Urological Surgery and Antiplatelet Drugs After Cardiac and Cerebrovascular Accidents

Received 26 August 2009 published online 16 April 2010.

Purpose

The perioperative treatment of patients on dual antiplatelet therapy after myocardial infarction, cerebrovascular event or coronary stent implantation represents an increasingly frequent issue for urologists and anesthesiologists. We assess the current scientific evidence and propose strategies concerning treatment of these patients.

Materials and Methods

A MEDLINE® and PubMed® search was conducted for articles related to antiplatelet therapy after myocardial infarction, coronary stents and cerebrovascular events, as well as the use of aspirin and/or clopidogrel in the context of surgery.

Results

Early discontinuation of antiplatelet therapy for secondary prevention is associated with a high risk of coronary thrombosis, which is further increased by the hypercoagulable state induced by surgery. Aspirin has recently been recommended as a lifelong therapy. Clopidogrel is mandatory for 6 weeks after myocardial infarction and bare metal stents, and for 12 months after drug-eluting stents. Surgery must be postponed beyond these waiting periods or performed with patients receiving dual antiplatelet therapy because withdrawal therapy increases 5 to 10 times the risk of postoperative myocardial infarction, stent thrombosis or death. The shorter the waiting period between revascularization and surgery the greater the risk of adverse cardiac events. The risk of surgical hemorrhage is increased approximately 20% by aspirin and 50% by clopidogrel.

Conclusions

The risk of coronary thrombosis when antiplatelet agents are withdrawn before surgery is generally higher than the risk of surgical hemorrhage when antiplatelet agents are maintained. However, this issue has not yet been sufficiently evaluated in urological patients and in many instances during urological surgery the risk of bleeding can be dangerous. A thorough dialogue among surgeon, cardiologist and anesthesiologist is essential to determine all risk factors and define the best possible strategy for each patient.

Key Words: platelet aggregation inhibitors, myocardial revascularization, stents, blood loss, surgical

a Urology Clinic, University Hospital Zürich, Zürich, Switzerland

b Institute of Anaesthesiology, University Hospital Zürich, Zürich, Switzerland

c Department of Biology and Medicine, University Hospital Lausanne, Lausanne, Switzerland

d Department of Cardiology, University Hospital Lausanne, Lausanne, Switzerland

e Department of Anaesthesiology and Intensive Care, Hotel-Dieu University Hospital, Paris, France

f Department of Anaesthesiology and Critical Care, Beaujon & Louis Mourier University Hospitals, Clichy, France

Correspondence: Urology Clinic, University Hospital Zürich, CH-8091 Zürich, Switzerland (telephone: +41-44-255-9616; FAX: +41-44-255-4566)

Editor's Note: This article is the first of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 2474 and 2475.

† Nothing to disclose.

‡ Financial interest and/or other relationship with Abbot, Alliance Pharmaceutical Corp., AstraZeneca, Bayer, Boehringer Ingelheim, CSL Behring, Fresenius, Galencia, GlaxoSmithKline, Janssen-Cilag, Novo Nordisk, Octapharma, Organon, Pentapharm, Roche Pharma and Schering-Plough International.

PII: S0022-5347(10)02661-3

doi:10.1016/j.juro.2010.02.2391

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