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Stroie FA, Taylor L, Fernandez-Crespo R, Parker J, Carrion R. Patient selection, counseling and preparation for penile prosthesis. Int J Impot Res 2023; 35:609-612. [PMID: 37607962 DOI: 10.1038/s41443-023-00735-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/23/2023] [Accepted: 07/05/2023] [Indexed: 08/24/2023]
Abstract
The penile prosthesis has revolutionized the management of erectile dysfunction and is a mainstay in the treatment of this clinical entity. The goal of proper patient selection and counseling is to achieve a satisfactory outcome for the patient. Most patients receiving a penile prosthesis are satisfied with their outcome, and while the penile prosthesis generally allows for high satisfaction rates, avenues for dissatisfaction can arise. Our aim is to aid the prosthetic urologist in identifying such avenues by discussing what factors can lead to a dissatisfied patient. Even a technically successful surgical outcome in the improperly counseled patient can have negative consequences for the patient and the patient-physician relationship. Satisfaction in the penile prosthesis arena can be variably defined and viewed from different perspectives. As such, establishing a personalized framework of expectation management, even in the patient who poses challenging factors, is paramount in preparation for penile prosthesis implantation.
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Affiliation(s)
- Florian A Stroie
- Department of Urology, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33603, USA
| | - Laura Taylor
- Department of Urology, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33603, USA
| | - Raul Fernandez-Crespo
- Department of Urology, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33603, USA
| | - Justin Parker
- Department of Urology, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33603, USA
| | - Rafael Carrion
- Department of Urology, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33603, USA.
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2
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Moukhtar Hammad MA, Barham DW, Sanford DI, Amini E, Jenkins L, Yafi FA. Maximizing outcomes in penile prosthetic surgery: exploring strategies to prevent and manage infectious and non-infectious complications. Int J Impot Res 2023; 35:613-619. [PMID: 37828138 PMCID: PMC10622320 DOI: 10.1038/s41443-023-00773-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 09/22/2023] [Accepted: 09/29/2023] [Indexed: 10/14/2023]
Abstract
Inflatable Penile Prostheses (IPP) implantation is a surgical treatment for patients desiring definitive treatment for erectile dysfunction. While this procedure has proven to be effective, it also carries its own set of unique risks that need to be carefully considered. The article reviews the current understanding of complications associated with penile prosthetic surgery and provides strategies to mitigate these adverse events. This article covers various aspects of IPP implantation, including the risks of infection, bleeding, injury to nearby structures, glans ischemia, and device malfunction. It also discusses the importance of careful preoperative screening to identify risk factors and the implementation of infection reduction strategies such as antimicrobial prophylaxis, skin prep, and operative techniques. In addition, it emphasizes the need for postoperative vigilance and prompt management of any complications that may arise. Overall, the article provides a comprehensive overview of the risks and strategies for mitigating complications associated with IPP implantation. Our recommendations are given based on the current consensus in the field and highlight the importance of careful planning, attention to detail, and effective communication between healthcare providers and patients. Despite the potential risks, this review underscores the fact that complications following penile prosthesis implantation are relatively rare.
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Affiliation(s)
| | - David W Barham
- Department of Urology, University of California, Irvine, Orange, CA, USA
| | - Daniel I Sanford
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Artificial Intelligence Center at USC Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | | | - Lawrence Jenkins
- Department of Urology, University of California, Irvine, Orange, CA, USA
| | - Faysal A Yafi
- Department of Urology, University of California, Irvine, Orange, CA, USA
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3
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Furrer MA, Abgottspon J, Huber M, Engel D, Löffel LM, Beilstein CM, Burkhard FC, Wuethrich PY. Perioperative continuation of aspirin, oral anticoagulants or bridging with therapeutic low-molecular-weight heparin does not increase intraoperative blood loss and blood transfusion rate in cystectomy patients: an observational cohort study. BJU Int 2022; 129:512-523. [PMID: 34585829 DOI: 10.1111/bju.15599] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/29/2021] [Accepted: 09/14/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To assess if uninterrupted anticoagulant agents' administration affects blood loss and blood transfusion during open radical cystectomy (RC) and urinary diversion. PATIENTS AND METHODS We conducted an observational single-centre cohort study of a consecutive series of 1430 RC patients, between 2000 and 2020. Blood loss was depicted according to body weight and duration of surgery (mL/kg/h), and blood transfusion. The group 'with anticoagulant agents' was considered if surgery was performed with uninterrupted low-dose aspirin (ASS), oral anticoagulants (OAC) with an international normalised ratio (INR) goal of 2-2.5 or bridging with therapeutic low-molecular-weight heparin (LMWH). Outcomes were intraoperative blood loss, blood transfusion rate (separately analysed if administered within 24 h perioperatively or >24 h after surgery) and the 90-day major adverse cardiac events (MACE) rate. We used propensity score (PS)-matching analysis to adjust for imbalances between groups with or without anticoagulant agents. RESULTS The PS-matched median (interquartile range [IQR]) blood loss was 2.10 (1.50-2.94) mL/kg/h in patients with anticoagulant agents vs 2.11 (1.47-2.94) mL/kg/h without anticoagulant agents (Padj > 0.99). The PS-matched blood transfusion rates were 26.2% vs 35.1% (Padj = 0.875) within 24 h perioperatively and 57.0% vs 55.0% (Padj = 0.680) if administered >24 h postoperatively. A sub-analysis of the three different anticoagulant agents could not detect any significance between ASS, OAC, or LMWH. The PS-matched incidence of MACE was 9.1% in the group with anticoagulant agents and 8.1% in those without anticoagulant agents (Padj > 0.99). Limitations include selection bias and retrospective analysis from prospectively assessed data. CONCLUSIONS Perioperative continuation of ASS, uninterrupted OAC with low INR goal or bridging with LMWH had no impact on blood loss and transfusion rate in RC patients. Therefore, there might be no compulsory need for discontinuation of anticoagulant agents.
