Advertisement

Perioperative antithrombotic (antiplatelet and anticoagulant) therapy in urological practice: a critical assessment and summary of the clinical practice guidelines

  • Konstantinos DimitropoulosEmail author
  • Muhammad Imran Omar
  • Athanasios Chalkias
  • Eleni Arnaoutoglou
  • James Douketis
  • Stavros Gravas
Invited Review

Abstract

Purpose

The perioperative management of patients who are receiving antithrombotic (antiplatelet or anticoagulant) therapy and require urologic surgery is challenging due to the inherent risk for surgical bleeding and the need to minimize thromboembolic risk. The aim of this review is to assess the quality and consistency of clinical practice guidelines (CPGs) and clinical practice recommendations (CPRs) on this topic, and to summarize the evidence and associated strength of recommendations relating to perioperative antithrombotic management.

Methods

A pragmatic search of electronic databases and guidelines websites was performed to identify relevant CPGs/CPRs. The AGREE II (Appraisal of Guidelines for REsearch and Evaluation) instrument was used to assess the methodological quality and integrity of the CPGs.

Results

The CPGs provided by the European Association of Urology (EAU), the American College of Chest Physicians (ACCP) and the European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA), and the CPRs provided by the International Consultation on Urological Disease (ICUD)/American Urologic Association (AUA) were retrieved and reviewed. The 3 CPGs were critically assessed using the AGREE II instrument. Inconsistent recommendations were provided based on the indication for antithrombotic medication, the antiplatelet/anticoagulant agent and the type of urological procedure. Based on the AGREE II tool for CPG assessment, the EAU CPGs scored higher (83.3 points) compared to the ESC/ESA (75 points) and ACCP CPG (66.7 points).

Conclusion

The perioperative management of antithrombotic therapy in urological patients is potentially challenging but inconsistent CPG of varying quality may create uncertainty as to best practices to minimize thromboembolic and bleeding risk.

Keywords

Antiplatelet Anticoagulant Antithrombotic Urology Urological Perioperative Surgery Guidelines 

Notes

Author contribution

KD: protocol/project development, data collection or management, data analysis, and manuscript writing/editing. MIO: protocol/project development, data collection or management, data analysis, and manuscript writing/editing. AC: data collection or management and manuscript writing/editing. EA: data collection or management and manuscript writing/editing. JD: protocol/project development, data collection or management, and manuscript writing/editing. SG: protocol/project development, data collection or management, and manuscript writing/editing.

Compliance with ethical standards

Conflict of interest

No financial conflicts of interest. K. Dimitropoulos is a Senior Associate of the EAU Guidelines Office and a member of the EAU Guidelines Office Urethral Strictures panel, M.I. Omar is the EAU Guidelines Office Methodology Supervisor, S. Gravas is the Chair of the EAU Guidelines Office Male LUTS panel and J. Douketis is the first author of the ACCP Guidelines publication.

Human animals rights

Not applicable.

Informed consent

Not applicable.

