Bladder Biopsy

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Creed3

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I have a mechanical aortic valve and have been on warfarin for over 20 years. My urologist wants to do a bladder biopsy due to bladder inflammation that is most likely due to chronic utis. They just want to biopsy to be safe and make sure its nothing else. The doctor's office was saying that i will most likely have to stop my baby aspirin and warfarin before the biopsy. I dont want to do that. Shouldnt i have bridging with lovenox for a procedure like this or should i stay on warfarin? My INR is to be kept between 2.0 and 3.0. My last INR was 3.0. Im just really worried about this. Has anyone here gone through something similar?
Thanks
Creed3
 
Im within my normal range for everday but the instructions from the urologist say to stop blood thinners a few days before the biopsy. I dont want to stop taking my baby aspirin or warfarin. I was wondering if i should have bridge therapy with lovenox or just stay on my warfarin. I am afraid to withold my warfarin. I am going to need to talk to my doctor that controls my warfarin.
 
I had two thyroid procedures while on warfarin. The first is known as ethanol ablation, which involved a needle draining the thyroid cyst and then another needle inserted to fill the cyst with ethanol, which is then withdrawn after 15 minutes with another needle. My INR range is 2.0 to 3.0 and no holding of warfarin was required, no reduction of INR required and no bridging. My doctor explained that the risk of bleeding was very low with just a needle insertion and no need to hold warfarin. I've had several biopsies done of my thyroid over the years, all before I was on warfarin, and I would estimate that the size of the needles used was similar for the biopsies, compared to the needles used for the ethanol ablation.

A few months later I had a second thyroid procedure, known as radio frequency ablation. This involved a significantly larger needle, which was used to ablate the remaining thyroid nodule. This was a more involved procedure, with a larger needle, as compared to the biopsies and the ethanol ablation, which had previously been done. Rather than hold my warfarin and bridge, the surgeon had me bring my INR down to below 1.5 before the procedure. As I self test, this was relatively easy to do. I was able to achieve this by reducing my warfarin dosage for a couple of days. Do you self test?

You might want to get another opinion about whether there is a need to hold warfarin and see if they can just reduce your INR, by reducing your dosage. For most procures, especially minor ones like a biopsy, probably getting INR down to 1.5 would be just fine, if lowering is requred at all. For my ethanol procedure, I did make sure that my INR was need the lower end of my range just for good measure.

I would not expect many medical professionals to require bridging for just a biopsy, but they might want to lower your INR a little. Bridging can create some complications and is generally used for more major procedures. I'd be curious as to how long they want you to hold your warfarin. If they want you to hold it for days, I would have a discussion about what the actual INR target is. Some will have a patient hold warfarin for 5 days, to be sure than INR is under 1.5 and then test the morning of the procedure to be sure. For me, personally, knowing how fast my INR drops, this would have been extreme overkill. Ideally, whatever the INR target is for the procedure, you want to spend as little time below that level as possible. This is one very big advantage of self testing, in my view. I was literally able to bring my INR down to 1.4 and just stay at that level for less than 24 hours.
 
Hi
I wanted also to go back to basics here, so;

I have a mechanical aortic valve and have been on warfarin for over 20 years.
noted ... do you self test? (or better, self manage?)
My urologist wants to do a bladder biopsy due to bladder inflammation that is most likely due to chronic utis. They just want to biopsy to be safe and make sure its nothing else.
prudent

The doctor's office was saying that i will most likely have to stop my baby aspirin and warfarin before the biopsy. I dont want to do that.
well you know that you have to go off AntiCoagulationTherapy for specific occasions, this is one of those occasions. However I understand from what you say later its the duration that matters here. Firstly I would encourage yo uto read this post of mine here:

https://www.valvereplacement.org/threads/short-of-breath.889249/post-927441
and the one I quote myself as that being to provide supplemental support .. just so that we're on the same page with what bridging means.

Shouldnt i have bridging with lovenox for a procedure like this or should i stay on warfarin?
the goal of the process is to ensure that you have sufficient coagulation (perhaps not full, but often INR < 1.5) to ensure you actually heal from the surgical wound. Yes, its a wound and bleeding results, the body and tissues needs coagulation to stop it and then allow the cells to commence regrowth.

My INR is to be kept between 2.0 and 3.0. My last INR was 3.0. Im just really worried about this. Has anyone here gone through something similar?
So, if your INR is 3.0 that's too high. As you know (after reading those above links) bridging is to exchange out one form of anticuagulation which is slow to respond but easy to administer for one which is annoying to administer but fast to respond (to switch on and off quickly).

Read those posts and hit me up with questions as you have them.

Fundamentally consult with your Urologist as to the desired INR that they want for the procedure (no, don't ask their reciption, they're twits). Usually phone or email is alright and they'll probably say INR < 1.5 is sufficient.

Naturally you'll use a few strips on this.

Reach out by "Conversation" (our direct messaging) if you want to.
 
Thank you for all of the information.
I used to test my Inr at home but my machine and the strips were recalled many years ago. I now am tested at my doctor's office on their machine.
I will definitely be contacting the urologist doing the biopsy to see where they want my Inr. I am also going to contact my doctor that regulates my warfarin.
 
Thank you for all of the information.
I used to test my Inr at home but my machine and the strips were recalled many years ago. I now am tested at my doctor's office on their machine.
I will definitely be contacting the urologist doing the biopsy to see where they want my Inr. I am also going to contact my doctor that regulates my warfarin.
If I was you (indeed I actually do this) I'd buy my own machine and buy my own strips and test myself.

If you feel you can't do this then that's an indication that you should just follow the instructions. You can't drive a car without practice either.

