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Stone management in bleeding diathesis Basuki B Purnomo Department of Urology RS Dr Saiful Anwar Malang Some loss of blood is always inevitable DE GASPERI Perioperative bleeding “surgical” bleeding • >70% of the cases is mainly attributable to surgical technical problems • It is characterized by uncontrolled bleeding at the operative site “non -surgical or haemostatic bleeding” • usually due to a dysfunction/failure in one or more of the phases of the haemostatic system • it appears as a generalised oozing with spontaneous, multiple sites bleeding (traumatized tissues, puncture sites, surgical wounds ) without any apparent single bleeding point. The non surgical bleeding • Pre-existing, previously undetected bleeding disorder • Induced by drugs (e.g.: aspirin, clopidogrel, NSAIDs, warfarin, LMWH) • Coexisting pathologies (eg: liver failure, CKD) • Hemostatic derangements induced by: • the surgical procedure itself (cardiopulmonary bypass,, prostate surgery, complicated obstetrics) • massive blood loss and massive transfusion in complicated surgery Diagnosis: Preoperative testing A careful history and physical is the most important component of the assessment for bleeding disorders in the preoperative setting. The history should include questions regarding: • A personal or family history of bleeding tendencies. • Histories of bleeding after dental extractions or surgeries are particularly relevant. • Pertinent questions also address any history of hematuria, menorrhagia, gastrointestinal bleeds, easy bruising, epistaxis, and hemarthroses. • Knowledge of the patients’ medications, medical conditions (especially hematologic, liver, or kidney diseases), and any unusual dietary habits is also essential. Diagnosis: Preoperative testing The physical examination should focus on the skin and mucous membranes, looking for evidence of bruises, petechiae, or bleeding. Adenopathy, hepato-splenomegaly, and signs of hepatic insufficiency, such as jaundice, telangiectasias, and gynecomastia, should also be assessed. The decision regarding which preoperative coagulation tests are needed is then based on this information in combination with the knowledge of the type of procedure being performed. Indication of preoperative coagulation studies If the patient has a history of abnormal bleeding If the surgery is high risk for bleeding complications, If the patient has liver disease or mal-absorption If the patient uses anticoagulants. • Coagulation is achieved by the interaction of three major components: • the vascular endothelium, • coagulation proteins, and • platelets. Stone management • MET (medical expulsive treatment) • Operative • • • • • • ESWL Lithotripsy URS PCNL Laparoscopic operation Open operation EAU Guidelines, 2014 EAU Guidelines: 2014 Open surgery on chronic anticoagulant therapy PCNL: General result Lessons learned from the CROES percutaneous nephrolithotomy global study Kamphuis et al, 2015 PCNL: Extensive hemorrhage Complications of Percutaneous Nephrolithotomy Classified by the Modified Clavien Grading System: A Single Center’s Experience over 16 Years Seun Sin et al, 2011 PCNL in Bleeding diathesis Postoperative outcomes ESWL: complication Acute injury • Animal studies have clearly established that SWL cause damage to the kidney vasculature. • SWL can cause parenchymal bleeding and mild to severe subcapsular hematomas, perirenal hematoma Chronic injury • Renal scar formation and Hypertension may develop after SWL • Induce DM Complication ESWL: hematoma ESWL: complication Semirigid URS: Complications Mandal et al UROLOGY 80: 995–1001, 2012 EUROPEAN UROLOGY 64 (2013) 101–105 SUMMARY • Perioperative surgical treatment of a patient with known bleeding diathesis represents a therapeutic dilemma and often requires the coordinated efforts of the surgeon, internist and anesthesiologist. • The indication for surgery, location and extent of the surgery, and ability to compress or physically control bleeding strongly influence management. • Although URS has been performed safely in patients with uncorrected bleeding disorders, normalizing hemostatic parameters is still considered a mainstay of patient care before intervention.
