Safety of percutaneous nephrolithotomy in patients on antithrombotic therapy: a review of guidelines and recommendations

With the expanding use of chronic antithrombotic medical management for coronary artery disease, surgeons face the growing challenge of balancing the risks of postoperative bleeding against perioperative cardiovascular events. Percutaneous nephrolithotomy (PCNL) carries a risk of bleeding and the need for transfusion at baseline, which is further increased in patients on anticoagulation and antiplatelet therapy. Broad perioperative recommendations for risk stratification and antithrombotic management exist for surgical patients, however, they are less clear in those undergoing PCNL. In this review we appraise available literature, guidelines and opinions and present a consensus statement forantithrombotic management in patients undergoing PCNL

Percutaneous nephrolithotomy in super obese patients (body mass index \u3e/= 50 kg/m ): overcoming the challenges

OBJECTIVE: To analyse our experience with and the outcomes and lessons learned from percutaneous nephrolithotomy (PCNL) in the super obese (body mass index [BMI] \u3e/=50 kg/m2 ). PATIENTS AND METHODS: In this institutional review board approved study we retrospectively reviewed our PCNL database between July 2011 and September 2014 and identified all patients with a BMI \u3e/= 50 kg/m2 . Patient demographics, peri-operative outcomes and complications were determined. Additionally, we identified a number of special PCNL considerations in the super obese that can maximize safe outcomes. RESULTS: A total of 21 PCNL procedures performed on 17 super obese patients were identified. The mean patient age was 54.8 years, the mean BMI was 57.2 kg/m2 and the mean stone area was 1 037 mm2 . Full staghorn stones were observed in six patients and partial staghorns in four patients. The mean operating time was 106 min and the mean haemoglobin decrease was 1.2 g/dL. The overall stone-free rate was 87%. There were four total complications: two Clavien grade II, one Clavien IIIb and one Clavien IVb. We identified several special considerations for safely preforming PCNL in the suber obese, including using extra-long nephroscopes and graspers, using custom-cut extra long access sheaths with suture \u27tails\u27 secured to easily retrieve the sheath, choosing the shortest possible access tract, readily employing flexible nephroscopes, placing nephroureteral tubes rather than nephrostomy tubes postoperatively, and meticulous patient positioning and padding. CONCLUSION: With appropriate peri-operative considerations and planning, PCNL is feasible and safe in the super obese. Stone clearance was similar to that reported in previous PCNL series in the morbidly obese, and is achievable with few complications

Outcomes of Laparoscopic Partial Nephrectomy in Patients Continuing Aspirin Therapy

PURPOSE: Clinical dilemma surrounds the use of aspirin therapy during laparoscopic partial nephrectomy. Despite reduced cardiac morbidity with perioperative aspirin use, fear of bleeding-related complications often prompts discontinuation of therapy prior to surgery. We evaluate perioperative outcomes among patients continuing aspirin and those in whom treatment is stopped preoperatively. MATERIALS AND METHODS: 430 consecutive cases of laparoscopic partial nephrectomy performed between January 2012 and October 2014 were reviewed. Patients on chronic aspirin therapy were stratified into two groups, on-aspirin and off-aspirin, based on perioperative status of aspirin use. Primary endpoints evaluated included estimated intraoperative blood loss and incidence of bleeding-related complications, major postoperative complications, and thromboembolic events. Secondary outcomes included operative time, transfusion rate, length of hospital stay, readmission rate, and surgical margin status. RESULTS: Among 101 (23.4%) patients on chronic aspirin therapy, antiplatelet treatment was continued in 17 patients (16.8%). One patient in the on-aspirin group developed bleeding postoperatively period requiring angioembolization. Conversely, one myocardial infarction was observed in the off-aspirin cohort. There was no significant difference in incidence of major postoperative complications, intraoperative blood loss, transfusion rate, length of hospital stay, and readmission rate. Operative time was increased with continued aspirin use (181 min vs. 136 min, p=0.01). CONCLUSIONS: Laparoscopic partial nephrectomy is safe and effective among patients on chronic antiplatelet therapy who require perioperative aspirin for cardio-protection. Larger, prospective studies are necessary to discern the true cardiovascular benefit derived from continued aspirin therapy as well better characterize associated bleeding risk