| Re:
Safety of Ultrasound-Guided Transrectal Extended Prostate Biopsy in Patients
Receiving Low-Dose Aspirin
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Ioannis
Kariotis, Prodromos Philippou, Demetrios Volanis, Efraim Serafetinides,
Demetrios Delakas
Department
of Urology, “Asklipieion” General Hospital, Athens, Greece
Int Braz
J Urol. 2010; 36: 308-16
To the Editor,
Clinicians
in general should note procedures that may appear to be associated with
a high or low risk of bleeding, despite the lack of high quality methodological
scientific evidence in this area. Furthermore, there are invasive procedures
which possess different risks of bleeding, as well as patients with different
risks of thrombosis. Additionally, clinicians must consider the existence
of various ways of perioperative anticoagulation and adequate identification
for those with “high risk” for antithrombotic cessation afterwards.
Studies dealing with safety of minor invasive procedures on patients taking
into consideration antithrombotics in general are not abundant in the
literature, which has often raised practical concerns and controversies
regarding how to manage them appropriately, mainly in perioperative intervention.
These interventions with minor risks have usually been undertaken using
exaggerated caution or individualized according to the urologist’s
experience.
In order to give some examples of this,
the following are cited:
- Resection
of colonic polyps, especially sessile polyps > 2 cm in diameter,
in which bleeding may occur at the transected stalk;
- Cardiac
pacemaker or defibrillator implantation, in which separation of the
infraclavicular fascial layers and lack of good hemostasis of unopposed
tissues within the pacemaker or defibrillator pocket may be predisposed
to hematoma development and serious complications.
- Biopsy
of the prostate or kidney, in which the presence of highly vascular
tissue and endogenous urokinase may promote post-biopsy bleeding (1,2).
The study carried out by Kariotis et al.
emphasized that the previous use of aspirin does not necessarily mean
it has been withdrawn. The action to maintain drugs such as oral anticoagulation
or even antiagregation has great relevance and was already considered
among other authors(3-5), generating matter for debate (3,6).
It is important to realize that nowadays, more patients that are elderly
will be referred to undergo a prostate biopsy. Also, the majority of
patients will coexist with cardiac diseases, such as coronary stents,
enlarged atriums with complex arrhythmias, valve problems, severe arterial
vasculopathy, or venous thrombosis among complex comorbities; all requiring
adequate anticoagulation or antiagregation in order to avoid severe
or disastrous thromboembolic events. Based on these assumptions, clinicians
have always to outweigh risks and benefits. Their ultimate decision
on whether to withdraw or withhold these antithrombotics is still a
matter of judgment, preferences and values as well as the type and amount
of biopsies undertaken.
In the same way, Lhezue et al. (2) already described similar findings
in 2005, but instead of administering aspirin, the concomitant use of
oral anticoagulant (warfarin), a stronger anticoagulant, was used. Also,
they concluded that its suspension, in order to perform prostate biopsy,
should not be necessary according to their favorable outcome and absence
of complications.
More recently, a prospective randomized trial was undergone in order
to determine whether the incidence and duration of bleeding complications
after transrectal prostate biopsy in patients not discontinuing low-dose
aspirin are greater than in those discontinuing it (4).
Despite the discussion regarding whether the number of biopsy cores
taken (between 4 and 9) would be considered the best practice, physicians
have to conjugate or balance its context of realization.
In addition, among all controversies still present in our practice,
the need to avoid a thromboembolic event, such as embolic stroke or
intracoronary stent thrombosis, will dominate perioperative antithrombotic
management, irrespective of bleeding risk.
Lastly, it is important to highlight 3
important aspects:
- 1. Resuming
antithrombotic therapy after a surgical or invasive procedure, it takes
2 to 3 days for an anticoagulant effect to begin after the administration
of warfarin. Whereas it takes minutes for an antiplatelet effect to
begin after the administration of aspirin, and 3 to 7 days for peak
inhibition of platelet aggregation to be reached after the application
of a (75 mg) maintenance dose of clopidogrel (1).
- The majority
of surgical or other invasive procedures are being performed without
hospitalization or with a short hospital stay; consequently, potential
thromboembolic or bleeding-related complications are likely to occur
while the patient is at home. Close follow-up of patients during the
early period after a procedure is, therefore, warranted to allow early
detection and expedited treatment of potential complications.
- Studies
are lacking with regard to patients who are receiving clopidogrel and
require a prostate biopsy, although it is probable that the continuation
of clopidogrel and aspirin in patients undergoing minor procedures will
increase the risk of bleeding as mentioned above that seen with the
use of aspirin alone.
REFERENCES
- Douketis
JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, et al.:
The perioperative management of antithrombotic therapy: American College
of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th
Edition). Chest. 2008; 133(6 Suppl): 299S-339S.
- Ihezue
CU, Smart J, Dewbury KC, Mehta R, Burgess L: Biopsy of the prostate
guided by transrectal ultrasound: relation between warfarin use and
incidence of bleeding complications. Clin Radiol. 2005; 60: 459-63;
discussion 457-8.
- Halliwell
OT, Lane C, Dewbury KC: Transrectal ultrasound-guided biopsy of the
prostate: should warfarin be stopped before the procedure? Incidence
of bleeding in a further 50 patients. Clin Radiol. 2006; 61: 1068-9.
- Giannarini
G, Mogorovich A, Valent F, Morelli G, De Maria M, Manassero F, et al.:
Continuing or discontinuing low-dose aspirin before transrectal prostate
biopsy: results of a prospective randomized trial. Urology. 2007; 70:
501-5.
- Halliwell
OT, Yadegafar G, Lane C, Dewbury KC: Transrectal ultrasound-guided biopsy
of the prostate: aspirin increases the incidence of minor bleeding complications.
Clin Radiol. 2008; 63: 557-61.
- Giannarini
G, Mogorovich A, Selli C: Re: transrectal ultrasound-guided biopsy of
the prostate: aspirin increases the incidence of minor bleeding complications.
Clin Radiol. 2008; 63: 1386-7; author reply 1387.
Dr.
Rubens Costa Filho
Chair, Intensive Care Unit
Pro-Cardiaco Hospital
Rio de Janeiro, RJ, Brazil
E-mail: rubens1956@gmail.com |