title: Coronary stent management in elective genitourinary surgery.
abstract: What's known on the subject? and What does the study add? Withdrawal of dual antiplatelet therapy before the recommended, 12 months for drug-eluting stents and 1 month for bare-metal stents increases the rate of major adverse coronary events and mortality. However, in those undergoing surgery the risk of bleeding is increased substantially for those on antiplatelet agents. Successful management in patients with coronary stents who must undergo elective or non-elective urological surgery should be a multidisciplinary decision. This article reviews the literature and recommends a protocol for clinical management of patients undergoing urological procedures after coronary stent placement. To review the literature on coronary stents and genitourinary surgery and provide a protocol for perioperative. The keywords, 'elective surgery', 'aspirin', 'clopidogrel', 'guidelines for percutaneous coronary intervention', and 'antiplatelet therapy after coronary stent placement' were used to search PubMed for any relevant articles relating to coronary stents. Recommendations were made based on the whether the procedures patients were exposed to placed them at low-, moderate- or high-bleeding risk based on the extent of the procedure. All elective procedures should be delayed for 1 month after bare-metal stent placement and 1 year after drug-eluting stent placement. In patients classified as low risk (endoscopy and laser prostatectomy), aspirin should be continued throughout the perioperative period and dual antiplatelet therapy should continue 24-48 h postoperatively, if there is no concern for active bleeding. In those classified as moderate risk (scrotal procedures, transurethral resection of bladder tumours, transurethral resection of the prostate, urinary sphincter placement) dual antiplatelet therapy should be discontinued 5-7 days before the procedure and continued within 7 days after procedure, if there is no concern for active bleeding, in consultation with cardiology. In high-risk procedures (cystectomy, nephrectomy, prostatectomy, penile prosthesis placement) dual antiplatelet therapy should be discontinued 10 days before the procedure and continued postoperatively within 7-10 days of the procedure, when there is no longer a concern for active bleeding with the assistance of a cardiologist. Coronary artery disease is becoming more prominent in our society, increasing the use of coronary stents and antiplatelet agents. With the proposed protocol, it is safe to proceed with surgical intervention in those that have adequate stent endothelialisation.
authors.affiliation: Departments of Urology, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA. agupta45@jhmi.edu
authors.forename: Angela D
authors.initials: AD
authors.lastname: Gupta
authors.forename: Michael
authors.initials: M
authors.lastname: Streiff
authors.forename: Jon
authors.initials: J
authors.lastname: Resar
authors.forename: Mark
authors.initials: M
authors.lastname: Schoenberg
mesh_terms: D015906:Angioplasty, Balloon, Coronary; D002985:Clinical Protocols; D003324:Coronary Artery Disease / Q000628:therapy; D017558:Elective Surgical Procedures / Q000379:methods*; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control*; D019990:Perioperative Care / Q000379:methods*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D018570:Risk Assessment; D024162:Second-Look Surgery / Q000379:methods; D015607:Stents; D014570:Urologic Diseases / Q000601:surgery; D013520:Urologic Surgical Procedures / Q000379:methods*
chemical_list: D010975:Platelet Aggregation Inhibitors