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STONE
DISEASE
Safety and efficacy of holmium: YAG laser lithotripsy in patients with
bleeding diatheses
Watterson JD, Girvan AR, Cook AJ, Beiko DT, Nott L, Auge BK, Preminger
GM, Denstedt JD
Division of Urology, University of Western Ontario, London, Ontario, Canada,
and Comprehensive Kidney Stone Center, Division of Urology, Duke University
Medical Center, Durham, North Caroline, USA
J Urol. 2002; 168:442-5
- Purpose:
We
assessed the safety and efficacy of ureteroscopy and holmium:YAG laser
lithotripsy for treating upper urinary tract calculi in patients with
known and uncorrected bleeding diathesis.
- Materials
and Methods: We
retrospectively reviewed the charts at 2 tertiary stone centers to identify
patients with known bleeding diathesis who were treated with holmium:YAG
laser lithotripsy for upper urinary tract calculi. A total of 25 patients
(29 upper urinary tract calculi) underwent ureteroscopic holmium laser
lithotripsy. Bleeding diathesis involved warfarin administration for
various conditions in 17 patients, liver dysfunction in 3, thrombocytopenia
in 4 and von Willebrand’s disease in 1. The mean international
normalized ratio, platelet count and bleeding time were 2.3, 50 x 109/L
and greater than 16 minutes in patients on warfarin and in those with
liver dysfunction, thrombocytopenia and von Willebrand’s disease,
respectively.
- Results:
Overall the stone-free rate was 96% (27 of 28 cases) and 29 of 30 procedures
were completed successfully without significant complication. In a patient
treated concomitantly with electrohydraulic lithotripsy significant
retroperitoneal hemorrhage required blood transfusion.
- Conclusions:
Upper tract urinary calculi in patients with uncorrected bleeding diathesis
can be safely managed by contemporary small caliber ureteroscopes and
the holmium laser as the only modality of lithotripsy. Ureteroscopic
holmium laser lithotripsy without preoperatively correcting hemostatic
parameters limits the risk of thromboembolic complications and costs
associated with an extended hospital stay. Avoiding electrohydraulic
lithotripsy is crucial for decreasing bleeding complications in this
cohort of patients.
- Editorial
Comment
The patient with a symptomatic stone and an uncorrected bleeding disorder
presents a challenging therapeutic dilemma. Traditionally, bleeding
diatheses have been corrected pre-operatively before any surgical intervention,
and treatment with shock wave lithotripsy or percutaneous lithotripsy
are still contraindicated with any uncorrected bleeding disorder. However,
the improved efficacy and efficiency of ureteroscopy in conjunction
with Holmium:YAG laser lithotripsy as well as the increased margin of
safety of the Holmium laser has expanded the indications of ureteroscopy
for the treatment of upper tract stones to potentially include treatment
of patients with uncorrected bleeding diatheses. The authors reviewed
their experience in 25 patients with known bleeding disorders undergoing
30 ureteroscopic procedures without correction of hemostatic parameters.
A stone free state was achieved in 96% of cases, and a single bleeding
complication (retroperitoneal hemorrhage) occurred in the only patient
in whom electrohydraulic lithotripsy was used in addition to Holmium:YAG
laser lithotripsy.
Although it is ideal to attempt to a correct bleeding disorder prior
to surgical intervention thus maintaining all therapeutic modalities
as options for treatment, this series demonstrates the safety of treating
symptomatic stone patients with ureteroscopy without correction of their
bleeding problems, thereby reducing cost and hospital length of stay
and avoiding the risk of discontinuing anticoagulation therapy. Although
it is difficult to draw conclusions based on a single bleeding complication,
the known lower margin of safety of electrohydraulic lithotripsy suggests
that this modality should be avoided in favor of the Holmium:YAG laser.
It should also be noted that laser lithotripsy in these patients should
be performed cautiously to avoid misfiring or misdirection of the laser.
Likewise, pressure irrigation should be applied gently and judiciously
to avoid forniceal or caliceal rupture with subsequent perinephric bleeding.
Dr.
Margaret S. Pearle
Associate Professor of Urology
University of Texas Southwestern Med Ctr
Dallas, Texas, USA
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