95%CI [0.91-1.16], P = .71) and hematospermia (RR = 0.93, 95%CI [0.82-1.06], P = .29).

CONCLUSION

Taking aspirin does not increase the risk of hematuria and hematospermia after TRUS-PB. However, the risk of rectal bleeding, which was slight and self-limiting, did increase. We concluded that it was not necessary to stop taking aspirin before undergoing TRUS-PB.

Office-Based Renal Tumor Biopsy: a Paradigm Change in the Management of a Small Renal Mass?

PURPOSE OF REVIEW

The goal of this paper is to evaluate the use of an office-based renal mass biopsy (RMB), whose feasibility could represent a paradigm shift in clinical practice.

RECENT FINDINGS

Despite the earlier diagnosis of patients with renal masses, the lack of evidence showing a reduction in cancer-specific mortality warrants an examination in treatment practices. RMB is underutilized when compared to biopsy practice for all other neoplasms in every other solid organ (except testis), and the majority of RMB performed are outsourced to interventional radiologists. Performing an ultrasound-guided, office-based RMB is safe, reproducible, and has a meaningful impact on management decisions. The use of percutaneous RMB in clinical practice is growing, and the use of RMB has meaningful impact on management decisions for renal masses. Incorporating ultrasound-guided biopsy of a renal mass into clinical practice is feasible, and in contemporary practice, the urologist has the skill set to perform the procedure reliably, with low morbidity, and with minimal patient discomfort.

The safety of continued low dose aspirin therapy during Complete Supine Percutaneous Nephrolithotomy (csPCNL)

OBJECTIVE

Using anticoagulants and antiplatelet drugs in patients with cardiovascular and medical comorbidities is prevalent. Because of hyper vascular nature of kidney, physicians tend to stop using aspirin before percutaneous nephrolithotomy (PCNL). We have shown the effects of remaining on low dose aspirin in complete supine PCNL (csPCNL).

MATERIAL AND METHODS

The records of 643 patients who underwent csPCNL between 2012 and 2018 were analyzed. Surgical outcomes and complications of patients who were on aspirin therapy and continued it daily (group A) were compared with those not taking aspirin (group B).

RESULTS

Of the 643 csPCNLs, 40 (6%) were performed in patients of group A and the rest of 603 (94%) cases were in group B. The differences between the mean age of groups were statistically significant (60.08±9.45, group A and 48.66±12.32, group B) (P<0.001). Thirty-nine (97.5%) of patients in group A and 548 (90.9%) of group B were stone free by the end of the study which was not statistically significant (P=0.118). The mean operative time between groups A and B (43.20±21.37 and 44.83±16.83, respectively) was not considered significant (P=0.561). There was also no significant difference between 2 groups in any types of complications. Multivariate analysis showed that, perioperative aspirin use was not a significant predictor of transfusion, Hb drop, operative time and other complications.

CONCLUSIONS

Remaining on aspirin does not increase the risk of bleeding, transfusionand other complications. Consequently, continuing aspirin prioperatively in csPCNL appears safe. There is no fear for continuing aspirin in csPCNL.

LEVEL OF EVIDENCE

3.

Comparison between thulium laser vapoenucleation and plasmakinetic resection of the prostate in men aged 75 years and older in a real-life setting: a propensity score analysis

BACKGROUND

Urologists may hesitate to offer transurethral resection of the prostate (TURP) because of increased morbidity in elderly patients.

AIMS

We aimed to compare data on postoperative outcomes of elderly men undergoing bipolar transurethral resection of the prostate (B-TURP) as compared to thulium laser vapoenucleation of the prostate (ThuVEP).

METHODS

We retrospectively reviewed data of all patients aged ≥ 75 years who underwent benign prostatic hyperplasia surgery. Differences between interventions were estimated using propensity scores (PS) to adjust for different patients characteristics.

RESULTS

Between 2017 and 2020, 275 men were included in the analysis. Propensity score retrieved 65 patients in each group. Median age was 78 (4) years in B-TURP group and 78 (6) in ThuVEP group. Median prostate volume was 63 (35) ml and 54 (24) ml in B-TURP group and ThuVEP group, respectively. Only American Society of Anesthesiologists score was significantly higher in ThuVEP group (p = 0.006). Median operation time, catheterization time, and hospital stay were similar in both groups (55 min, 2 and 3 days). Overall, 84.6% of men had no complications, with no significant differences between the groups (p = 0.234). Only one patient in B-TURP group experienced a Clavien grade IIIb complication. By 1 year, there were a statistically significant differences in International Prostate Symptom Score (p = 0.000) in favor of B-TURP group and in maximal urine flow rate (p = 0.000) in favor of ThuVEP group.

