Can a patient take aspirin (acetylsalicylic acid) when scheduled for a cystoscopy?

Management of Aspirin Therapy for Patients Undergoing Cystoscopy

For patients undergoing cystoscopy, aspirin therapy should be continued without interruption as cystoscopy is considered a low-risk endoscopic procedure. 1

Risk Stratification for Cystoscopy

Cystoscopy falls under the category of diagnostic endoscopic procedures, which are classified as low-risk procedures according to current guidelines. The British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) clearly categorize diagnostic procedures with or without biopsy as low-risk procedures.

Low-Risk Endoscopic Procedures:

• Diagnostic endoscopy (including cystoscopy)
• Procedures with biopsy without polypectomy
• Biliary or pancreatic stenting
• EUS without sampling

Management Algorithm for Aspirin Therapy Before Cystoscopy

1. For patients on aspirin monotherapy:

   • Continue aspirin therapy without interruption 1
   • No dose adjustment is necessary
   • No need to skip the morning dose on the day of procedure

2. For patients on dual antiplatelet therapy (aspirin plus P2Y12 inhibitor):

   • Continue both medications without interruption for low-risk procedures like cystoscopy 1
   • No need to consult with a cardiologist for cystoscopy specifically

3. For patients on aspirin for primary prevention:

   • Continue aspirin therapy without interruption 1

4. For patients on aspirin for secondary prevention:

   • Absolutely continue aspirin therapy without interruption 1
   • Discontinuation could lead to significant thrombotic risk

Evidence Supporting Continuation of Aspirin

The 2021 BSG/ESGE guidelines strongly recommend continuing aspirin for all endoscopic procedures (strong recommendation, low quality evidence) 1. This is supported by earlier 2016 guidelines that also recommended continuing aspirin for all endoscopic procedures except for specific high-risk interventions like ESD, large colonic EMR, upper GI EMR, and ampullectomy 1.

Research has shown that discontinuing aspirin therapy in patients taking it for secondary prevention is associated with a three-fold increased risk of cardiovascular or cerebrovascular events, with 70% of these events occurring within 7-10 days after interruption 1. The thrombotic risk from discontinuing aspirin typically outweighs the minimal bleeding risk associated with low-risk procedures like cystoscopy.

Bleeding Risk vs. Thrombotic Risk

• Bleeding risk with cystoscopy: Minimal and typically easily controlled if it occurs
• Thrombotic risk with aspirin discontinuation: Potentially severe with risk of stroke, myocardial infarction, or death, especially in patients on aspirin for secondary prevention

Studies have demonstrated that the normal hemostatic function returns within 5-6 days after stopping aspirin 2, but this temporary discontinuation creates an unnecessary window of thrombotic risk for a procedure with minimal bleeding risk.

Common Pitfalls to Avoid

1. Inappropriate discontinuation of aspirin: Despite guidelines, many patients (up to 47.5% in some studies) inappropriately alter their aspirin therapy before endoscopic procedures 3. This creates unnecessary thrombotic risk.

2. Confusion between high and low-risk procedures: Cystoscopy is a low-risk procedure and does not require aspirin discontinuation, unlike higher-risk procedures such as ESD or large polypectomy.

3. Failure to distinguish between primary and secondary prevention: While aspirin discontinuation might be considered for primary prevention in some contexts, it should almost never be discontinued when used for secondary prevention of cardiovascular events.

4. Assuming all antiplatelet agents are managed the same way: While aspirin should be continued for cystoscopy, management of other antiplatelet agents like P2Y12 inhibitors may differ for higher-risk procedures (though not for cystoscopy).

By continuing aspirin therapy for patients undergoing cystoscopy, clinicians can minimize thrombotic risk while maintaining a safe procedural profile with minimal bleeding complications.