Urologic Procedures

Thromboembolic Risks

Assess individual patient and Procedure specific risk factors for thromboembolism. PTE is one of the most common causes of non-surgical death in patients undergoing Urologic surgery.

Some form of DVT prophylaxis (including early ambulation and IPC) should be considered in all patients undergoing Urologic surgery. To assess risk, both the patient characteristics and the inherent risk factors of the procedure should be considered.

Higher risk patients:

  • Immobility
  • Trauma
  • Malignancy
  • Prior history of DVT
  • Estrogen use
  • Pregnancy
  • Obesity
  • Smoking
  • Advanced age
  • Varicose veins.

Bleeding Risks

The venous anatomy of the prostate is an important source of hemorrhage in prostate related procedures. Bleeding may also be affected by the presence of endogenous fibrinolytic molecules in the urine. Bleeding complications after urologic procedures depends on the procedure, with high rate of bleeding after TURP, though serious bleeding complications are infrequent. Hemorrhage may occur within several weeks of surgery.

Minor bleeding complications are common in patients undergoing a prostate biopsy. Postoperative bleeding is better tolerated if the bleeding site can be directly observed and compressed.

Higher risk patients:

  • Patients with underlying hematological diseases
  • Liver disease
  • Renal failure or prior surgical bleeding
  • Malignancy

General Recommendations for Pre-Procedure Warfarin Management

  • Warfarin is generally held for 5 days prior to prostate biopsy/surgery, lithotripsy. Restart of warfarin often delayed after procedure based on post-procedure bleeding.
  • No need to hold warfarin for surveillance cystoscopy. If biopsy is expected or planned, hold warfarin 3-5 days prior to procedure.
  • For vasectomy, keep INR near 2.0 to minimize bleeding.

 

References

Krane LS, Laungani R, Satyanarayana R, Kaul S, Bhandari M, Peabody JO, Menon M. Vattikuti. Robotic-assisted radical prostatectomy in patients receiving chronic anticoagulation therapy: role of perioperative bridging. Urology. 2008 Dec;72(6):1351-5.

Daniels PR. Therapy Insight: management of urology patients taking long-term warfarin anticoagulation therapy. Nat Clin Pract Urol. 2005 Jul;2(7):343-50.

 

Special thanks to Michael Albo, MD for his expert guidance.