Use of ureteroscopy and holmium:YAG laser in patients with bleeding diatheses.

OBJECTIVES: To assess the safety and efficacy of ureteroscopy and holmium laser in patients with known bleeding diatheses and upper tract calculi or transitional cell carcinoma (TCC).
METHODS: Eight patients with stone disease and 1 patient with upper tract TCC were treated ureteroscopically with the holmium laser. The mean age was 58.3 years (range 42 to 74). Six patients were receiving Coumadin, with a mean international normalized ratio (INR) of 2.1 (normal INR less than 1.1). Two patients were thrombocytopenic, and 1 had von Willebrand's disease. None of the bleeding diatheses were corrected before surgery. Semirigid or flexible ureteroscopes were used to access the ureter or intrarenal collecting system. The holmium laser was used to fragment calculi or ablate tumor.
RESULTS: Only 1 patient had a postoperative bleeding complication related to the procedure, involving an episode of oliguria secondary to a small ureteral clot. This cleared without surgical intervention. Another patient developed an episode of epistaxis after administration of ketorolac for pain. Six of 7 patients who underwent laser fragmentation for calculi were stone free on follow-up intravenous urogram at 1 month, and no tumor recurrence was noted in the patient with TCC (follow-up of 4 months).
CONCLUSIONS: Ureteroscopy allowed excellent access to all regions of the upper tracts, and holmium laser fragmentation of calculi or ablation of tumor was effective in managing each particular problem. Use of the holmium laser with ureteroscopic access provides a safe and acceptable combination for treating upper tract pathology in patients with uncorrected bleeding diatheses. As a result, these patients can avoid added costs of extended hospital stay and risks associated with transfusions.