Nefrolitotomía percutánea en pacientes con trastornos de la coagulación: reporte de caso

Objective To report a case of percutaneous nephrolithotomy in patients with protein C and S deficiency. Introduction Patients with protein C and S deficiency have a high risk of thromboembolic events reporting rates of 6% and 8.4%, respectively. Case Report A 43-year-old female patient with a history of protein C and S deficiency with chronic warfarin anticoagulation for deep venous thrombosis (DVT). CT scan with full right staghorn calculi. Enoxaparin was administered bridge therapy. She was taken to right percutaneous nephrolithotomy, access was through the lower calyx. Because it was not possible to access the calculus of the middle and upper calyx it was necessary to perform a second puncture in the upper calyx, leaving the patient free of calculus. Full anticoagulation was resumed at 12 hours postoperatively without associated bleeding. Discussion Patients with protein C and S deficits are at high risk for thromboembolic events. Kefer et al. conducted a study evaluating the efficacy of bridge therapy in patients on NLP, finding that warfarin anticoagulation can be discontinued 5 days earlier and restarted 5 days after the surgical procedure without the need for enoxaparin bridging therapy. Results The protein C and S deficiency corresponds to an entity, with a very low prevalence and conditions the requirement of oral anticoagulants indefinitely. It was possible to perform a surgical procedure without hemorrhagic or thromboembolic complications. Copyright © 2019, Sociedad Colombiana de Urología

Nefrolitotomía percutánea en pacientes con trastornos de la coagulación: reporte de caso

"Objective To report a case of percutaneous nephrolithotomy in patients with protein C and S deficiency. Introduction Patients with protein C and S deficiency have a high risk of thromboembolic events reporting rates of 6% and 8.4%, respectively. Case Report A 43-year-old female patient with a history of protein C and S deficiency with chronic warfarin anticoagulation for deep venous thrombosis (DVT). CT scan with full right staghorn calculi. Enoxaparin was administered bridge therapy. She was taken to right percutaneous nephrolithotomy, access was through the lower calyx. Because it was not possible to access the calculus of the middle and upper calyx it was necessary to perform a second puncture in the upper calyx, leaving the patient free of calculus. Full anticoagulation was resumed at 12 hours postoperatively without associated bleeding. Discussion Patients with protein C and S deficits are at high risk for thromboembolic events. Kefer et al. conducted a study evaluating the efficacy of bridge therapy in patients on NLP, finding that warfarin anticoagulation can be discontinued 5 days earlier and restarted 5 days after the surgical procedure without the need for enoxaparin bridging therapy. Results The protein C and S deficiency corresponds to an entity, with a very low prevalence and conditions the requirement of oral anticoagulants indefinitely. It was possible to perform a surgical procedure without hemorrhagic or thromboembolic complications. Copyright © 2019, Sociedad Colombiana de Urología.

Secondary intrarenal pseudoaneurysm after percutaneous nephrolithotomy: review of the literature and case report

Introducción: El pseudoaneurisma intrarrenal posterior a la nefrolitotomía percutánea (NLP) es una entidad clínica rara, que está presente en menos del 1% de los casos. Se realiza la revisión sistemática de la literatura disponible y la descripción de un caso con pseudoaneurisma intrarrenal secundario a NLP. Materiales y métodos: Presentamos un paciente de 26 años de edad, llevado a NLP izquierda. Después del procedimiento, presenta cuadro clínico de hematuria persistente, anemia e inestabilidad hemodinámica. Por angiografía con tomografía axial computarizada se documenta pseudo aneurisma intrarrenal, por lo que es tratado por radiología intervencionista con embolización selectiva de Histoacryl® al 15%. Conclusiones: El abordaje endovascular se puede considerar hoy por hoy como el estándar de manejo de las complicaciones vasculares de la NLP, con unas altas tasas de éxito y ventajas para el paciente como baja morbilidad y mayor preservación de función renal.Abstract Introduction: The intrarenal pseudoaneurysm after percutaneous nephrolithotomy is a rare clinical entity, and is present in less than 1% of cases. A review is made of the available literature, as well as a case report of a patient with intrarenal pseudoaneurysm after percutaneous nephrolithotomy. Materials and Methods: The case of 26 year-old patient is presented, on whom a left percutaneous nephrolithotomy was performed. The patient had hematuria, anemia, and hemodynamic instability. And therefore an Intrarenal Pseudoaneurysm was detected by CT angiography. The patient was treated with selective Histoacryl® 15% endovascular embolization. Conclusions: The endovascular approach can currently be considered as the standard management of vascular complications of percutaneous nephrolithotomy, with high success rates and advantages for the patient, such as low morbidity, and preservation of renal function

Randomized phase III study of standard systemic therapy (SST) versus standard systemic therapy plus definitive treatment (surgery or radiation) of the primary tumor in metastatic prostate cancer