References

  1. 1.
    Holbrook A, Schulman S, Witt DM et al (2012) Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest 141:e152S–e184S.  https://doi.org/10.1378/chest.11-2295 CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Patrono C, Baigent C, Hirsh J, Roth G (2008) Antiplatelet drugs: American college of chest physicians evidence-based clinical practice guidelines (8th edition). Chest 133:199–233.  https://doi.org/10.1378/chest.08-0672 CrossRefGoogle Scholar
  3. 3.
    DiNicolantonio JJ, D’Ascenzo F, Tomek A et al (2013) Clopidogrel is safer than ticagrelor in regard to bleeds: a closer look at the PLATO trial. Int J Cardiol 168:1739–1744.  https://doi.org/10.1016/j.ijcard.2013.06.135 CrossRefPubMedGoogle Scholar
  4. 4.
    Wallentin L, Becker RC, Budaj A et al (2009) Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 361:1045–1057.  https://doi.org/10.1056/NEJMoa0904327 CrossRefPubMedGoogle Scholar
  5. 5.
    Tafur A, Douketis J (2018) Perioperative management of anticoagulant and antiplatelet therapy. Heart Br Card Soc 104:1461–1467.  https://doi.org/10.1136/heartjnl-2016-310581 CrossRefGoogle Scholar
  6. 6.
    Schwarz UR, Walter U, Eigenthaler M (2001) Taming platelets with cyclic nucleotides. Biochem Pharmacol 62:1153–1161.  https://doi.org/10.1016/s0006-2952(01)00760-2 CrossRefPubMedGoogle Scholar
  7. 7.
    Diener HC, Cunha L, Forbes C et al (1996) European stroke prevention study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 143:1–13.  https://doi.org/10.1016/s0022-510x(96)00308-5 CrossRefPubMedGoogle Scholar
  8. 8.
    Dornbos D, Nimjee SM (2018) Reversal of systemic anticoagulants and antiplatelet therapeutics. Neurosurg Clin N Am 29:537–545.  https://doi.org/10.1016/j.nec.2018.06.005 CrossRefPubMedGoogle Scholar
  9. 9.
    Altenburg A, Haage P (2012) Antiplatelet and anticoagulant drugs in interventional radiology. Cardiovasc Intervent Radiol 35:30–42.  https://doi.org/10.1007/s00270-011-0204-0 CrossRefPubMedGoogle Scholar
  10. 10.
    Sedat J, Chau Y, Mondot L et al (2014) Is eptifibatide a safe and effective rescue therapy in thromboembolic events complicating cerebral aneurysm coil embolization? Single-center experience in 42 cases and review of the literature. Neuroradiology 56:145–153.  https://doi.org/10.1007/s00234-013-1301-3 CrossRefPubMedGoogle Scholar
  11. 11.
    Ageno W, Gallus AS, Wittkowsky A et al (2012) Oral anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest 141:e44S–e88S.  https://doi.org/10.1378/chest.11-2292 CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Hackett CT, Ramanathan RS, Malhotra K et al (2015) Safety of venous thromboembolism prophylaxis with fondaparinux in ischemic stroke. Thromb Res 135:249–254.  https://doi.org/10.1016/j.thromres.2014.11.041 CrossRefPubMedGoogle Scholar
  13. 13.
    Levy JH, Douketis J, Weitz JI (2018) Reversal agents for non-vitamin K antagonist oral anticoagulants. Nat Rev Cardiol 15:273–281.  https://doi.org/10.1038/nrcardio.2017.223 CrossRefPubMedGoogle Scholar
  14. 14.
    Gómez-Outes A, Terleira-Fernández AI, Calvo-Rojas G et al (2013) Dabigatran, rivaroxaban, or apixaban versus warfarin in patients with nonvalvular atrial fibrillation: a systematic review and meta-analysis of subgroups. Thrombosis 2013:640723.  https://doi.org/10.1155/2013/640723 CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    O’Donnell MJ, Eikelboom JW, Yusuf S et al (2016) Effect of apixaban on brain infarction and microbleeds: AVERROES-MRI assessment study. Am Heart J 178:145–150.  https://doi.org/10.1016/j.ahj.2016.03.019 CrossRefPubMedGoogle Scholar
  16. 16.
    Potpara TS, Polovina MM, Licina MM et al (2012) Novel oral anticoagulants for stroke prevention in atrial fibrillation: focus on apixaban. Adv Ther 29:491–507.  https://doi.org/10.1007/s12325-012-0026-8 CrossRefPubMedGoogle Scholar
  17. 17.
    Granger CB, Alexander JH, McMurray JJV et al (2011) Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 365:981–992.  https://doi.org/10.1056/NEJMoa1107039 CrossRefPubMedGoogle Scholar
  18. 18.
    Frost C, Wang J, Nepal S et al (2013) Apixaban, an oral, direct factor Xa inhibitor: single dose safety, pharmacokinetics, pharmacodynamics and food effect in healthy subjects. Br J Clin Pharmacol 75:476–487.  https://doi.org/10.1111/j.1365-2125.2012.04369.x CrossRefPubMedGoogle Scholar
  19. 19.
    Brouwers MC, Kho ME, Browman GP et al (2010) AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ Can Med Assoc J J Assoc Med Can 182:E839–842.  https://doi.org/10.1503/cmaj.090449 CrossRefGoogle Scholar
  20. 20.
    Tikkinen KAO, Craigie S, Agarwal A et al (2018) Procedure-specific risks of thrombosis and bleeding in urological cancer surgery: systematic review and meta-analysis. Eur Urol 73:242–251.  https://doi.org/10.1016/j.eururo.2017.03.008 CrossRefPubMedGoogle Scholar
  21. 21.
    Tikkinen KAO, Craigie S, Agarwal A et al (2018) Procedure-specific Risks of Thrombosis and Bleeding in Urological Non-cancer Surgery: systematic review and meta-analysis. Eur Urol 73:236–241.  https://doi.org/10.1016/j.eururo.2017.02.025 CrossRefPubMedGoogle Scholar
  22. 22.
    Douketis JD, Spyropoulos AC, Spencer FA et al (2012) Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest 141:e326S–e350S.  https://doi.org/10.1378/chest.11-2298 CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Kristensen SD, Knuuti J, Saraste A et al (2014) 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: the Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 35:2383–2431.  https://doi.org/10.1093/eurheartj/ehu282 CrossRefPubMedGoogle Scholar
  24. 24.
    Culkin DJ, Exaire EJ, Green D et al (2014) Anticoagulation and antiplatelet therapy in urological practice: ICUD/AUA review paper. J Urol 192:1026–1034.  https://doi.org/10.1016/j.juro.2014.04.103 CrossRefPubMedGoogle Scholar
  25. 25.
    Douketis JD, Spyropoulos AC, Duncan J et al (2019) Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med.  https://doi.org/10.1001/jamainternmed.2019.2431 CrossRefPubMedGoogle Scholar
  26. 26.
    Brosseau L, Rahman P, Toupin-April K et al (2014) (2014) A systematic critical appraisal for non-pharmacological management of osteoarthritis using the Appraisal of Guidelines Research and Evaluation II instrument. PLoS ONE 9(1):e82986CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Authors and Affiliations

  1. 1.Academic Urology UnitUniversity of AberdeenAberdeenScotland, UK
  2. 2.Department of AnaesthesiologyUniversity Hospital of LarissaLarissaGreece
  3. 3.Department of MedicineMcMaster UniversityHamiltonCanada
  4. 4.Department of UrologyUniversity Hospital of LarissaLarissaGreece

Personalised recommendations