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Affiliation(s)
- Marc A Furrer
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Janine Abgottspon
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas M Löffel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian M Beilstein
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fiona C Burkhard
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Albisinni S, Diamand R, Mjaess G, Assenmacher G, Assenmacher C, Loos S, Verhoest G, Holz S, Naudin M, Ploussard G, Mari A, Di Maida F, Minervini A, Aoun F, Tay A, Issa R, Roumiguié M, Bajeot AS, Simone G, Anceschi U, Umari P, Sridhar A, Kelly J, Hendricksen K, Einerhand S, Sanchez-Salas R, Colomer A, Quackels T, Peltier A, Montorsi F, Briganti A, Pradere B, Moschini M, Roumeguère T. Continuing acetylsalicylic acid during Robotic-Assisted Radical Cystectomy with intracorporeal urinary diversion does not increase hemorrhagic complications: results from a large multicentric cohort. Urol Oncol 2021; 40:163.e11-163.e17. [PMID: 34580028 DOI: 10.1016/j.urolonc.2021.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/26/2021] [Accepted: 08/23/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate whether continuing the antiplatelet drug acetylsalicylic acid≤100mg (ASA) during Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) increases the risk of peri-and postoperative hemorrhagic complications and overall morbidity. Indeed, guidelines recommend interrupting antiplatelet therapy before radical cystectomy; however, RARC with ICUD is associated to reduced estimated blood loss and blood transfusions compared to its open counterpart. METHODS Data from a multicentric European database were analyzed. All participating centers maintained a prospective database of patients undergoing RARC with ICUD. We identified patients receiving antiplatelet therapy by acetylsalicylic acid ≤100mg. Patients were divided into three groups: those not taking acetylsalicylic acid (no-ASA), those where ASA was continued perioperatively (c-ASA) and those where ASA was interrupted perioperatively (i-ASA). Estimated blood loss and peri-and post-operative transfusions were recorded. Hemorrhagic complications, ischemic, thrombotic and cardiac morbidity was recorded and classified using the Clavien-Dindo score by a senior urologist. RESULTS 640 patients were analyzed. Patients on acetylsalicylic acid were significantly older and had more comorbidities. No significant difference was found for estimated blood loss between no-ASA, c-ASA and i-ASA (280 vs. 300 vs. 200ml respectively; P = 0.09). Similarly, no significant difference was found for intraoperative (5% vs. 9% vs. 11%; P = 0.07) and postoperative transfusion rate (11% vs. 13% vs. 18%; P = 0.17). Higher ischemic complications were noted in the i-ASA group compared to no-ASA and c-ASA (4% vs. 0.6% vs. 1.4%; P = 0.03). On uni and multivariate logistic regression, continuing acetylsalicylic acid was not significantly associated to either major complications or post-operative transfusions. CONCLUSIONS Peri-operative acetylsalicylic acid continuation in RARC with ICUD does not increase hemorrhagic complications. Interrupting acetylsalicylic acid peri-operatively may expose patients to a higher risk of ischemic events.
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Affiliation(s)
- Simone Albisinni
- Department of Urology, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
| | - Romain Diamand
- Department of Urology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Georges Mjaess
- Department of Urology, Hotel Dieu de France, Beirut, Lebanon
| | | | | | - Shirley Loos
- Department of Urology, Cliniques de l'Europe-Saint Elisabeth, Brussels, Belgium
| | | | - Serge Holz
- Department of Urology, CHU Ambroise Paré, Mons, Belgium
| | - Michel Naudin
- Department of Urology, CHU Ambroise Paré, Mons, Belgium
| | - Guillaume Ploussard
- Department of Urology, La Croix du Sud Hospital, Institut Universitaire du Cancer Toulouse - Oncopole, Toulouse, France
| | - Andrea Mari
- Department of Experimental and Clinical Medicine, Unit of Oncologic Minimally-Invasive Urology and Andrology, University of Florence, Careggi University Hospital, Florence, Italy
| | - Fabrizio Di Maida
- Department of Experimental and Clinical Medicine, Unit of Oncologic Minimally-Invasive Urology and Andrology, University of Florence, Careggi University Hospital, Florence, Italy
| | - Andrea Minervini
- Department of Experimental and Clinical Medicine, Unit of Oncologic Minimally-Invasive Urology and Andrology, University of Florence, Careggi University Hospital, Florence, Italy
| | - Fouad Aoun
- Department of Urology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; Department of Urology, Hotel Dieu de France, Beirut, Lebanon
| | - Andrea Tay
- Department of Urology, Saint Georges Hospital, London, UK
| | - Rami Issa
- Department of Urology, Saint Georges Hospital, London, UK
| | - Mathieu Roumiguié
- Department of Urology, Andrology and Renal Transplantation, CHU Rangueil, Paul-Sabatier University, Toulouse Cedex, France
| | - Anne Sophie Bajeot
- Department of Urology, Andrology and Renal Transplantation, CHU Rangueil, Paul-Sabatier University, Toulouse Cedex, France
| | - Giuseppe Simone
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Umberto Anceschi
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Paolo Umari
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Ashwin Sridhar
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - John Kelly
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Kees Hendricksen