DISCUSSION AND CONCLUSIONS

Both procedures showed excellent functional improvements one year after surgery with a low rate of major complications in men aged ≥ 75 years with small-to-medium sized prostates.

Collaborative Review: Factors Influencing Treatment Decisions for Patients with a Localized Solid Renal Mass

CONTEXT

With the addition of active surveillance and thermal ablation (TA) to the urologist's established repertoire of partial (PN) and radical nephrectomy (RN) as first-line management options for localized renal cell carcinoma (RCC), appropriate treatment decision-making has become increasingly nuanced.

OBJECTIVE

To critically review the treatment options for localized, nonrecurrent RCC; to highlight the patient, renal function, tumor, and provider factors that influence treatment decisions; and to provide a framework to conceptualize that decision-making process.

EVIDENCE ACQUISITION

A collaborative critical review of the medical literature was conducted.

EVIDENCE SYNTHESIS

We identify three key decision points when managing localized RCC: (1) decision for surveillance versus treatment, (2) decision regarding treatment modality (TA, PN, or RN), and (3) decision on surgical approach (open vs minimally invasive). In evaluating factors that influence these treatment decisions, we elaborate on patient, renal function, tumor, and provider factors that either directly or indirectly impact each decision point. As current nomograms, based on preselected patient datasets, perform poorly in prospective settings, these tools should be used with caution. Patient decision aids are an underutilized tool in decision-making.

CONCLUSIONS

Localized RCC requires highly nuanced treatment decision-making, balancing patient- and tumor-specific clinical variables against indirect structural influences to provide optimal patient care.

PATIENT SUMMARY

With expanding treatment options for localized kidney cancer, treatment decision is highly nuanced and requires shared decision-making. Patient decision aids may be helpful in the treatment discussion.

Evaluation of a Novel Female Gender Flexible Ureteroscope: Comparison of Flow and Deflection to a Standard Flexible Ureteroscope

Introduction: The advent of single-use disposable flexible ureteroscopes allows for rapid prototyping of novel endoscopes. In this regard, we sought to develop a female-specific ureteroscope, with a shorter working length, to account for the female anatomy. We hypothesized that the shorter, female-specific single-use flexible ureteroscope would engender higher irrigation flow at a given pressure than that of the standard-length ureteroscope. Methods: An in vitro analysis of a standard 65 cm Dornier Axis™ ureteroscope and a shorter, 45 cm female-specific Dornier Axis ureteroscope was performed. All other aspects of the endoscopes were identical. Each ureteroscope was oriented vertically and connected to a Thermedx^® irrigation system to provide uniform pressurized flow. The average flow rate was computed over five, 2-minute periods at pressure settings of 50, 100, 150, and 200 mm Hg. Data were collected with the working channel unoccupied, after placement of a 200 μm (0.6F) holmium laser fiber and after passage of a 1.7F stone basket. The procedure was then repeated with the endoscopes at maximum deflection. Results: The female gender ureteroscope had significantly higher irrigation flow rates than the standard-length ureteroscope under all conditions by an average of 11% (p < 0.02). The highest average percent increase, 17% (p < 0.001), was seen with the 1.7F NGage^® basket in the working channel with the endoscope straight. The maximum angle of deflection was not significantly different between the female gender and standard ureteroscopes with an open working channel (314° vs 315°, p = 0.86), with the 1.7F NGage basket in place (314° vs 315°, p = 0.15), and with the 200 μm holmium laser in place (316° vs 309°, p = 0.09). Conclusions: A 45 cm female gender ureteroscope allows for a higher irrigation flow rate than the standard-length ureteroscope under all test conditions. There is no added benefit with regard to deflection capabilities.