Best Wishes

PS: I'm 4 years older than you

PPS: stuff like this exists and is usually totally fine
https://www.ebay.com/itm/256226629201
 
Thank you for all of the information.
I used to test my Inr at home but my machine and the strips were recalled many years ago. I now am tested at my doctor's office on their machine.
I will definitely be contacting the urologist doing the biopsy to see where they want my Inr. I am also going to contact my doctor that regulates my warfarin.
Your correct INR and the risks of going out of range is dependent upon your physiology, your valve type, placement and manufacturer. I've stopped warfarin for 3 procedures and each case my cardiologist, the warfarin prescriber, gave me instructions on when to stop before the procedure. The doctor doing the procedure told me when to restart (same day for two of them, 1 day later for another procedure). To lower my INR, if my INR was high, it was stop 3 days before, with a lower INR it was 2 days before. With my valve type and placement there was no need to bridge.
 
Your correct INR and the risks of going out of range is dependent upon your physiology, your valve type, placement and manufacturer. I've stopped warfarin for 3 procedures and each case my cardiologist, the warfarin prescriber, gave me instructions on when to stop before the procedure. The doctor doing the procedure told me when to restart (same day for two of them, 1 day later for another procedure). To lower my INR, if my INR was high, it was stop 3 days before, with a lower INR it was 2 days before. With my valve type
 
My doctor got back to me this evening. He said he spoke with my warfarin pharmacist and they want me to stop warfarin five days before the procedure. I am very nervous about this. In their opinion there is a risk of bleeding from the biopsy. I have a St Jude bileaflet in the aortic position.
I have asked my doctor where they want my INR before the surgery.
 
My doctor got back to me this evening. He said he spoke with my warfarin pharmacist and they want me to stop warfarin five days before the procedure. I am very nervous about this. In their opinion there is a risk of bleeding from the biopsy. I have a St Jude bileaflet in the aortic position.
I have asked my doctor where they want my INR before the surgery.
I have a St. Jude in the aortic position as well. In my experience, I did what they said but didn't monitor to make sure I hit a target. Right before the procedure the nurse took my INR to make sure it was where it needed to be for surgery. It was a little over 1. They will tell you when to restart warfarin. In my case I resumed my normal dose and checked my INR in ~5 days. It was in range.

I had one procedure, a transurethral resection of the prostate aka TURP. After surgery, I had clear urine but as my INR went up I got some blood in my urine. This was a good indicator that my INR needed to be low for the surgery and that a higher INR slightly inhibited my recovery. My urologist said that was normal for someone on warfarin after a TURP.

Don't worry, you should be fine. My cardiologist said that the St. Jude is a robust product with years of history and can stand a low INR for awhile w/o any problem. My valve used to have a recommended range of 2-3 INR but was changed to 2-2.5 due to its good historical performance.
 
Hi

My doctor got back to me this evening. He said he spoke with my warfarin pharmacist and they want me to stop warfarin five days before the procedure. I am very nervous about this.
personally I wouldn't be "very nervous" because Tom has suggested the risk of thrombosis is not so great with modern bileaflet valves such as the St Jude

There are some great examples of just how long you can go without ACT (warfarin) but I don't suggest you enter this competition

https://www.valvereplacement.org/threads/how-long-can-you-go-without-it.887951/#post-903896
Myself I'm a conservative person and would prefer to steer town to a target set by the practitioner (and if they said INR = 1.1 I'd do that too) but I'd be resuming rapidly

Here is my blog post about what I did last time I had a bleed creating invasive procedure (which involved taking a few biopsies of polyps). I suggest you read it carefully as if you were going to take an exam on that and didn't want to fail.

https://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html
but the main point I have is how long my INR was below 1.4

2017colonoscopyINR.jpg


you can see
  • the days I withheld,
  • the INR measured on those days,
  • the amount of dose I took in recovery to the desired the Anti Coagulated State
I mention that I took one heparin shot in that post.

HTH
 
Oh and its good to see that I get the offiical approval from the Sherrif here on the site
fig1.jpg


Its always good to get feedback that I'm on point with my posts
 
I just heard from my doctor about how to bring my INR down for my bladder biopsy. My doctor spoke to my urologist and said that just a small tissue sample is being taken for the biopsy. The procedure can be done with an INR of 2.0 and they will get me back to my normal range right away. My normal range is 2.0 to 3.0 so technically i will still be in range.
 
I’m very glad that you took the suggestion to ask specifically about INR target. Holding INR for 5 days for a biopsy was insanity and he was about to put you needlessly at risk of stroke. The risk would not have been high, but also would not have been insignificant. Strokes do happen during procedures.

Well done!
 
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I just found out from a ct scan i had yesterday that i have a large staghorn calculus (kidney stone) in my left kidney. I am going to have to have a procedure to have it removed. Im sure my INR will need to be decreased more than the biopsy INR due to chances of bleeding in the kidney.
 
I just found out from a ct scan i had yesterday that i have a large staghorn calculus (kidney stone) in my left kidney.

well that's annoying

I am going to have to have a procedure to have it removed. Im sure my INR will need to be decreased more than the biopsy INR due to chances of bleeding in the kidney.

maybe, but really, don't overblow the risks of a controlled and planned for (rather than just slack and kept forgetting to take warfarin) withdrawal from ACT. Its expected and the risks of complications from it are very low (just not non-zero).

Its easy to over think this.

I suggest you buy a meter (if you can afford it) and start testing yourself and start documenting that even if only to see what happens if you make (say) a 30% dose reduction for 3 days straight.

Best Wishes
 

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