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sarah Einerhand
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Anna Colomer
- Department of Urology, Institut Mutualiste Montsouris, Paris, France
| | - Thierry Quackels
- Department of Urology, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Peltier
- Department of Urology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Francesco Montorsi
- Unit of Urology/Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Briganti
- Unit of Urology/Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Marco Moschini
- Unit of Urology/Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Thierry Roumeguère
- Department of Urology, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium; Department of Urology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
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5
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Huynh LM, Osman MM, Yafi FA. Risk profiling in patients undergoing penile prosthesis implantation. Asian J Androl 2020; 22:8-14. [PMID: 31489849 PMCID: PMC6958986 DOI: 10.4103/aja.aja_92_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Linda M Huynh
- Department of Urology, University of California, Irvine Medical Center, Orange, CA 92868, USA
| | - Mohamad M Osman
- Department of Urology, University of California, Irvine Medical Center, Orange, CA 92868, USA
| | - Faysal A Yafi
- Department of Urology, University of California, Irvine Medical Center, Orange, CA 92868, USA
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6
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Kubota M, Matsuoka T, Yamasaki T, Kokubun H, Hagimoto H, Murata S, Makita N, Suzuki I, Abe Y, Tohi Y, Tsutsumi N, Inoue K, Kawakita M. Effect of Continued Perioperative Anticoagulant Therapy on Bleeding Outcomes Following Robot-assisted Radical Prostatectomy. Urology 2020; 148:151-158. [PMID: 33248139 DOI: 10.1016/j.urology.2020.08.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/20/2020] [Accepted: 08/26/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Masashi Kubota
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan.
| | - Takashi Matsuoka
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Toshinari Yamasaki
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Hidetoshi Kokubun
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Hiroki Hagimoto
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Shiori Murata
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Noriyuki Makita
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Issei Suzuki
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Yohei Abe
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Yoichiro Tohi
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Naofumi Tsutsumi
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Koji Inoue
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Mutsushi Kawakita
- Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
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7
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Smelser WW, Jones CP. Management of anticoagulation and antiplatelet agents in the radical cystectomy patient. Urol Oncol 2020; 39:691-697. [PMID: 31928866 DOI: 10.1016/j.urolonc.2019.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/02/2019] [Accepted: 12/10/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Bladder cancer is a disease of the older adult, and management of comorbid conditions requiring anticoagulation (AC) or antiplatelet agents (APA) around the time of radical cystectomy (RC) is a frequent clinical challenge. It is estimated that 10% of adult surgical patients are on chronic anticoagulation medications, and considerations surrounding the perioperative disruption, resumption, and modification or substitution of AC and APA in patients undergoing radical cystectomy are critical for the practicing urologist. METHODS In our report, we performed a comprehensive literature review using PubMed to evaluate all available studies from 1950 to present. Additionally, we reviewed current multidisciplinary guideline papers from the American College of Surgeons, American College of Cardiology, and CHEST Society regarding perioperative management of anticoagulation and antiplatelet agents. RESULTS Our keyword search yielded 35 articles from 1950 to 2019. We identified 16 studies pertaining specifically to evaluation and perioperative management of anticoagulation in patient undergoing RC. Many of the recommendations in this realm are informed by trial data outside the RC population in the general surgical population or general adult population. Current guidelines from the American College of Surgeons, American College of Cardiology/American Heart Association, and CHEST Society inform our recommendations heavily and are summarized in Table 1. CONCLUSIONS Radical cystectomy remains both a mainstay of therapy for patients with muscle-invasive bladder cancer and a morbid procedure. Competing risks of perioperative hemorrhage and thromboembolic events make management of anticoagulation and antiplatelet agents an important and modifiable risk factor. Our review of the current literature highlights the knowledge gap that exists in management of these agents in the radical cystectomy patient. A multi-disciplinary approach to management of this clinical challenge remains a mainstay of treatment.
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Affiliation(s)
- Woodson W Smelser
- Department of Urology, The University of Kansas Health System, Kansas City, KS.
