Context: The perioperative management of patients under dual antiplatelet therapy after myocardial infarction, cerebrovascular event or coronary stent implantation represents an increasingly frequent issue for urologists and anaesthesiologists.Objective: To assess the current scientific evidence and propose strategies concerning the management of urologic patients under antiplatelet therapy. A Medline & PubMed search was conducted for articles related to antiplatelet therapy after myocardial infarction, coronary stents and cerebrovascular events, and to the management of aspirin and/or clopidogrel in the context of surgery.Results: Early discontinuation of antiplatelet therapy in secondary prevention is associated with a high risk of coronary thrombosis, further increased by the hypercoagulable state induced by surgery. Aspirin has recently been recommended to be 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 be performed under dual antiplatelet therapy, because withdrawal therapy increases 5-10 times the risk of postoperative myocardial infarction, stent thrombosis or death. The shorter the waiting periods between revascularisation and surgery, the higher is the risk of adverse cardiac events. The risk of surgical haemorrhage is increased approximately 20% by aspirin and 50% by clopidogrel.
Conclusions:The present review of the literature demonstrates that the risk of coronary thrombosis when antiplatelet agents are withdrawn before surgery is generally higher than the risk of surgical haemorrhage when antiplatelet agents are upheld. However, this issue has not yet been sufficiently evaluated in urologic patients and in many instances during urologic surgery the risk of bleeding might be exceedingly dangerous. In this problematic situation, a thorough dialogue between surgeon, cardiologist and anaesthesiologist is essential to determine all risk factors and to define the best possible strategy for each individual patient.