Is Percutaneous Nephrolithotomy (PCN) a high-risk bleeding operation and how long should rivaroxaban (Xarelto) be stopped before it?

Perioperative Management of Rivaroxaban for Percutaneous Nephrolithotomy (PCN)

Percutaneous nephrolithotomy (PCN) is considered a high bleeding risk procedure, and rivaroxaban should be discontinued at least 48 hours before the procedure in patients with normal renal function.

Classification of PCN Bleeding Risk

PCN is classified as a high bleeding risk procedure due to:

• Direct puncture of highly vascular renal tissue
• Risk of injury to renal vessels
• Potential for significant hemorrhage requiring transfusion

Rivaroxaban Discontinuation Timeline

The timing of rivaroxaban discontinuation depends on renal function and procedure risk:

1. For patients with normal renal function (CrCl ≥50 mL/min):

   • Discontinue rivaroxaban 48 hours (2 days) before PCN 1
   • This allows approximately 4-5 half-lives to elapse, ensuring minimal residual anticoagulant effect

2. For patients with impaired renal function:

   • CrCl 30-49 mL/min: Discontinue 72 hours (3 days) before PCN 2
   • CrCl 15-29 mL/min: Consider longer discontinuation period

Factors That May Require Longer Discontinuation

Certain factors may necessitate extending the discontinuation period beyond standard recommendations:

• Concomitant use of medications that interact with rivaroxaban (e.g., amiodarone) 2
• Advanced age
• History of bleeding complications
• Severe renal impairment

Perioperative Management Algorithm

1. Pre-procedure assessment:

   • Determine renal function (CrCl)
   • Assess for drug interactions
   • Evaluate individual thrombotic risk

2. Discontinuation timing:

   • Normal renal function: Stop rivaroxaban 48 hours before PCN
   • Impaired renal function: Stop 72+ hours before PCN

3. Laboratory monitoring:

   • Standard coagulation tests have limited value in predicting perioperative bleeding 3
   • If available, anti-Xa levels <30-50 ng/mL are considered hemostatically safe 4

4. Bridging therapy:

   • Routine bridging with LMWH is NOT recommended as it increases bleeding risk 3
   • Consider bridging only for patients at very high thrombotic risk (recent VTE <3 months, mechanical heart valve) 1

5. Resumption after procedure:

   • Low bleeding risk: Resume 24 hours after procedure
   • High bleeding risk or ongoing concerns: Resume 48-72 hours after procedure 1
   • Consider reduced dose initially (rivaroxaban 10 mg once daily) for 2-3 days before returning to full dose 1

Special Considerations

• For emergency procedures when rivaroxaban cannot be discontinued for sufficient time, be prepared for bleeding management including prothrombin complex concentrate (PCC) 3
• Ensure adequate hemostasis is achieved before resuming rivaroxaban 5
• The risk of thromboembolism during temporary discontinuation is generally low for most patients with atrial fibrillation

Potential Complications

PCN performed while on rivaroxaban or with insufficient discontinuation time carries significant risks:

• Increased intraoperative bleeding
• Higher transfusion requirements
• Potential for severe hemorrhagic complications 6
• Difficulty achieving hemostasis during and after the procedure

By following these guidelines for rivaroxaban discontinuation before PCN, the risk of perioperative bleeding can be minimized while maintaining appropriate management of thrombotic risk.