El tratamiento definitivo del tumor primario se ha reservado tradicionalmente para el tratamiento de cáncer localizado de próstata (PC) pero un número cada vez mayor de estudios sugieren que mejora la sobrevida global (OS) y la sobrevida específica del cáncer (CSS) de hombres con enfermedad metastásica (≥ M1a). El tratamiento definitivo del tumor primario puede provocar un efecto en la biología de la enfermedad que contribuye al mejoramiento en los resultados. Se quiere comparar la sobrevida global en pacientes con cáncer metastásico de próstata que son aleatorizados a terapia sistémica estándar (SST) más tratamiento definitivo del tumor primario versus solo terapia sistémica estándar.Definitive treatment of the primary tumor has traditionally been reserved for the treatment of localized prostate cancer (PC), but an increasing number of studies suggest that it improves the overall survival (OS) and cancer-specific survival (CSS) of men with metastatic disease (≥ M1a). Definitive treatment of the primary tumor may cause an effect on the biology of the disease that contributes to improved outcomes. We want to compare the overall survival in patients with metastatic prostate cancer who are randomized to standard systemic therapy (SST) plus definitive treatment of the primary tumor versus only standard systemic therapy.Especializació

Apixaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: A subgroup analysis of the ARISTOTLE trial

Background: In the ARISTOTLE trial, the rate of stroke or systemic embolism was reduced by apixaban compared with warfarin in patients with atrial fibrillation (AF). Patients with AF and previous stroke or transient ischaemic attack (TIA) have a high risk of stroke. We therefore aimed to assess the efficacy and safety of apixaban compared with warfarin in prespecified subgroups of patients with and without previous stroke or TIA. Methods: Between Dec 19, 2006, and April 2, 2010, patients were enrolled in the ARISTOTLE trial at 1034 clinical sites in 39 countries. 18 201 patients with AF or atrial flutter were randomly assigned to receive apixaban 5 mg twice daily or warfarin (target international normalised ratio 2·0-3·0). The median duration of follow-up was 1·8 years (IQR 1·4-2·3). The primary efficacy outcome was stroke or systemic embolism, analysed by intention to treat. The primary safety outcome was major bleeding in the on-treatment population. All participants, investigators, and sponsors were masked to treatment assignments. In this subgroup analysis, we estimated event rates and used Cox models to compare outcomes in patients with and without previous stroke or TIA. The ARISTOTLE trial is registered with ClinicalTrials.gov, number NTC00412984. Findings: Of the trial population, 3436 (19%) had a previous stroke or TIA. In the subgroup of patients with previous stroke or TIA, the rate of stroke or systemic embolism was 2·46 per 100 patient-years of follow-up in the apixaban group and 3·24 in the warfarin group (hazard ratio [HR] 0·76, 95% CI 0·56 to 1·03); in the subgroup of patients without previous stroke or TIA, the rate of stroke or systemic embolism was 1·01 per 100 patient-years of follow-up with apixaban and 1·23 with warfarin (HR 0·82, 95% CI 0·65 to 1·03; p for interaction=0·71). The absolute reduction in the rate of stroke and systemic embolism with apixaban versus warfarin was 0·77 per 100 patient-years of follow-up (95% CI -0·08 to 1·63) in patients with and 0·22 (-0·03 to 0·47) in those without previous stroke or TIA. The difference in major bleeding with apixaban compared with warfarin was 1·07 per 100 patient-years (95% CI 0·09-2·04) in patients with and 0·93 (0·54-1·32) in those without previous stroke or TIA. Interpretation: The effects of apixaban versus warfarin were consistent in patients with AF with and without previous stroke or TIA. Owing to the higher risk of these outcomes in patients with previous stroke or TIA, the absolute benefits of apixaban might be greater in this population. Funding: Bristol-Myers Squibb and Pfizer. © 2012 Elsevier Ltd

Apixaban versus warfarin in patients with atrial fibrillation

BACKGROUND: Vitamin K antagonists are highly effective in preventing stroke in patients with atrial fibrillation but have several limitations. Apixaban is a novel oral direct factor Xa inhibitor that has been shown to reduce the risk of stroke in a similar population in comparison with aspirin. METHODS: In this randomized, double-blind trial, we compared apixaban (at a dose of 5 mg twice daily) with warfarin (target international normalized ratio, 2.0 to 3.0) in 18,201 patients with atrial fibrillation and at least one additional risk factor for stroke. The primary outcome was ischemic or hemorrhagic stroke or systemic embolism. The trial was designed to test for noninferiority, with key secondary objectives of testing for superiority with respect to the primary outcome and to the rates of major bleeding and death from any cause. RESULTS: The median duration of follow-up was 1.8 years. The rate of the primary outcome was 1.27% per year in the apixaban group, as compared with 1.60% per year in the warfarin group (hazard ratio with apixaban, 0.79; 95% confidence interval [CI], 0.66 to 0.95; P<0.001 for noninferiority; P = 0.01 for superiority). The rate of major bleeding was 2.13% per year in the apixaban group, as compared with 3.09% per year in the warfarin group (hazard ratio, 0.69; 95% CI, 0.60 to 0.80; P<0.001), and the rates of death from any cause were 3.52% and 3.94%, respectively (hazard ratio, 0.89; 95% CI, 0.80 to 0.99; P = 0.047). The rate of hemorrhagic stroke was 0.24% per year in the apixaban group, as compared with 0.47% per year in the warfarin group (hazard ratio, 0.51; 95% CI, 0.35 to 0.75; P<0.001), and the rate of ischemic or uncertain type of stroke was 0.97% per year in the apixaban group and 1.05% per year in the warfarin group (hazard ratio, 0.92; 95% CI, 0.74 to 1.13; P = 0.42). CONCLUSIONS: In patients with atrial fibrillation, apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding, and resulted in lower mortality. Copyright © 2011 Massachusetts Medical Society. All rights reserved