When should anticoagulation be restarted after a cystoscopy procedure?

From the Guidelines

Anticoagulation should be restarted at least 24 hours after a low-to-moderate-bleed-risk cystoscopy, and 48-72 hours after a high-bleed-risk procedure, as suggested by the most recent guidelines 1. When considering the resumption of anticoagulation after cystoscopy, several factors must be taken into account, including the type of anticoagulant used, the patient's thrombotic risk, and the bleeding risk associated with the procedure.

• For patients on direct oral anticoagulants (DOACs), the resumption of therapy can occur as early as 24 hours post-procedure for low-to-moderate-bleed-risk surgeries, given their rapid onset of action and peak effect within 1 to 3 hours after intake 1.
• The decision to restart anticoagulation should be individualized, considering the patient's specific risk factors, such as recent venous thromboembolism or mechanical heart valves, which may necessitate earlier resumption, and procedural complications or additional bleeding risk factors, which may require delayed restart.
• Recent guidelines also suggest that for patients on vitamin K antagonists (VKAs), such as warfarin, resumption can begin as early as 12 to 24 hours postoperatively, once hemostasis is achieved, and at the previous therapeutic dose, with consideration for additional monitoring due to potential alterations in concomitant medications, nutrition, and drug clearance during the perioperative period 1.
• The timing of anticoagulation resumption should balance the need for thrombotic protection with the risk of bleeding, taking into account the specifics of the cystoscopy, including its invasiveness, whether biopsies were taken, and if therapeutic interventions were performed.
• Ultimately, the goal is to minimize the risk of both thrombotic events and bleeding complications, and the most recent and highest quality evidence should guide clinical decision-making, with the American College of Chest Physicians clinical practice guideline 1 providing a framework for the perioperative management of antithrombotic therapy.

From the Research

Anticoagulation Restart After Cystoscopy

• The decision to restart anticoagulation after cystoscopy depends on the patient's individual risk of bleeding and thromboembolism 2.
• For patients undergoing minimal bleeding risk procedures like cystoscopy, anticoagulation may be continued or discontinued on the day of the procedure if there is concern about excessive bleeding 2.
• However, there is no specific guidance on when to restart anticoagulation after cystoscopy, as the provided studies focus on more general perioperative management of anticoagulation and do not address cystoscopy specifically.
• Studies on the management of anticoagulation in patients with atrial fibrillation and venous thromboembolism suggest that the risk of bleeding and thromboembolism should be carefully weighed when deciding when to restart anticoagulation 3, 4, 5.
• A study on the management dilemmas in restarting anticoagulation after gastrointestinal bleeding highlights the importance of balancing the risk of rebleeding with the risk of thromboembolic events, but does not provide specific guidance on cystoscopy 6.

Considerations for Restarting Anticoagulation

• The patient's individual risk factors, such as the presence of atrial fibrillation or venous thromboembolism, should be taken into account when deciding when to restart anticoagulation 3, 4, 5.
• The type of anticoagulant used, such as a direct oral anticoagulant (DOAC) or warfarin, may also influence the decision on when to restart anticoagulation 2, 3, 4, 5.
• The risk of bleeding and thromboembolism should be carefully monitored after restarting anticoagulation, and the patient should be educated on the signs and symptoms of these complications 6.