Procedure-specific Risks of Thrombosis and Bleeding in Urological Cancer Surgery: Systematic Review and Meta-analysis

Incidence and Associated Risk Factors of Venous Thromboembolism After Open and Laparoscopic Nephrectomy in Patients Administered Short-period Thromboprophylaxis: A Danish Nationwide Population-based Cohort Study

OBJECTIVE

To report the incidence of venous thromboembolism (VTE) after nephrectomy in Denmark and explore associated risk factors.

MATERIALS AND METHODS

A nationwide population-based retrospective cohort study was performed. All nephrectomies from January 2010 to August 2018 were assessed for postoperative VTE events. Univariable and multivariable analyses were used to evaluate the odds ratio (OR) of clinical variables' effect on postoperative VTEs, within 4 weeks and 4 months after nephrectomy.

RESULTS

In 5213 nephrectomized patients, postoperative VTE incidence was 1% and 2% within 4 weeks and 4 months, respectively. Multivariable analyses revealed that predictors of postoperative VTE within 4 months were: open nephrectomy (OR 2.5, P = .001), history of VTE (OR 13.3, P <.001), length of hospital stay (OR 0.98, P = .02), and lymph node dissection (OR 2.0, P = .04). Limitations included the retrospective and registry-based study design and absence of individual patient data on patient body mass index and length of surgery.

CONCLUSION

For nephrectomy, postoperative VTE is rare. Open nephrectomy, history of VTE, length of hospital stay, and lymph node dissection are important risk factors which should be evaluated when tailoring VTE prophylaxis regimens.

An International Survey on the Use of Thromboprophylaxis in Urological Surgery

BACKGROUND

The use of perioperative thromboprophylaxis in urological surgery is common but not standardized.

OBJECTIVE

To characterize international practice variation in thromboprophylaxis use in urological surgery.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a scenario-based survey addressing the use of mechanical and pharmacological thromboprophylaxis in urological cancer procedures (radical cystectomy [RC], radical prostatectomy [RP], and radical nephrectomy [RN]) among practicing urologists in Canada, Finland, and Japan. The survey presented patient profiles reflecting a spectrum of risk for venous thromboembolism; the respondents described their clinical practice.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The proportion of respondents who routinely used (1) mechanical, (2) pharmacological, and (3) extended pharmacological prophylaxis was stratified by procedure. A logistic regression identified characteristics associated with thromboprophylaxis use.

RESULTS AND LIMITATIONS

Of 1051 urologists contacted, 570 (54%) participated in the survey. Japanese urologists were less likely to prescribe pharmacological prophylaxis than Canadian or Finnish urologists (p < 0.001 for all procedures). Canadian and Finnish urologists exhibited large variation for extended pharmacological prophylaxis for RP and RN. Finnish urologists were most likely to prescribe extended prophylaxis versus Canadian and Japanese urologists (RC 98%, 84%, and 26%; Open RP 25%, 8%, and 3%; robotic RP 11%, 9%, and 0%; and RN 43%, 7%, and 1%, respectively; p < 0.001 for each procedure). Less variation was found regarding the prescription of mechanical prophylaxis, which was most commonly used until ambulation or discharge. The length of hospital stay was longer in Japan and may bias estimates of extended prophylaxis in Japan.

CONCLUSIONS

We found large variation in clinical practice regarding pharmacological thromboprophylaxis within and between countries. Knowledge translation of evidence-based guidelines may reduce problematic international variation in practice.

PATIENT SUMMARY

Use of medications to decrease blood clots after urological cancer surgery differs within and between countries. Closer adherence to urology guidelines addressing the prevention of blood clots may decrease this variation and improve patient outcomes.

Effect of Pharmacologic Prophylaxis on Venous Thromboembolism After Radical Prostatectomy: The PREVENTER Randomized Clinical Trial

BACKGROUND

Direct high-quality evidence is lacking evaluating perioperative pharmacologic prophylaxis (PP) after radical prostatectomy (RP) to prevent venous thromboembolism (VTE) leading to significant practice variation.

OBJECTIVE

To study the impact of in-hospital PP on symptomatic VTE incidence and adverse events after RP at 30 d, with the secondary objective of evaluating overall VTE in a screening subcohort.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, phase 4, single-center, randomized trial of men with prostate cancer undergoing open or robotic-assisted laparoscopic RP was conducted (July 2017-November 2018).

INTERVENTION

PP (subcutaneous heparin) plus routine care versus routine care alone. The screening subcohort was offered lower extremity duplex ultrasound at 30 d.

OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS

The primary efficacy outcome was symptomatic VTE incidence (pulmonary embolism [PE] or deep venous thrombosis [DVT]). Primary safety outcomes included the incidence of symptomatic lymphocele, hematoma, or bleeding after surgery. Secondary outcomes were overall VTE, estimated blood loss, total surgical drain output, complications, and surveillance imaging bias. Fisher's exact test and modified Poisson regression were performed.

RESULTS AND LIMITATIONS

A total of 501 patients (75% robotic) were randomized and >99% (500/501) completed follow-up. At second interim analysis (N = 445), the symptomatic VTE rate was 2.3% (four PE + DVT and one DVT) for routine care versus 0.9% (one PE + DVT and one DVT) for PP (relative risk 0.40 [95% confidence interval 0.08-2.03], p = 0.3) meeting a futility threshold for early stopping. In the screening subcohort, the overall VTE rate was 3.3% versus 2.4% (p = 0.7). Results were similar at the final analysis (symptomatic VTE: 2.0% vs 0.8%, p = 0.3; overall VTE: 2.9% vs 2.8%, p = 1). No differences were observed in safety or secondary outcomes. All VTE events (seven symptomatic and three asymptomatic) occurred in patients undergoing pelvic lymph node dissection.

CONCLUSIONS

This study was not able to demonstrate a statistically significant reduction in symptomatic VTE associated with PP. There was no increase in the development of symptomatic lymphoceles, bleeding, or other adverse events. Given that the event rate was lower than powered for, further research is needed among high-risk patients (Caprini score ≥8) or patients receiving pelvic lymph node dissection.

PATIENT SUMMARY

In this report, we randomized patients undergoing radical prostatectomy to perioperative pharmacologic prophylaxis or routine care alone. We found that pharmacologic prophylaxis did not reduce postoperative symptomatic venous thromboembolism significantly for men at routine risk. Importantly, pharmacologic prophylaxis did not increase adverse events, such as formation of lymphoceles or bleeding, and can safely be implemented when indicated for patients with risk factors undergoing radical prostatectomy.

Pharmacological venous thromboembolism prophylaxis in radical prostatectomy

BACKGROUND AND AIM

Pulmonary thromboembolism is one of the most common causes of non-surgical death in patients following urological abdominopelvic surgery. Since the beginning of prophylaxis for venous thromboembolic disease, episodes of deep vein thrombosis and pulmonary thromboembolism have decreased. Our objective is to analyse the prognosis factors of thromboembolic disease, the clinical variability in the use of pharmacological prophylaxis and the results of its application.

MATERIAL AND METHODS

Retrospective multicentric study of 610 patients undergoing radical prostatectomy between December 2013 and November 2014, in 7general hospitals in Spain, Italy and Portugal. Patients were classified according to their baseline characteristics into thrombotic risk groups and haemorrhagic risk groups. The venous thromboembolic events that occurred in the different groups were analysed.

RESULTS

The average age was 65.22years (48-78). The average body mass index was 26.7 and the average ASA risk 2.1. In all patients, early mobilization began in the first 24hours. In 4.1% intermittent pneumatic compression was used and 84.6% received pharmacological prophylaxis with low molecular weight heparins. Only 3.4% used the combination of mechanical prophylaxis with pharmacological prophylaxis. We observed a decrease in the incidence of thromboembolic events in the patients who received pharmacological prophylaxis, with an absolute risk reduction of 6.8%. There was no increase in the risk of haemorrhage in the patients who received pharmacological prophylaxis.

CONCLUSIONS

In this study on patients undergoing radical prostatectomy, there was no difference in haemorrhagic complications derived from the use of pharmacological prophylaxis for venous thromboembolic disease. Pharmacological prophylaxis reduces the risk of presenting a thromboembolic event in patients undergoing radical prostatectomy, although this risk is not associated with the approach technique.

The impact of extended pelvic lymph node dissection on the risk of hospital readmission within 180 days after robot assisted radical prostatectomy

OBJECTIVE

To evaluate the factors associated with the risk of hospital readmission after robot assisted radical prostatectomy (RARP) with or without extended pelvic lymph node dissection (ePLND) for prostate cancer (PCA) over a long term.

MATERIALS AND METHODS

The risk of readmission was evaluated by clinical, pathological, and perioperative factors. Skilled and experienced surgeons performed the procedures. Patients were followed for complications and hospital readmission for a period of six months. The logistic regression model and Cox's proportional hazards assessed the association of factors with the risk of readmission.

