Safety and efficacy of holmium:yag laser lithotripsy in patients with bleeding diatheses

Purpose: To assess the safety and efficacy of ureteroscopy and holmium:YAG (yttrium-aluminum-garnet) laser lithotripsy in the treatment of upper urinary tract calculi in patients with known and uncorrected bleeding diatheses. Materials and Methods: A retrospective chart review from 2 tertiary stone centers was performed to identify patients with known bleeding diatheses who were treated with holmium:YAG laser lithotripsy for upper urinary tract calculi. Twenty-five patients with 29 upper urinary tract calculi were treated with ureteroscopic holmium laser lithotripsy. Bleeding diatheses identified were coumadin administration for various conditions (17), liver dysfunction (3), thrombocytopenia (4), and von Willebrand's disease (1). Mean international normalized ratio (INR), platelet count and bleeding time were 2.3, 50 x 10(9)/L, and > 16 minutes, for patients receiving coumadin or with liver dysfunction, thrombocytopenia, or von Willebrand's disease, respectively. Results: Overall, the stone-free rate was 96% (27/28) and 29 of 30 procedures were completed successfully without significant complication. One patient who was treated concomitantly with electrohydraulic lithotripsy (EHL) had a significant retroperitoneal hemorrhage that required blood transfusion. Conclusions: Treatment of upper tract urinary calculi in patients with uncorrected bleeding diatheses can be safely performed using contemporary small caliber ureteroscopes and holmium laser as the sole modality of lithotripsy. Ureteroscopic holmium laser lithotripsy without preoperative correction of hemostatic parameters limits the risk of thromboembolic complications and costs associated with an extended hospital stay. Avoidance of the use of EHL is crucial in reducing bleeding complications in this cohort of patients.