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Therapy Insight: management of urology patients taking long-term warfarin anticoagulation therapy

Abstract

Chronic warfarin anticoagulation is commonly used to prevent thromboembolism in patients with atrial fibrillation or venous thromboembolism, and in the management of patients with mechanical heart valves. Interruption of long-term anticoagulation therapy for elective, planned urologic procedures in these patients creates a complex situation in which competing risks of thrombosis and hemorrhage must be managed; when anticoagulation is withheld patients are at risk of thrombosis, and when it is restarted they are at risk of hemorrhage. Patients at a high risk of thrombosis are typically given bridging therapy with heparin to reduce the amount of time without anticoagulation. Outcomes from bridging therapy are influenced by patient characteristics, including the risk of thromboembolism from underlying medical conditions and the risk of perioperative bleeding, and by characteristics of the procedures themselves. The safety and efficacy of different approaches are not well documented. Data regarding periprocedural anticoagulation management of urology patients is limited and principally describes outcomes related to transurethral prostate surgery. Results from these studies indicate that various strategies of anticoagulation interruption and bridging therapy result in low frequencies of thromboembolism, but variable rates of hemorrhage. Patients on anticoagulation therapy who are due to undergo invasive urologic procedures that have a low risk of developing thromboembolism can discontinue warfarin 4–5 days before the procedure, and resume it postprocedure. Bridging therapy to prevent thrombosis is necessary for patients at a higher risk of developing thromboembolism. Future research should develop strategies to maintain low rates of thrombosis but reduce the frequency of postoperative hemorrhage.

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References

  1. Ansell J et al. (2004) The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126 (Suppl): S204–S233

    Article  Google Scholar 

  2. Douketis JD et al. (1999) Physician preferences for perioperative anticoagulation in patients with a mechanical heart valve who are undergoing elective noncardiac surgery. Chest 116: 1240–1246

    CAS  Article  Google Scholar 

  3. Eckman MH et al. (1990) Anticoagulation for noncardiac procedures in patients with prosthetic heart valves. Does low risk mean high cost? JAMA 263: 1513–1521

    CAS  Article  Google Scholar 

  4. Singer DE et al. (2004) Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126 (Suppl): S429–S456

    Article  Google Scholar 

  5. Gage BF et al. (2001) Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 285: 2864–2870

    CAS  Article  Google Scholar 

  6. White RH (2003) The epidemiology of venous thromboembolism. Circulation 107 (Suppl 1): SI4–SI8

    Google Scholar 

  7. Kearon C (2003) Natural history of venous thromboembolism. Circulation 107 (Suppl 1): SI22–SI30

    Google Scholar 

  8. Prandoni P et al. (1996) The long-term clinical course of acute deep venous thrombosis. Ann Intern Med 125: 1–7

    CAS  Article  Google Scholar 

  9. Hansson PO et al. (2000) Recurrent venous thromboembolism after deep vein thrombosis: incidence and risk factors. Arch Intern Med 160: 769–774

    CAS  Article  Google Scholar 

  10. Cannegieter SC et al. (1994) Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation 89: 635–641

    CAS  Article  Google Scholar 

  11. Bonow RO et al. (1998) ACC/AHA guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease). J Am Coll Cardiol 32: 1486–1588

    Article  Google Scholar 

  12. Hautmann RE et al. (1994) Radical retropubic prostatectomy: morbidity and urinary continence in 418 consecutive cases. Urology 43 (Suppl): S47–S51

    Article  Google Scholar 

  13. Catalona WJ et al. (1999) Potency, continence and complication rates in 1,870 consecutive radical retropubic prostatectomies. J Urol 162: 433–438

    CAS  Article  Google Scholar 

  14. Andriole GL et al. (1994) Early complications of contemporary anatomical radical retropubic prostatectomy. J Urol 152: 1858–1860

    CAS  Article  Google Scholar 

  15. Neal DE (1997) The National Prostatectomy Audit. Br J Urol 79 (Suppl 2): S69–S75

    Article  Google Scholar 

  16. Mebust WK et al. (1989) Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 141: 243–247

    CAS  Article  Google Scholar 

  17. Uchida T et al. (1999) Factors influencing morbidity in patients undergoing transurethral resection of the prostate. Urology 53: 98–105

    CAS  Article  Google Scholar 

  18. Wilson JR et al. (2004) The changing practice of transurethral prostatectomy: a comparison of cases performed in 1990 and 2000. Ann R Coll Surg Engl 86: 428–431

    CAS  Article  Google Scholar 

  19. Doll HA et al. (1992) Mortality, morbidity and complications following transurethral resection of the prostate for benign prostatic hypertrophy. J Urol 147: 1566–1573

    CAS  Article  Google Scholar 

  20. Lepor H et al. (2001) Intraoperative and postoperative complications of radical retropubic prostatectomy in a consecutive series of 1,000 cases. J Urol 166: 1729–1733