RESULTS

From January 2013 to December 2018, 890 patients underwent RARP; ePLND was performed in 495 of these patients. Hospital readmission was detected in 25 cases (2.8%); moreover, it was more frequent when RARP was performed with ePLND (4.4% of cases) than without (0.8% of patients). On the final multivariate model, ePLND was the only independent factor that was positively associated with the risk of hospital readmission (hazard ratio, HR = 5935; 95%CI 1777-19,831; p = 0.004).

CONCLUSIONS

Over the long term after RARP for PCA, the risk of hospital readmission is associated with ePLND. In patients who underwent RARP and ePLND, 4.4% of them had a readmission, compared to RARP alone, in which only 0.8% of cases had a readmission. When ePLND is planned for staging pelvic lymph nodes, patients should be informed of the increased risk of hospital readmission.

American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients

BACKGROUND

Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality.

OBJECTIVE

These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic reviews. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 30 recommendations, including for major surgery in general (n = 8), orthopedic surgery (n = 7), major general surgery (n = 3), major neurosurgical procedures (n = 2), urological surgery (n = 4), cardiac surgery and major vascular surgery (n = 2), major trauma (n = 2), and major gynecological surgery (n = 2).

CONCLUSIONS

For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH). For major general surgery, the panel suggested pharmacological prophylaxis over no prophylaxis, using LMWH or unfractionated heparin. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. For major trauma surgery or major gynecological surgery, the panel suggested pharmacological prophylaxis over no prophylaxis.

Surgical thromboprophylaxis in daily urologic surgery: Beyond bridge therapy

INTRODUCTION

With the advanced laparoscopic and robotic surgery, thromboembolic prophylaxis in urologic procedures has traditionally been based on the experience of other surgical specialties. This paper aims to analyze the current recommendations, through a detailed study of the European clinical guidelines and bibliography, applying the recommendations of thromboprophylaxis to the daily urological practice.

OBJECTIVES

To elaborate general recommendations to surgical patients in Urology, avoiding the risk of perioperative thromboembolic events. Optimize medication in chronic patients and accurately classify who are eligible for bridge therapy.

MATERIAL AND METHODS

A review of the available literature and the European clinical guidelines was carried out. We analyzed the most recent consensus articles by studying the available bibliography, trials and reviews on which the European guidelines for thromboprophylaxis in urology are based.

RESULTS

Thromboembolic prophylaxis should be targeted towards surgeries that require abdominal approaches, prolonged bed rest or oncological pathologies. Bridge therapies with low molecular weight heparins should be limited. Patients undergoing treatment for chronic conditions can benefit from bridge therapies in specific cases.

CONCLUSIONS

According to the current guidelines, there might be an overuse of heparins in the daily clinical practice. The development of -direct oral- anticoagulants have shown to reduce the time to reintroduction of medication for chronic conditions as well as a more effective bleeding management.

The role of extended venous thromboembolism prophylaxis for major urological cancer operations

OBJECTIVES

Venous thromboembolism (VTE), consisting of both pulmonary embolism (PE) and deep vein thromboses (DVT), remains a well-recognised complication of major urological cancer surgery. Several international guidelines recommend extended thromboprophylaxis (ETP) with LMWH, whereby the period of delivery is extended to the post-discharge period, where the majority of VTE occurs. In this literature review we investigate whether ETP should be indicated for all patients undergoing major urological cancer surgery, as well procedure specific data that may influence a clinician's decision.

METHODS

We performed a search of six databases (PubMed, Cochrane, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and British Nursing Index (BNI)) from inception to June 2019, for studies looking at adult patients who received VTE prophylaxis after surgery for a major urological malignancy.

RESULTS

Eighteen studies were analysed. VTE risk is highest in open and robotic Radical Cystectomy (RC) (2.6-11.6%) and ETP demonstrates a significant reduction in risk of VTE, but not a significant difference in Pulmonary Embolism (PE) or mortality. Risk of VTE in open Radical Prostatectomy (RP) (0.8-15.7%) is comparable to RC, but robotic RP (0.2-0.9%), open partial/radical nephrectomy (1.0-4.4%) and robotic partial/radical nephrectomy (0.7-3.9%) were lower risk. It has not been shown that ETP reduces VTE risk specifically for RP or nephrectomy.

CONCLUSION

The decision to use ETP is a fine balance between variables such as VTE incidence, bleeding risk and perioperative morbidity/mortality. This balance should be assessed for each specific procedure type. While ETP still remains of net benefit for open RP as well as open and robotic RC, the balance is closer for minimally invasive RP as well as radical and partial nephrectomy. Due to a lack of procedure specific evidence for the use of ETP, adherence with national guidelines remains poor. Therefore, we advocate further studies directly comparing ETP vs standard prophylaxis, for specific procedure types, in order to allow clinicians to make a more informed decision in future.