| | - Charles P Jones
- Department of Urology, The University of Kansas Health System, Kansas City, KS
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8
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Wessels F, Kriegmair MC, Oehme A, Rassweiler-Seyfried MC, Erben P, Oberneder R, Kriegmair M, Ritter M, Michel MS, Honeck P. Radical cystectomy under continuous antiplatelet therapy with acetylsalicylic acid. Eur J Surg Oncol 2019; 45:1260-1265. [PMID: 30827801 DOI: 10.1016/j.ejso.2019.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/08/2019] [Accepted: 02/17/2019] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Aim of this study was to analyse the perioperative outcome of patients undergoing radical cystectomy under continuous antiplatelet therapy with acetylsalicylic acid. MATERIALS AND METHODS Using prospectively maintained databases of two departments of urology, we identified 461 consecutive patients who underwent radical cystectomy for bladder cancer (2011-2017). Patients were divided into three groups: 1) on-going antiplatelet therapy with acetylsalicylic acid (n = 50), 2) discontinuing antiplatelet therapy (n = 65) and 3) no antiplatelet therapy (n = 346). Perioperative outcome was compared between the three groups using ANOVA, likelihood ratio or Kruskal Wallis test with post-hoc testing. Uni- and multivariate analyses were performed to identify predictor for perioperative complications and transfusion. RESULTS Group 1 showed an average estimated blood loss of 732 ± 424, group 2 752 ± 488 and group 3 810 ± 544 ml (p = 0.51). There was no significant difference in transfusion rate (44% in group 1, 45% and 39% in groups 2 and 3, p = 0.63). Severe complications occurred in 26%, 15% and 15% in groups 1-3 (p = 0.19). Ischemic complications were more often observed in group 1 (n = 4, 8%) and 2 (n = 5, 8%) than group 3 (n = 7, 2%), p = 0.02. 90-day readmission (n = 99, 22%) and mortality rate (n = 10, 2.2%) were low and did not show any significant differences between the groups. In uni- and multivariate analysis ongoing therapy with acetylsalicylic acid was no independent risk factor for transfusion or severe complications. CONCLUSION Perioperative continuation of therapy with acetylsalicylic acid in radical cystectomy is safe with no difference in intraoperative blood loss, transfusion rate, complications or mortality.
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Affiliation(s)
- F Wessels
- University Medical Centre Mannheim, Urology, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - M C Kriegmair
- University Medical Centre Mannheim, Urology, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - A Oehme
- Clinic for Urology, Munich-Planegg, Germeringer Strasse, Germany
| | - M C Rassweiler-Seyfried
- University Medical Centre Mannheim, Urology, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - P Erben
- University Medical Centre Mannheim, Urology, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - R Oberneder
- Clinic for Urology, Munich-Planegg, Germeringer Strasse, Germany
| | - M Kriegmair
- Clinic for Urology, Munich-Planegg, Germeringer Strasse, Germany
| | - M Ritter
- University Medical Centre Mannheim, Urology, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - M S Michel
- University Medical Centre Mannheim, Urology, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - P Honeck
- University Medical Centre Mannheim, Urology, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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9
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Carneiro A, Cha JD, Baccaglini W, Husain FZ, Wroclawski ML, Nunes-Silva I, Sanchez-Salas R, Ingels A, Kayano PP, Claros OR, Saviano Moran NK, Sotelo R, Lemos GC. Should aspirin be suspended prior to robot-assisted radical prostatectomy? A systematic review and meta-analysis. Ther Adv Urol 2019; 11:1756287218816595. [PMID: 30671139 PMCID: PMC6329037 DOI: 10.1177/1756287218816595] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 11/06/2018] [Indexed: 12/03/2022] Open
Abstract
Background: Low-dose aspirin use has been correlated with an increased risk of bleeding and overall complications in surgical and invasive diagnostic procedures. In this review, our aim was to analyze the current literature on whether robot-assisted radical prostatectomy (RARP) is feasible and safe in patients taking low-dose aspirin perioperatively. Methods: A systematic review was performed identifying a total of 767 studies, published between January 2000 and September 2017, with five of these studies meeting the inclusion criteria for the meta-analysis, totalizing 1481 patients underwent RARP. Patients were divided into two groups: taking aspirin (group A) and those not taking aspirin (group B) perioperatively. Results: There were no significant differences between groups in the overall [group A 10.7% versus group B 15.7%, risk ratio (RR) 0.83; p = 0.45; I2 = 0%] or major complication rates (group A 1% versus group B 3%, RR 0.98; p = 0.98; I² = 0%), rate of cardiovascular events (group A 1.4% and group B 0.5%, RR 2.06; p = 0.24; I2 = 9%), blood loss (group A 278 ml versus group B 307 ml, SMD −0.12; p = 0.91; I2 = 96%), or hospital length of stay [group A 4 days (3–5) and group B 4 days (3–4), SMD −0.09; p = 0.52; I² = 0%]. There was a slightly higher blood-transfusion rate in group A (2.6%) versus group B (1.6%) (RR, 5.05; p = 0.04; I2 = 0%). Conclusion: Continued aspirin use in the perioperative period does not correlate with an increase in surgical morbidity, blood loss, or hospital length of stay. There was a slightly higher blood-transfusion rate in patients taking low-dose aspirin (group A) perioperatively.
