Flexible ureteroscopy and Holmium:YAG laser lithotripsy for stone disease in patients with bleeding diathesis: a systematic review of the literature

Abstract

INTRODUCTION AND OBJECTIVES: The management of urolithiasis in patients on anticoagulants presents a challenge to the endourologist. Due to multiple comorbidities, it may be impossible to safely discontinue the anticoagulant treatment. Other modalities such as shock wave lithotripsy and PCNL are contraindicated in these patients, so ureteroscopic treatment may be the only option. We conducted a systematic review of the literature to look at the safety and efficacy of ureteroscopic management in these patients. METHODS: Systematic review and quantitative meta-analysis was performed using studies identified by a systematic electronic literature search from January 1990 to August 2011. All articles reporting on treatment for stones in patients with a bleeding diathesis using ureteroscopy and a Holmium:YAG laser were included. Two reviewers independently extracted the data from each study. The data was included into a meta-analysis and discussed. RESULTS: Three studies were identified reporting on 70 patients (73 procedures). All patients had stone fragmentation using Holmium laser. The mean stone size was 13.2mm with a range of 5-35mm. The quality of the included studies was modest. Stone free status was achieved in sixty-four patients (87.7%). There were no major complications and only 11% of the patients developed minor complications with only 4% rate of minor bleeding. CONCLUSIONS: Retrograde stone treatment using ureteroscopy and holmium laser lithotripsy can be safely performed in patients with bleeding diathesis with a low complication rate

CUA Guideline: Management of ureteral calculi

“…SWL, laparoscopic, percutaneous and open surgeries are contraindicated in these patients. 109,110 This is because there is 20-to 40-fold increased risk of peri-renal hematomas and hemorrhagic complications in patients with uncorrected coagulopathies undergoing SWL when compared with patients with a normal bleeding profile. 111,112 Therefore, in consultation with a haematologist or a cardiologist, bleeding coagulopathies need to be corrected and anticoagulation therapy appropriately withheld perioperatively.…”

“…116 Recent advances in manufacturing small-calibre ureteroscopes and introduction of Ho:YAG laser energy in lithotripsy have made it possible for patients with coagulopathies to safely undergo URS and laser lithotripsy while anticoagulated. 110,[117][118][119] However, this is associated with lower stone-free rates and increased risk of postoperative gross hematuria necessitating admission and bladder irrigation. 111,120 Therefore, risks and benefits of withholding anticoagulation or proceeding with URS while anti-coagulated should be discussed with the patient and his/her cardiologist or hematologist.…”

Influence of Saline on Temperature Profile of Laser Lithotripsy Activation

“…In general, these lasers can be categorized into groups according to their pulse duration time (Tp): Nanosecond lasers (Tp < 1000 nsec) [Q-switched ND: YAG, Q-switched alexandrite, Q-switched ruby, XeCl excimer, short-pulsed lasers (1 lsec < Tp < 10 lsec) Flashlamp-Pumped Pulsed-Dye, Flashlamp-Pumped Ti:Sapphire, Q-switched KTP], longpulsed lasers (10 lsec < Tp < 1000 lsec) [Ho:YAG, Er: Cr:YSGG, ND:YAG], and continuous-wave lasers (continuous pulse duration -Tp) [CW-CO 2, CW-Nd: YAG]. 8 Nanosecond and short-pulsed laser lithotripters fragment stones through acoustic shockwaves. 8 The emission process from the acoustic shockwaves is closely related to the short pulse duration profile of these lasers.…”

“…8 Nanosecond and short-pulsed laser lithotripters fragment stones through acoustic shockwaves. 8 The emission process from the acoustic shockwaves is closely related to the short pulse duration profile of these lasers. These short pulse-width lasers rapidly generate and accumulate energy in water (stress confinement phenomena), inducing a rapid formation and expansion of a spherical plasma cavitation bubble at the laser fiber tip.…”

Possibilities to Improve the Therapy of the Patients With Ureteral Concretions

“…Mostly, young people of working age suffer from this disease, 70 % of patients aging from 20 to 50 years old. The disease can occur with the acute or chronic pyelo- nephritis, frequent recurrence of UD (30-80 %), which, in turn, leads to renal failure, disability and mortality in patients [3]. UD etiology and pathogenesis have not been completely determined until now.…”