Perioperative antithrombotic therapy does not increase the incidence of early postoperative thromboembolic complications and bleeding in kidney transplantation - a retrospective study

Perioperative antithrombotic therapy could play a role in preventing thromboembolic complications (TEC) after kidney transplantation (KTx), but little is known on postoperative bleeding risks. This retrospective analysis comprises 2000 single‐organ KTx recipients transplanted between 2011 and 2016 in the two largest transplant centers of the Netherlands. TEC and bleeding events were scored ≤7 days post‐KTx. Primary analyses were for associations of antithrombotic therapy with incidence of TEC and bleeding. Secondary analyses were for associations of other potential risk factors. Mean age was 55 ± 14 years, 59% was male and 60% received a living donor kidney. Twenty‐one patients (1.1%) had a TEC. Multiple donor arteries [OR 2.79 (1.15–6.79)] and obesity [OR 2.85 (1.19–6.82)] were identified as potential risk factors for TEC. Bleeding occurred in 88 patients (4.4%) and incidence varied significantly between different antithrombotic therapies (P = 0.006). Cardiovascular disease [OR 2.01 (1.18–3.42)], pre‐emptive KTx [OR 2.23 (1.28–3.89)], postoperative heparin infusion [OR 1.69 (1.00–2.85)], and vitamin K antagonists [OR 6.60 (2.95–14.77)] were associated with an increased bleeding risk. Intraoperative heparin and antiplatelet therapy were not associated with increased bleeding risk. These regimens appear to be safe for the possible prevention of TEC without increasing the risk for bleeding after KTx.

New oral anti-coagulation drugs and prostate biopsy: a call for guidelines

Background:

Prostate biopsy is a rather frequent procedure, mostly performed in outpatient settings. Bleeding complications following this procedure require precise and delicate management of pre-, peri- and post-procedure anti-coagulation treatments. New oral anti-coagulation drugs (NOACs) are increasingly used. However, the management of such treatments is feared and not yet well known to urologists. A protocol for prostate biopsy management of NOACs seems mandatory.

Materials and methods:

A review of the literature, using Pubmed and Cochrane databases, together with analysis of several medical associations’ recommendations in urology, anaesthesiology, cardiology, oncology and drug safety agency, was performed.

Results:

There are no recommendations about NOAC management for prostate biopsy available from scientific societies. There is also a lack of specific urological studies. However, several panels of expert recommendations could be helpful in establishing standardized protocols adapted from surgery to prostate biopsy. With the growing use of NOACs, recommendations have shifted to continue anti-coagulant treatment without bridging NOACs for low bleeding risk procedures such as prostate biopsy, in carefully selected groups of patients.

Conclusion:

Extensive indications coupled with the ease of use of NOACs contribute significantly to the widespread replacement of traditional vitamin K antagonist. Knowing that heparin bridging leads to more bleeding, and in the pursuit of more autonomy and safety, urologists should be able to propose dedicated anti-coagulant management using NOACs adapted to carefully selected patients before the prostate biopsy procedure. Further studies and guidelines specific to the concept of non-bridging for anti-coagulant-requiring patients are mandatory for this routine procedure.

Venous Thromboembolism and Peri-Operative Chemotherapy for Muscle-Invasive Bladder Cancer: A Population-based Study

Background:

Chemotherapy and major pelvic surgery are established risk factors for venous thromboembolism (VTE). We evaluate the incidence rate, timing, and factors associated with VTE in patients with bladder cancer who underwent radical cystectomy and peri-operative chemotherapy in routine clinical practice.

Methods:

Electronic records of treatment were linked to the population-based Ontario Cancer Registry to identify all patients who underwent cystectomy for bladder cancer in Ontario 1994–2013. VTE events within 6 months of before or after cystectomy were identified using diagnostic codes recorded on hospital admissions and emergency department visits. Multivariable logistic regression was used to analyze factors associated with VTE prior to surgery, within 90-days of cystectomy, and 120-days after the start of adjuvant chemotherapy.

Results:

4205 patients had cystectomy and 26% (1084/4205) received peri-operative chemotherapy. The overall incidence rate of VTE within 6 months of cystectomy was 9% (363/4205). VTE rate was highest among those patients treated with neoadjuvant chemotherapy (NACT) compared to patients treated with no chemotherapy or only adjuvant chemotherapy (ACT) (12% vs 8% vs 9%, p = 0.002). Among all VTE events, 10%, 28%, and 61% occurred before, during, and after hospitalization for cystectomy. Pre-operative VTE rate was highest among cases treated with NACT (4%) compared to patients with no chemotherapy (<1%) or ACT (<1%) (p < 0.001). VTE within 90 days of surgery was associated with greater length of hospital admission (p < 0.001) across all treatment groups.