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Affiliation(s)
- Arie Carneiro
- Israelita Albert Einstein Hospital, São Paulo, Brazil Discipline of Urology, ABC Medical School, São Paulo, Brazil
| | - Jonathan Doyun Cha
- Israelita Albert Einstein Hospital, São Paulo, Brazil Discipline of Urology, ABC Medical School, São Paulo, Brazil
| | - Willy Baccaglini
- Discipline of Urology - ABC Medical School, Av. Lauro Gomes, 2000 - Anexo II, Vila Sacadura Cabral - Santo André/SP, CEP: 09060-870, Brazil
| | - Fatima Z Husain
- Institute of Urology, University of Southern California, Los Angeles, California, USA
| | - Marcelo Langer Wroclawski
- Israelita Albert Einstein Hospital, São Paulo, Brazil Discipline of Urology, ABC Medical School, São Paulo, Brazil
| | - Igor Nunes-Silva
- Arnaldo Vieira de Carvalho Cancer Institute - IAVC, São Paulo, Brazil
| | | | - Alexandre Ingels
- Department of Urology, Institut Mutualiste Montsouris, Paris, France
| | | | | | | | - René Sotelo
- Institute of Urology, University of Southern California, Los Angeles, California, USA
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10
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A User’s Guide for Surgery Involving the Artificial Urinary Sphincter. Sex Med Rev 2019; 7:167-177. [DOI: 10.1016/j.sxmr.2018.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/12/2018] [Accepted: 10/13/2018] [Indexed: 11/23/2022]
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11
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Coscarella M, Motte S, Dalati MF, Oliveira-E-Silva T, Entezari K, Roumeguere T. New oral anti-coagulation drugs and prostate biopsy: a call for guidelines. Ther Adv Urol 2018; 10:437-443. [PMID: 30574204 PMCID: PMC6295786 DOI: 10.1177/1756287218811037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 10/11/2018] [Indexed: 01/14/2023] Open
Abstract
Background: Prostate biopsy is a rather frequent procedure, mostly performed in outpatient settings. Bleeding complications following this procedure require precise and delicate management of pre-, peri- and post-procedure anti-coagulation treatments. New oral anti-coagulation drugs (NOACs) are increasingly used. However, the management of such treatments is feared and not yet well known to urologists. A protocol for prostate biopsy management of NOACs seems mandatory. Materials and methods: A review of the literature, using Pubmed and Cochrane databases, together with analysis of several medical associations’ recommendations in urology, anaesthesiology, cardiology, oncology and drug safety agency, was performed. Results: There are no recommendations about NOAC management for prostate biopsy available from scientific societies. There is also a lack of specific urological studies. However, several panels of expert recommendations could be helpful in establishing standardized protocols adapted from surgery to prostate biopsy. With the growing use of NOACs, recommendations have shifted to continue anti-coagulant treatment without bridging NOACs for low bleeding risk procedures such as prostate biopsy, in carefully selected groups of patients. Conclusion: Extensive indications coupled with the ease of use of NOACs contribute significantly to the widespread replacement of traditional vitamin K antagonist. Knowing that heparin bridging leads to more bleeding, and in the pursuit of more autonomy and safety, urologists should be able to propose dedicated anti-coagulant management using NOACs adapted to carefully selected patients before the prostate biopsy procedure. Further studies and guidelines specific to the concept of non-bridging for anti-coagulant-requiring patients are mandatory for this routine procedure.
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Affiliation(s)
- Mathieu Coscarella
- Department of Urology, Erasme Hospital, University Clinics of Brussels, Route de Lennik 808, 1070 Brussels, Belgium Department of Urology, CHU St Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Serge Motte
- Department of Vascular Diseases, University Clinics of Brussels, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Mohamad-Fadi Dalati
- Department of Urology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Tania Oliveira-E-Silva
- Department of Urology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Kim Entezari
- Department of Urology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Roumeguere
- Department of Urology, University Clinics of Brussels, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Tamhankar AS, Patil SR, Ahluwalia P, Gautam G. Does Continuation of Low-Dose Aspirin During Robot-Assisted Radical Prostatectomy Compromise Surgical Outcomes? J Endourol 2018; 32:852-858. [DOI: 10.1089/end.2018.0390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Puneet Ahluwalia
- Department of Urooncology, Max Institute of Cancer Care, New Delhi, India
| | - Gagan Gautam
- Department of Urooncology, Max Institute of Cancer Care, New Delhi, India
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13
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Prader R, De Broca B, Chevallier D, Amiel J, Durand M. Outcome of Transurethral Resection of Bladder Tumor: Does Antiplatelet Therapy Really Matter? Analysis of a Retrospective Series. J Endourol 2017; 31:1284-1288. [PMID: 29037064 DOI: 10.1089/end.2017.0587] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Transurethral resection of bladder tumor (TURBT) is considered to be at a moderate or high risk of bleeding during surgical procedure. The number of patients on antiplatelet (AP) drugs has been increasing; we wanted to assess their impact on the outcome of patients undergoing scheduled TURBT. MATERIALS AND METHODS A retrospective assessment of noninferiority of 450 consecutive procedures performed between April 2013 and June 2015 was conducted. Patients were divided in two groups: naive or AP drug users. The primary endpoint was the average length of stay (ALOS). Noninferiority was set at 1 day. A subgroup analysis comparing the acetylsalicylic acid (ASA) group and clopidogrel group to the naive group was performed. Multivariate analysis was performed to find the determinants of a longer ALOS. Chi-square or Fisher tests were used to analyze categorical variables, and Student's or Mann-Whitney tests were used to analyze quantitative variables. RESULTS We included 325 patients who underwent TURBT: 117 received AP drugs (ASA, 85; clopidogrel, 32) and 208 were naive to AP drugs (of whom 117 were consecutively analyzed). The ALOSs were 2.5 days (naive group) and 2.9 days (AP group). The subgroup analysis showed ALOSs of 2.6 days (ASA group) and 3.7 days (clopidogrel group). Clopidogrel therapy (odds ratio = 4.1 [1.7-9.6]) and the duration and depth of resection emerged as determinants of a longer ALOS in multivariate analysis. Perioperative management of AP therapies was achieved according to recommended practices. CONCLUSIONS The ALOS of patients receiving AP drugs was not clinically different from naive patients. This result was identical for patients receiving ASA. However, clopidogrel increased the length of stay, making us question its use in perioperative management.
