How should anticoagulation be managed in patients on chronic anticoagulation (e.g. warfarin, direct oral anticoagulants (DOACs) like apixaban (eliquis) or rivaroxaban (xarelto)) who require a prostate biopsy with a ureteral stent?

Management of Anticoagulation for Prostate Biopsy with Ureteral Stent

For patients on chronic anticoagulation requiring prostate biopsy with ureteral stent placement, anticoagulants should be temporarily discontinued and managed according to specific timing protocols based on the type of anticoagulant, with warfarin stopped 5 days before the procedure and DOACs stopped 48-72 hours before, without bridging therapy for most patients. 1

Risk Stratification

Procedure Risk

• Prostate biopsy with ureteral stent placement is considered a high bleeding risk procedure 1
• Transrectal ultrasound-guided prostate biopsy (TRUSBx) carries risk of hematuria, rectal bleeding, and hemospermia 1

Patient Thrombotic Risk

Stratify patients into:

• High risk: Mechanical mitral valve, recent (<3 months) stroke/TIA, recent (<3 months) VTE, severe thrombophilia 1
• Moderate risk: Bileaflet aortic valve with risk factors, CHADS₂ score 3-4, VTE within past 3-12 months, active cancer 1
• Low risk: Bileaflet aortic valve without risk factors, CHADS₂ score 0-2, VTE >12 months ago 1

Anticoagulation Management Protocol

Warfarin Management

• Stop warfarin 5 days before procedure 1
• Check INR prior to procedure to ensure INR <1.5 1
• Resume warfarin evening of procedure at usual daily dose 1
• Check INR 1 week later to ensure adequate anticoagulation 1

DOAC Management

• Stop DOACs at least 48 hours before procedure 1
• For dabigatran with CrCl 30-50 ml/min, stop 72 hours before procedure 1
• Resume DOACs 24-48 hours after procedure if hemostasis is adequate 2, 3
• DOACs reach therapeutic effect within 2-4 hours after administration 4

Bridging Therapy

• Bridging with heparin is NOT recommended for most patients 1, 3
• For high thrombotic risk patients only (mechanical mitral valve, recent stroke/TIA, recent VTE):
  • Start LMWH 2 days after stopping warfarin 1
  • Stop LMWH 24 hours before procedure 2
  • Resume LMWH 24-48 hours after procedure if hemostasis is adequate 1
  • Do not overlap LMWH with resumed oral anticoagulants 2

Special Considerations

Aspirin Management

• Low-dose aspirin can be safely continued through prostate biopsy 1
• Studies show no significant increase in major bleeding complications with continued aspirin 1, 5
• For patients on dual antiplatelet therapy, continue aspirin but stop P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) 5 days before procedure 1

Post-Procedure Monitoring

• Monitor for hematuria, rectal bleeding, and hemospermia 6, 5
• Grade 2 or higher bleeding complications (requiring intervention) occur in approximately 3.5% of patients on antithrombotic therapy 6
• Resume full anticoagulation only when adequate hemostasis is confirmed 1

Common Pitfalls and Caveats

1. Avoid bridging for low-risk patients: Unnecessary bridging increases bleeding risk without clinical benefit 4

2. Don't delay anticoagulation restart excessively: Prolonged interruption increases thrombotic risk; resume as soon as hemostasis is adequate 1

3. Consider renal function: Adjust DOAC timing based on renal function, particularly for dabigatran 1, 4

4. Individualize timing for high-risk patients: Those with mechanical heart valves or recent thrombotic events may need earlier resumption of anticoagulation 1

5. Routine coagulation tests are not reliable for DOACs: PT/INR and aPTT should not guide resumption decisions for DOACs 4

This approach balances the risks of procedure-related bleeding against the risks of thromboembolism, with specific protocols based on both the type of anticoagulant and the patient's thrombotic risk profile.