Real-World Experience of Holmium Laser Enucleation of the Prostate with Patients on Anticoagulation Therapy

Background: Holmium laser enucleation of the prostate (HoLEP) is a highly effective procedure for benign prostatic hyperplasia that is size independent and has been recommended for patients necessitating antiplatelet (AP) and anticoagulant (AC) medications. Although HoLEP is feasible in AP/AC patients, there is a lack of published results on real-world outcomes of patients on AP/AC therapy undergoing HoLEP. Patients and Methods: We performed a retrospective review of our institutional HoLEP database of demographics, perioperative and postoperative data, and outcomes of patients on AP and AC therapy compared with none. We also further stratified patients on warfarin compared with direct oral anticoagulants (DOACs). Results: Of 472 patients who underwent HoLEP at our institution from July 2018 to December 2019 with data on AP/AC drugs, 30 (6.3%) were on AP and 65 (17.2%) were on AC. One patient continued AP (3.3%), six patients (9.2%) were bridged on AC, and one patient (1.5%) continued AC through the time of HoLEP at the discretion of the prescribing provider. Preoperatively, only age was significantly different among the three groups (p < 0.001). There were no intraoperative differences. Postoperatively, there was a higher 90-day complication rate in AP and AC groups (p = 0.035), but not an increase in emergency department (ED) visits (p = 0.557) or Clavien ≥3 complications (p = 0.16). In comparison of patients on warfarin with DOAC, there was a lower rate of successful voiding trial (p = 0.009), higher 90-day complications (p = 0.003), and more ED visits (p = 0.003) in the warfarin group. Conclusions: HoLEP is safe and effective for patients who require AP or AC therapy. There is no increase in serious complications or worsened postoperative voiding parameters. Of patients on AC, those on DOAC have better outcomes compared with warfarin.

Risk profiling in patients undergoing penile prosthesis implantation

Penile prosthesis implantation is the gold standard of surgical therapy for patients with medication-refractory erectile dysfunction. However, this umbrella definition includes significant heterogeneity and associated risk profiles that should be candidly discussed and addressed perioperatively. Factors associated with operative success and patient satisfaction are often surgery specific; however, risk profiling via patient selection, preoperative optimization, proper device selection, and intraoperative consideration are highly correlated. Some examples of common risk profiles include comorbidity(ies) such as cardiovascular disease, diabetes mellitus, prior abdominal surgery, Peyronie's disease, and psychological risk factors. Similarly, integration of surgeon- and patient-amenable characteristics is key to decreasing risk of infection, complication, and need for revision. Finally, patient risk profiling provides a unique context for proper device selection and evidence-based intraoperative considerations.

Effect of Continued Perioperative Anticoagulant Therapy on Bleeding Outcomes Following Robot-assisted Radical Prostatectomy

OBJECTIVE

To assess the impact of continued perioperative anticoagulant drug administration on bleeding and complications in patients undergoing robot-assisted radical prostatectomy.

METHODS

Between January 2014 and January 2020, 620 patients with prostate cancer underwent robot-assisted radical prostatectomies and were retrospectively reviewed. Fourteen patients who discontinued antithrombotic therapy were excluded. Among the 606 included patients, 31 continued anticoagulant therapy during the perioperative phase (anticoagulant group). The anticoagulant group outcomes were compared with those of patients who continued clopidogrel and prasugrel (thienopyridine group = 13), aspirin monotherapy (aspirin group = 61), and no chronic antithrombotic agent (control group = 501). The primary outcome was the incidence of bleeding complications requiring transfusion, additional intervention, or readmission. Secondary outcomes were the incidence of thrombotic complications, estimated blood loss, and overall complication rates.

RESULTS

Among the 31 patients in the anticoagulant group, 20 (65%) used directed oral anticoagulants, 11 (35%) used warfarin, and 5 used combined aspirin. Only 1 (3%) patient in the anticoagulant group required postoperative transfusion, and none required additional interventions or readmission. No significant differences were detected between the anticoagulant and other groups (anticoagulant vs thienopyridine, aspirin, and control groups) regarding bleeding complications (3% vs 8%, P = .51; 0%, P = .34; 0.4%, P = .17, respectively), thrombotic complications (3% vs 0%, P = .70; 2%, P = .56; 0.2%, P = .11, respectively), estimated blood loss (200 vs 100 mL, P = .63; 175 mL, P = .64; 165 mL, P = .74, respectively), or other high-grade complications (6% vs 0%, P = .49; 2%, P = .26; 3%, P = .24, respectively).