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Affiliation(s)
- Romain Prader
- 1 Department of Urology and Transplantation, University Hospital of Nice , Nice, France
| | - Bruno De Broca
- 2 Department of Anesthesia, University Hospital of Amiens, Salouel, France
| | - Daniel Chevallier
- 1 Department of Urology and Transplantation, University Hospital of Nice , Nice, France
| | - Jean Amiel
- 1 Department of Urology and Transplantation, University Hospital of Nice , Nice, France
| | - Matthieu Durand
- 1 Department of Urology and Transplantation, University Hospital of Nice , Nice, France
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Masterson TA, Palmer J, Dubin J, Ramasamy R. Medical pre-operative considerations for patients undergoing penile implantation. Transl Androl Urol 2017; 6:S824-S829. [PMID: 29238662 PMCID: PMC5715179 DOI: 10.21037/tau.2017.03.85] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Penile prosthesis surgery has become the standard treatment for patients with erectile dysfunction refractory to medical management. Refinements in the both the surgical technique and device manufacturing have made this a safe and reliable treatment with excellent patient satisfaction. In this review, we will overview the basic medical and pre-operative considerations for patients undergoing penile prosthesis implantation. We intend to provide a simple and practical checklist for the implanter to reference when considering implantation of a penile prosthesis.
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Affiliation(s)
- Thomas A Masterson
- University of Miami Miller School of Medicine department of Urology, Miami, FL 33136, USA
| | - Joseph Palmer
- University of Miami Miller School of Medicine department of Urology, Miami, FL 33136, USA
| | - Justin Dubin
- University of Miami Miller School of Medicine department of Urology, Miami, FL 33136, USA
| | - Ranjith Ramasamy
- University of Miami Miller School of Medicine department of Urology, Miami, FL 33136, USA
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15
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Ito T, Derweesh IH, Ginzburg S, Abbosh PH, Raheem OA, Mirheydar H, Hamilton Z, Chen DY, Smaldone MC, Greenberg RE, Viterbo R, Kutikov A, Uzzo RG. Perioperative Outcomes Following Partial Nephrectomy Performed on Patients Remaining on Antiplatelet Therapy. J Urol 2017; 197:31-36. [DOI: 10.1016/j.juro.2016.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2016] [Indexed: 01/20/2023]
Affiliation(s)
- Timothy Ito
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Ithaar H. Derweesh
- Department of Urology, University of California San Diego School of Medicine, San Diego, California
| | - Serge Ginzburg
- Department of Urology, Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - Philip H. Abbosh
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Omer A. Raheem
- Department of Urology, University of California San Diego School of Medicine, San Diego, California
| | - Hossein Mirheydar
- Department of Urology, University of California San Diego School of Medicine, San Diego, California
| | - Zachary Hamilton
- Department of Urology, University of California San Diego School of Medicine, San Diego, California
| | - David Y.T. Chen
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Marc C. Smaldone
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Richard E. Greenberg
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Rosalia Viterbo
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Alexander Kutikov
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Robert G. Uzzo
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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16
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Packiam VT, Nottingham CU, Cohen AJ, Pearce SM, Shalhav AL, Eggener SE. The Impact of Perioperative Aspirin on Bleeding Complications Following Robotic Partial Nephrectomy. J Endourol 2016; 30:997-1003. [DOI: 10.1089/end.2016.0290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
| | | | - Andrew J. Cohen
- Section of Urology, University of Chicago, Chicago, Illinois
| | - Shane M. Pearce
- Section of Urology, University of Chicago, Chicago, Illinois
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17
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Leavitt DA, Keheila M, Siev M, Shah PH, Moreira DM, George AK, Salami SS, Schwartz MJ, Richstone L, Vira MA, Kavoussi LR. Outcomes of Laparoscopic Partial Nephrectomy in Patients Continuing Aspirin Therapy. J Urol 2016; 195:859-64. [DOI: 10.1016/j.juro.2015.10.132] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2015] [Indexed: 01/20/2023]
Affiliation(s)
- David A. Leavitt
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Mohamed Keheila
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Michael Siev
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Paras H. Shah
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Daniel M. Moreira
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Arvin K. George
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Simpa S. Salami
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Michael J. Schwartz
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Lee Richstone
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Manish A. Vira
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Louis R. Kavoussi
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
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18
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[New oral anticoagulants and prostate biopsy: Which usual precaution should we use?]. Prog Urol 2015; 25:510-5. [PMID: 25957818 DOI: 10.1016/j.purol.2015.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 04/10/2015] [Accepted: 04/11/2015] [Indexed: 11/23/2022]
Abstract
INTRODUCTION In 2013, more than 30,000 prostate biopsies have been performed in France. Bleeding complications are not rare. It imposes meticulous perioperative management in order to avoid them. In a close future, new oral anticoagulants (NOAC) will probably substitute vitamin K antagonist in many indications. The management of these new drugs is not really familiar in urology. The authors have specified it by using a systematic literature search in association to guidelines analysis edited by learned society. METHODS This article is based on a systematic literature search by using Pubmed database and by consulting international learned society of urology, anesthesiology or cardiology and the French National Agency of Drugs Security. RESULTS There was no guidelines edited by urological learned society. A standardized protocol adapted to prostate biopsies has been suggested using French Anesthesiologist and Hemostasian guidelines. The authors recommended stopping the oral anticoagulant treatment 5 days prior the biopsy. A bridge, by using a curative dose of heparin, was required during the preoperative period in order to manage the bleeding risk. It must be stopped 12 hours or 24 hours before biopsy (standard or low molecular weight heparin). Contrary to vitamin K antagonist, the re-initiation of the oral should begin 6-8 hours after procedure. The treatment should not overlap with heparin. The NOAC anticoagulant effect is quickly effective after 2 to 4 hours. The treatment should be re-initiated directly after the biopsy, in the absence of bleeding complications. CONCLUSIONS The perioperative management of new oral anticoagulants seems to be more simple than vitamin K antagonist (VKA) during prostate biopsy. A standardized protocol should be recommended.