    CAS  Article  Google Scholar 

  21. Hedican SP and Walsh PC (1994) Postoperative bleeding following radical retropubic prostatectomy. J Urol 152: 1181–1183

    CAS  Article  Google Scholar 

  22. Rodriguez LV and Terris MK (1998) Risks and complications of transrectal ultrasound guided prostate needle biopsy: a prospective study and review of the literature. J Urol 160: 2115–2120

    CAS  Article  Google Scholar 

  23. Nielsen JD et al. (1997) Post-operative blood loss after transurethral prostatectomy is dependent on in situ fibrinolysis. Br J Urol 80: 889–893

    CAS  Article  Google Scholar 

  24. Mulcahy JJ et al. (1975) Transurethral prostatic resection in patients with prosthetic cardiac valves. J Urol 113: 642–643

    CAS  Article  Google Scholar 

  25. Tscholl R et al. (1980) Electroresection of the prostate in patients treated with heparin. J Urol 124: 221–222

    CAS  Article  Google Scholar 

  26. Parr NJ et al. (1989) Transurethral resection of the prostate and bladder tumour without withdrawal of warfarin therapy. Br J Urol 64: 623–625

    CAS  Article  Google Scholar 

  27. Chakravarti A and MacDermott S (1998) Transurethral resection of the prostate in the anticoagulated patient. Br J Urol 81: 520–522

    CAS  Article  Google Scholar 

  28. Hirsh J and Raschke R (2004) Heparin and low-molecular-weight heparin: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126 (Suppl): S188–S203

    Article  Google Scholar 

  29. Gould MK et al. (1999) Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. A cost-effectiveness analysis. Ann Intern Med 130: 789–799

    CAS  Article  Google Scholar 

  30. O'Brien B et al. (1999) Economic evaluation of outpatient treatment with low-molecular-weight heparin for proximal vein thrombosis. Arch Intern Med 159: 2298–2304

    CAS  Article  Google Scholar 

  31. Warkentin TE et al. (1995) Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med 332: 1330–1335

    CAS  Article  Google Scholar 

  32. Ranze O et al. (2000) The use of low-molecular-weight heparins in heparin-induced thrombocytopenia (HIT): a cohort study [abstract]. Ann Hematol 79 (Suppl 2): Sa198

    Google Scholar 

  33. Dotan ZA et al. (2002) The efficacy and safety of perioperative low molecular weight heparin substitution in patients on chronic oral anticoagulant therapy undergoing transurethral prostatectomy for bladder outlet obstruction. J Urol 168: 610–613

    CAS  Article  Google Scholar 

  34. Douketis JD et al. (2004) Low-molecular-weight heparin as bridging anticoagulation during interruption of warfarin: assessment of a standardized periprocedural anticoagulation regimen. Arch Intern Med 164: 1319–1326

    CAS  Article  Google Scholar 

  35. Kabalin JN and Gill HS (1993) Urolase laser prostatectomy in patients on warfarin anticoagulation: a safe treatment alternative for bladder outlet obstruction. Urology 42: 738–740

    CAS  Article  Google Scholar 

  36. Bolton DM and Costello AJ (1994) Management of benign prostatic hyperplasia by transurethral laser ablation in patients treated with warfarin anticoagulation. J Urol 151: 79–81

    CAS  Article  Google Scholar 

  37. Kingston TE et al. (1995) Further evaluation of transurethral laser ablation of the prostate in patients treated with anticoagulant therapy. Aust N Z J Surg 65: 40–43

    CAS  Article  Google Scholar 

  38. Keoghane SR and Cranston DW . (1996) Contact laser prostatectomy in anti-coagulated patients: mixed results. Br J Urol 77: 613–614

    CAS  Article  Google Scholar 

  39. Mueller EJ (1998) Contact laser vaporization of the prostate in patients on chronic anticoagulant therapy. Tech Urol 4: 156–159

    CAS  PubMed  Google Scholar 

  40. van Melick HH et al. Laser prostatectomy in patients on anticoagulant therapy or with bleeding disorders. J Urol 170: 1851–1855

  41. White RH et al. (2000) A population-based study of the effectiveness of inferior vena cava filter use among patients with venous thromboembolism. Arch Intern Med 160: 2033–2041

    CAS  Article  Google Scholar 

  42. Decousus H et al. (1998) A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. N Engl J Med 338: 409–415

    CAS  Article  Google Scholar 

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Correspondence to Paul R Daniels.

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Glossary

INTERNATIONAL NORMALIZED RATIO (INR)

A method that standardizes prothrombin times obtained from reagents of different sensitivities, allowing for comparison between different laboratories

BRIDGING THERAPY

The process of substitution of heparin for warfarin before and after invasive procedures

FACTOR XA

A vitamin K-dependent coagulation factor that is part of the enzymatic complex that activates thrombin from prothrombin

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Daniels, P. Therapy Insight: management of urology patients taking long-term warfarin anticoagulation therapy. Nat Rev Urol 2, 343–350 (2005). https://doi.org/10.1038/ncpuro0204

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