CONCLUSION

Perioperative continuation of anticoagulant use is feasible for patients undergoing robot-assisted radical prostatectomy.

Risks and complications of robot-assisted radical prostatectomy (RARP) in patients receiving antiplatelet and/or anticoagulant therapy: a retrospective cohort study in a single institute

The objective of the study was to evaluate the risk of bleeding complications in patients undergoing robot-assisted radical prostatectomy (RARP) while taking antiplatelet (AP) and/or anticoagulant (AC) agents. We analyzed the data of 334 patients undergoing RARP from May 2015 to May 2019. Patients were categorized into AP, AC, and control groups; the bleeding complications were compared among them. The end points were the estimated blood loss, decrease in hemoglobin level, and bleeding complications. The patient characteristics did not differ significantly among groups, with the exception of ASA scores, which were significantly higher in the AP and AC groups vs. the control group. The estimated blood loss and hemoglobin decrease were not significantly different between the AP and AC groups and the control group. The frequency of bleeding complications did not differ significantly between the AP and the control groups, but was significantly higher in the AC vs. the control group (4.3% in the AP and 23.5% in the AC group vs. 3.7% in the control group; P = 0.63 and P < 0.01, respectively). There was no significant difference in bleeding complications between the AP continuation (continuation of a single AP) and the AP interruption group or between the heparin bridging and the AC interruption group. All bleeding complications observed in the AC group occurred after resuming AC therapy. RARP can be performed safely with continuation of a single AP, and in patients taking ACs by interrupting these agents or via heparin bridging, without increasing intraoperative bleeding, whereas postoperative bleeding complications may increase after resuming ACs.

Prostate MRI-TRUS fusion biopsy: a review of the state of the art procedure

Prostate cancer is the fourth most common cancer and population-based screening programmes are being increasingly adopted worldwide. Screening-positive patients undergo routine transrectal ultrasound (TRUS)-guided systematic biopsy, which is the current diagnostic standard for prostate cancer. However, systematic biopsies suffer from poor sensitivity, especially for the tumors of the anterior prostate and apex as well as in large volume glands. In the past decade, MRI-guided targeted biopsies have come up, which utilize the multiparametric capability of MRI to target lesions for sampling. MRI/TRUS fusion biopsies combine the advantages of MRI-targeting with that of real-time guidance made possible by TRUS. MRI-TRUS fusion biopsies are being increasingly used in men with high clinical suspicion of prostate cancer who have had prior negative systematic biopsies. A large number of fusion biopsy platforms are currently available commercially. Although the basic workflow is similar, there are differences in the operational software, biopsy routes offered, TRUS acquisition technique, type of correction applied at the time of fusion and in the probe tracking hardware. The article describes the current role and indications of MRI-TRUS fusion biopsy followed by a discussion on the workflow, patient preparation, biopsy procedure and complications.

Thulium Laser Vapoenucleation of the Prostate (ThuVEP) in Men at High Cardiovascular Risk and on Antithrombotic Therapy: A Single-Center Experience

Bleeding is the most common complication of transurethral resection of the prostate and simple open prostatectomy, especially in men on antiplatelet/anticoagulant therapy. The present study aimed to evaluate the safety and effectiveness of thulium laser vapoenucleation of the prostate (ThuVEP) for benign prostatic hyperplasia in patients on chronic antithrombotic medications. Between January 2015 and December 2019, 88 men underwent the procedure under antithrombotic agents in our center. The mean age was 74.7 ± 6.1 years. Median prostate volume was 66.5 mL. Patients on oral anticoagulants were bridged to low-molecular-weight heparin (n = 35). Aspirin (n = 39), clopidogrel (n = 10), and ticlopidine (n = 4) were maintained. Of the patients, 69.3% had an American Society of Anesthesiologists score ≥ 3. Blood loss at 24 h was comparable in all groups. Median catheterization length and postoperative stays were 2 and 3 days respectively. Acute cardiovascular events occurred in 2 patients (2.3%). Of the patients, 4 required prolonged bladder irrigation, 2 required blood transfusions, 1 required a cystoscopy for bleeding control, and 1 required a suprapubic cystostomy for blood clot evacuation. No patients died within 30 days of being discharged. Late complications occurred in 3 (3.8%) patients (1 optical urethrotomy and 1 bladder neck incision for stenosis; 1 acute myocardial infarction). All follow-up visits (1, 6, and 12-month) showed a significant improvement in all urinary parameters compared to baseline. ThuVEP appears to be a feasible surgical option in high-risk patients on antithrombotic regimens, with acceptable postoperative morbidity, good functional outcome, and low incidence of medium-term reoperation rate.