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Leavitt DA, Theckumparampil N, Moreira DM, Elsamra SE, Morganstern B, Hoenig DM, Smith AD, Okeke Z. Percutaneous nephrolithotomy during uninterrupted aspirin therapy in high-cardiovascular risk patients: preliminary report. Urology 2014; 84:1034-8. [PMID: 25443896 DOI: 10.1016/j.urology.2014.06.076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 04/11/2014] [Accepted: 06/02/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine the feasibility and safety of performing percutaneous nephrolithotomy (PCNL) in high-cardiovascular risk patients remaining on aspirin therapy. METHODS We retrospectively reviewed all PCNLs performed by 3 fellowship-trained endourologists at a single institution between July 2012 and January 2014. All patients remaining on aspirin for imperative indications through the day of surgery were evaluated for surgical outcomes and thromboembolic events. RESULTS Of 281 PCNL procedures performed during the study period, 16 (5.7%) were performed in 14 patients taking aspirin, uninterrupted, through surgery. Mean surgery time was 66 minutes, mean estimated blood loss was 161 mL, and mean length of hospital stay was 2.8 days. All patients were stone free. There were no intraoperative complications. A total of 5 patients experienced a postoperative complication (n = 4, Clavien grade II; n = 1, Clavien grade IIIa). No patient experienced a perioperative thromboembolic or cardiac event. Three patients required a blood transfusion postoperatively, and none experienced delayed renal bleeding. CONCLUSION PCNL can be performed safely and effectively in high-cardiovascular risk patients continuing aspirin perioperatively. Compared with the potential sequelae of a thromboembolic or cardiac event, PCNL is associated with an acceptably low transfusion rate, and should be considered a viable treatment option for large renal stones in this population.
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Affiliation(s)
- David A Leavitt
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY.
| | - Nithin Theckumparampil
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
| | - Daniel M Moreira
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
| | - Sammy E Elsamra
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
| | - Bradley Morganstern
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
| | - David M Hoenig
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
| | - Arthur D Smith
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
| | - Zeph Okeke
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
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20
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Leyh-Bannurah SR, Hansen J, Isbarn H, Steuber T, Tennstedt P, Michl U, Schlomm T, Haese A, Heinzer H, Huland H, Graefen M, Budäus L. Open and robot-assisted radical retropubic prostatectomy in men receiving ongoing low-dose aspirin medication: revisiting an old paradigm? BJU Int 2014; 114:396-403. [PMID: 24127902 DOI: 10.1111/bju.12504] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess blood loss, transfusion rates and 90-day complication rates in patients receiving ongoing 100 mg/day aspirin medication and undergoing open radical prostatectomy (RP) or robot-assisted RP (RARP). PATIENTS AND METHODS Between February 2010 and August 2011, 2061 open RPs and 400 RARPs were performed. All patients received low-molecular-weight heparin for thrombembolism prophylaxis. Aspirin intake during surgery was recorded in 137 patients (5.5%). Descriptive statistics and multivariable analyses after propensity-score matching for balancing potential differences in patients with and without aspirin medication were used to assess the risk of blood loss above the median in patients undergoing open RP or RARP. RESULTS The median blood loss in the open RP cohort with and without aspirin medication was 750 and 700 mL, respectively, and in the RARP cohort it was 200 and 150 mL, respectively. Within the same cohorts, transfusions were administered in 21 and 8% and 0 and 1% of patients, respectively. The 90-day complication rates in patients with ongoing aspirin medication were 5.8, 4.4, 7.3 and 0% for Clavien grades I, II, III and IV complications, respectively. In multivariable analyses and after propensity-score matching, prostate volume (odds ratio 1.03; 95% CI 1.02-1.04; P < 0.01) but not ongoing aspirin medication achieved independent predictor status for the risk of blood loss above the median. CONCLUSIONS Major surgery such as open RP and RARP can be safely performed in patients with ongoing aspirin medication without greater blood loss. Higher 90-day complication rates were not detected in such patients. Differences in transfusion rates between the groups receiving and not receiving ongoing aspirin medication may be explained by a higher proportion of patients with coronary artery disease in the group receiving ongoing aspirin medication. This comorbidity may result in a higher peri-operative threshold for allogenic blood transfusion.
