Ureteroscopy in Patients Receiving Systemic Anticoagulants: A Systematic Review and Meta-analysis of Safety, Efficacy, and Perioperative Management.

Abstract

Context: To evaluate the safety and efficacy of ureteroscopy (URS) in adults receiving systemic anticoagulant (AC) therapy, including vitamin K antagonists and direct oral anticoagulants (DOACs), compared with non-AC controls.

Objective: Using a Population, Intervention, Comparator, Outcomes (PICO) framework, we examined whether continuation, interruption, or peri-operative bridging of AC influences bleeding complications, thromboembolic events, and stone-free rates (SFR) in adults undergoing URS for stone disease.

Evidence acquisition: A systematic review of PubMed, Embase, and Scopus identified studies reporting URS outcomes in anticoagulated patients. The review adhered to PRISMA standards and was registered with PROspective Register of Systematic Reviews (PROSPERO) (Centre for Reviews and Dissemination (CRD)420251154766). Studies limited to antiplatelet monotherapy were excluded. Random-effects meta-analysis was performed for outcomes where sufficient comparative data were available. SFR was summarised descriptively. Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I).

Evidence synthesis: Eleven studies (1,516 AC patients; 20,708 controls) published between 1998 and 2024 met inclusion criteria. Anticoagulation was not associated with a statistically significant increase in overall postoperative complications (RR 1.83, 95% CI 0.95-3.52). Bleeding-related complications were variably reported across studies, with absolute event rates ranging from 0-20% in anticoagulated patients and 0-0.60% in controls. In the largest comparative cohort, bleeding occurred in 1.1% (8/702) of anticoagulated patients versus 0.40% (44/10,859) of controls. Thirty-day readmission rates did not differ significantly (RR 1.59, 95% CI 0.27-9.29). SFRs ranged between 70-97% across studies. Most studies were judged at serious risk of bias, primarily due to non-random allocation of AC strategies.

Conclusions: Bleeding complications were variably reported across studies, with several observational cohorts reporting higher absolute bleeding rates in anticoagulated patients than controls, although definitions were heterogeneous and absolute event rates were low. Thromboembolic events were rare. Continuation may be justified in carefully selected high-thrombotic-risk patients.