Caprini score and surgical times linked to the risk for venous thromboembolism after robotic-assisted radical prostatectomy

OBJECTIVE

To evaluate the Caprini score as an independent predictor of venous thromboembolism (VTE) in patients undergoing robotic-assisted radical prostatectomy (RARP) and to identify appropriate cut-points for clinical use.

MATERIAL AND METHODS

We performed a retrospective review of patients who underwent RARP for prostate cancer between December 2003 and February 2016. VTE cases developed the condition within 90 days of discharge. The control group was comprised of patients whose RARP most closely preceded and followed each VTE case in time and who were matched on lymph node dissection and surgeon. The Caprini score was calculated for each patient, and the groups were compared on a number of clinical variables. Multiple logistic regression was used to evaluate whether the Caprini score was an independent predictor of VTE. Receiver operating characteristics (ROC) curves were used to establish appropriate clinical cutpoints.

RESULTS

A total of 3719 patients underwent RARP during the study period. A total of 52 (1.4%) of patients met the criteria for cases. Data were available for 97 patients who met the criteria for controls. Multiple logistic regression indicated that the Caprini score and operative time were independently both significant predictors of VTE (p=0.005 and p=0.044, respectively). ROC indicated that the Caprini score showed a significant but moderate relationship to VTE (area under curve [AOC]=0.64; p=0.004). A Caprini score >6 was the best arithmetic balance for sensitivity (61.5; 95% confidence interval [CI]: 47.0-74.7) and specificity (59.8; 95% CI: 49.3-69.6).

CONCLUSION

The Caprini score predicts postoperative VTE in patients undergoing RARP.

Venous thromboprophylaxis in urological cancer surgery

Venous thromboembolism (VTE) represents a major complication of cancer and its treatment, contributing to increased morbidity and mortality. The appropriate choice of thromboprophylaxis method and duration is, therefore, of utmost importance. We conducted an extensive review of the literature concerning VTE in patients undergoing surgery for urological cancers. Special attention was paid to risk factors, different types of surgery (transurethral, pelvic, abdominal-open, laparoscopic and robot-assisted) and different medications used (heparins, vitamin K antagonists and new oral anticoagulants). Original papers, reviews and guidelines were identified in Medline database. The available data were then summarised for the purpose of this article. Venous thromboprophylaxis is obligatory in urological cancer patients undergoing surgical treatment. Unless individual contraindications are recognised, the available guidelines should be followed. The variety of clinical scenarios and patients' comorbidities necessitate cooperation with other specialists (cardiologists, neurologists, etc.) in choosing the optimal management. Thrombosis risk must be carefully weighed against bleeding risk.

Office-based, Minimal-Incision Modified Fenestration Technique for Symptomatic Hydroceles Under Local Anesthesia

OBJECTIVE

To describe a minimal-incision modified fenestration technique (MIMFeT) for symptomatic hydroceles utilizing local anesthesia.

METHODS

A database was maintained for men undergoing in-office MIMFeT for symptomatic hydroceles between June 2015 and August 2018. Following local anesthesia, the hydrocele was sequentially everted through a small upper hemiscrotal incision, excised, and oversewn without delivering the testicle through the wound. Patient demographics and clinical outcomes were subsequently reviewed.

RESULTS

A total of 54 men (median age 67) underwent MIMFeT under local anesthesia for symptomatic hydrocele. Median estimated hydrocele size was 250 mL (IQR 150;500). Medical comorbidities included coronary artery disease (12%), hypertension (43%), diabetes (13%), and current antiplatelet or anticoagulant (44%) use. Six patients (11%) were deemed unsafe for monitored or general anesthesia. About 48 patients had follow-up data available (median 9 months; IQR 2-18). Mild recurrent scrotal swelling occurred in 4 patients (8%) and 9/48 (18%) experienced postoperative complications including hematoma (n = 2), prolonged pain (n = 3), wound infection (n = 2), and partial incisional separation (n = 2). No patient required repeat hydrocelectomy.