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Affiliation(s)
- Sami-Ramzi Leyh-Bannurah
- Martini Clinic, Prostate Cancer Center at University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Abstract
With populations ageing and active treatment of urinary stones increasingly in demand, more patients with stones are presenting with an underlying bleeding disorder or need for regular thromboprophylaxis, by means of antiplatelet and other medication. A practical guide to thromboprophylaxis in the treatment of urinary tract lithiasis has not yet been established. Patients can be stratified according to levels of risk of arterial and venous thromboembolism, which influence the requirements for antiplatelet and anticoagulant medications, respectively. Patients should also be stratified according to their risk of bleeding. Consideration of the combined risks of bleeding and thromboembolism should determine the perioperative thromboprophylactic strategy. The choice of shockwave lithotripsy, percutaneous nephrolithotomy or ureteroscopy with laser lithotripsy for treatment of lithiasis should be determined with regard to these risks. Although ureteroscopy is the preferred method in high-risk patients, shockwave lithotripsy and percutaneous nephrolithotomy can be chosen when indicated, if appropriate guidelines are strictly followed.
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22
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Naspro R, Rossini R, Musumeci G, Gadda F, Pozzo LFD. Antiplatelet Therapy in Patients With Coronary Stent Undergoing Urologic Surgery: Is It Still No Man's Land? Eur Urol 2013; 64:101-5. [DOI: 10.1016/j.eururo.2013.01.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/22/2013] [Indexed: 10/27/2022]
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23
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Mortezavi A, Hermanns T, Hefermehl LJ, Spahn DR, Seifert B, Weber D, Brunnschweiler S, Schmid DM, Sulser T, Eberli D. Continuous low-dose aspirin therapy in robotic-assisted laparoscopic radical prostatectomy does not increase risk of surgical hemorrhage. J Laparoendosc Adv Surg Tech A 2013; 23:500-5. [PMID: 23611162 DOI: 10.1089/lap.2013.0013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Withdrawal of oral antiplatelet therapy (OAT) is a major risk factor for stent thrombosis, myocardial infarction, and cerebral strokes. In order to minimize the risk for thrombotic complications, since 2007 robotic-assisted laparoscopic radical prostatectomy (RARP) has taken place under continuous OAT with aspirin at our institution. In this retrospective study we analyzed the risk for perioperative bleeding and surgical outcome after RARP with OAT. PATIENTS AND METHODS All patients who underwent RARP with aspirin OAT at our institution since 2007 were included in this analysis. The OAT group was compared with a group that underwent RARP without OAT, which contained twice the number of patients. Matching of the two groups was performed with regard to the tumor stage and whether a lymph node dissection or nerve-sparing was performed. RESULTS Thirty-eight patients were assigned to the OAT group and 76 to the control group. A difference in the decrease of postoperative hemoglobin concentration was not detectable between the two groups (mean drop of 2.9±1.4 g/dL and 2.9±1.1 g/dL, respectively; P=.93). RARP was completed in all OAT patients without conversion to open surgery. Two of the 38 patients (5.3%) in the OAT group and none in the control group required blood transfusions (P=.11). Equivalent rates of positive surgical margins for pT2 tumors were detected (16% OAT versus 14% control group; P=1.0). No adverse cardiovascular events occurred in either group during the hospitalization. CONCLUSIONS Continued perioperative OAT with aspirin in RARP is safe, feasible, and not associated with increased blood loss.
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Affiliation(s)
- Ashkan Mortezavi
- Department of Urology, University Hospital Zürich, Zürich, Switzerland
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24
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Epstein NE. How much medicine do spine surgeons need to know to better select and care for patients? Surg Neurol Int 2012; 3:S329-49. [PMID: 23248752 PMCID: PMC3520072 DOI: 10.4103/2152-7806.103866] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Accepted: 08/13/2012] [Indexed: 12/13/2022] Open
Abstract
Background: Although we routinely utilize medical consultants for preoperative clearance and postoperative patient follow-up, we as spine surgeons need to know more medicine to better select and care for our patients. Methods: This study provides additional medical knowledge to facilitate surgeons’ “cross-talk” with medical colleagues who are concerned about how multiple comorbid risk factors affect their preoperative clearance, and impact patients’ postoperative outcomes. Results: Within 6 months of an acute myocardial infarction (MI), patients undergoing urological surgery encountered a 40% mortality rate: similar rates may likely apply to patients undergoing spinal surgery. Within 6 weeks to 2 months of placing uncoated cardiac, carotid, or other stents, endothelialization is typically complete; as anti-platelet therapy may often be discontinued, spinal surgery can then be more safely performed. Coated stents, however, usually require 6 months to 1 year for endothelialization to occur; thus spinal surgery is often delayed as anti-platelet therapy must typically be continued to avoid thrombotic complications (e.g., stroke/MI). Diabetes and morbid obesity both increase the risk of postoperative infection, and poor wound healing, while the latter increases the risk of phlebitis/pulmonary embolism. Both hypercoagluation and hypocoagulation syndromes may require special preoperative testing/medications and/or transfusions of specific hematological factors. Pulmonary disease, neurological disorders, and major psychiatric pathology may also require further evaluations/therapy, and may even preclude successful surgical intervention. Conclusions: Although we as spinal surgeons utilize medical consultants for preoperative clearance and postoperative care, we need to know more medicine to better select and care for our patients.
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Affiliation(s)
- Nancy E Epstein
- Clinical Professor of Neurological Surgery, The Albert Einstein College of Medicine, Department of Neurosurgery, Bronx, New York, Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, New York, President, Long Island Neurosurgical Associates, PC, 410 Lakeville Rd Suite 204, New Hyde Park, New York, USA
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