CONCLUSION

Our early results suggest that the MIMFeT for management of symptomatic hydroceles can be safely performed in the office setting under local anesthesia, including in those patients who are determined to be unsafe for monitored and general anesthesia.

Perioperative Management of Patients Receiving New Anticoagulants

There is an increased use of oral anticoagulants for the prevention of venous and arterial thrombosis. Vitamin-K antagonists have been used for decades as the main oral anticoagulants but they have the draback a complex therapeutic management, slow onset of action and by a different oral intake caused by dietary vitamin K intake. New non-vitamin K antagonist oral anticoagulants (NOACs) have been developed to overcome the limitations of warfarin. Their management is easier as it requires a fixed daily dose without coagulation monitoring. Although their therapeutic profile is safe, proper attention should be paid in case of unexpected need for the reversal of their coagulation effect and in case a patient needs to have a scheduled surgery. For non-acute cardiac surgery, discontinuation of NOACs should start at least 48 hours prior surgery. Intracranial bleedings associated with NOACs are less dangerous comparing to those warfarin-induced. NOACs need to be stopped ≥24 hours in case of elective surgery for low bleeding-risk procedures and ≥48 hours for high bleeding-risk surgery in patients with normal renal function and 72 hours in case of reduced CrCl < 80. The therapy with NOACs should be resumed from 48 to 72 hours after the procedure depending on the perceived bleeding, type of surgery and thrombotic risks. There are some available NOAC reversal agents acting within 5 to 20 minutes. In case of lack of reversal agent, adequate diuresis, renal replacement therapy and activated charcoal in case of recent ingestion should be considered.

Is it safe to continue antithrombotic agents before prostate biopsy?

Background

Whether antithrombotic agents should be stopped before prostate biopsy is unsettled. We investigated the impact of antithrombotic agents on bleeding complications after prostate biopsy.

Materials and methods

Among the patients who underwent transrectal ultrasound-guided prostate biopsy from June 2006 to December 2013 at Ebina General Hospital, Kanagawa, Japan, 1817 cases were retrospectively assessed. Patients were divided into two groups: those not taking antithrombotic agents (control group) and those taking them (experimental group). The frequency and severity of bleeding complications after the procedure were compared. The severity of bleeding events was graded using the Common Terminology Criteria for Advanced Events vol. 4.0.

Results

Hemorrhagic complications were classified into grades 1 to 3. Patients with complications of Grade 2 and above needed treatment. As for the Grade 1 event, there were no differences between two groups. The frequency of more than Grade 2 bleeding events was 1.7% and 3.5% in the control and experimental group, respectively; the odds ratio was 2.18 (P = 0.039). Grade 3 events occurred in seven patients of the control group (0.5%) and four patients of the experimental group (1.2%).

Conclusions

The present study showed that continuation of antithrombotic agents increased the frequency of hemorrhagic complications requiring intervention. It suggests that attention should be paid to the patients taking antithrombotic agents before prostate biopsy.

Prostate biopsy: when and how to perform

Prostate cancer, unlike other cancers, has been sampled in a non-targeted, systematic manner in the past three decades. On account of the low volume of prostate sampled despite the multiple cores acquired, systematic transrectal (TRUS) biopsy suffered from low sensitivity in picking up clinically significant prostate cancer. In addition, a significant number of cancers of the anterior, lateral peripheral zone, and the apex were missed as these areas were undersampled or missed during this biopsy protocol. Subsequently, the number of cores acquired was increased with special focus given to targeting the previously undersampled areas. These procedures led to an increase in the complication rates as well as detection of more clinically insignificant cancers. The advent of multiparametric magnetic resonance imaging (MRI) and its high intrinsic tissue contrast enabled better detection of prostate cancer. This led to the introduction of MRI-targeted biopsies with either MRI-TRUS fusion or under direct (in-gantry) guidance. MRI-targeted biopsies increased the percentage of positive cores and detection of clinically significant prostate cancers; however, these are expensive, time-intensive, require significant capital investment and operator expertise. This article describes the indications, workflow, complications, advantages, and disadvantages of TRUS-guided biopsy followed by MRI-guided biopsies.