Conclusions:

A substantial proportion of patients treated with peri-operative chemotherapy will develop VTE. The majority of these occur after discharge from hospital following cystectomy. Extended thromboprophylaxis treatment in high-risk patients including those who receive peri-operative chemotherapy should be considered.

Performance Measurement and Quality Improvement Initiatives for Bladder Cancer Care

PURPOSE OF REVIEW

Bladder cancer care is costly due to long surveillance periods for non-muscle-invasive bladder cancer (NMIBC) and comorbidities associated with the surgical treatment of muscle-invasive bladder cancer (MIBC). We reviewed current evidence-based practices and propose quality metrics for NMIBC and MIBC.

RECENT FINDINGS

For patients with NMIBC, we propose four categories of candidate quality metrics: (1) appropriate use of imaging, (2) re-staging transurethral resection of bladder tumor, (3) perioperative intravesical chemotherapy, and (4) induction and maintenance BCG in high-risk NMIBC. For patients with MIBC, we propose eight candidate quality measures: (1) neoadjuvant chemotherapy, (2) multidisciplinary consultation, (3) urinary diversion teaching, (4) appropriate perioperative antibiotics, (5) venous thromboembolic prophylaxis, (6) lymphadenectomy, (7) monitoring of complications, and (8) inclusion of enhanced recovery after surgery protocols. Marked variation in evidence-based practice exists among patients with bladder cancer and represents opportunity for quality improvement. Regional and national physician-led collaboratives may be the best vehicle to achieve quality improvement in bladder cancer.

[Venous thromboembolism and urological cancer: Epidemiology and therapeutically management]

INTRODUCTION

Active cancer is a risk factor in the occurrence of venous thromboembolism (VTE). This is the second cause of death for these patients. In onco-urology, some cancers are associated with an increased risk of VTE. The aim of this study was to propose a focus of epidemiology and VTE therapy management.

MATERIAL AND METHODS

A systematic analysis of the PubMed^® database was performed through the PRISMA methodology using the followings keywords : "neoplasm", "venous thromboembolism", "prophylaxis", "pulmonary embolism", "urology". The original papers were included with a priority on: meta-analyzes, literature reviews, randomized controlled trials and good-level proof cohort studies. Only publications in English or French have been selected.

RESULTS

The incidence of VTE was more important in case of renal carcinomas (3.5%/year). When surgery was proposed cystectomy was the riskiest procedure (2.6 to 11.6% VTE). Chemotherapy alone was an important risk factor increasing by a factor of six the occurrence of VTE. Hormonotherapy also increased this risk by induced hypogonadism. The curative treatment for VTE associated with cancers has to be performed through the injection of low molecular weight heparin. The implantation of a prophylactic treatment was not systematic among patients diagnosed with urological cancer.

CONCLUSION

The understanding of mechanisms associated with the occurrence of VTE among these patients has enabled to improve patient management, especially those suffering from urological cancer. Undeniably, frequency of VTE is probably underestimated by urologists during clinical practice.

Certainty ranges facilitated explicit and transparent judgments regarding evidence credibility

OBJECTIVES

The Grading of Recommendations Assessment, Development and Evaluation approach to rating certainty of evidence includes five domains of reasons for rating down certainty. Only one of these, precision, is easily amenable-through the confidence interval-to quantitation. The other four (risk of bias, inconsistency, indirectness, and publication bias) are not. Nevertheless, conceptually, one could consider a quantified "certainty range" within which the true effect lies. The certainty range would be at least as wide as the confidence interval and would expand with each additional reason for uncertainty.

STUDY DESIGN AND SETTING

We have applied this concept to rating the certainty of evidence in the baseline risk of venous thromboembolism (VTE) and bleeding in patients undergoing urological surgery. We considered rating up moderate or low quality evidence when the net benefit of VTE prophylaxis was unequivocally positive, that is, when the smallest plausible value of VTE reduction was greater than the largest plausible value of increased bleeding. To establish whether the net benefit was unequivocally positive, we expanded the range of plausible values by 20% for each of the four nonquantitative domains in which there were serious limitations.

RESULTS

We present how we applied these methods to examples of open radical cystectomy and laparoscopic partial nephrectomy. In high-VTE risk laparoscopic partial nephrectomy patients and high- and medium-VTE risk open radical cystectomy patients, results proved robust to expanded certainty intervals, justifying rating up quality of evidence. In low-risk patients, the results were not robust, and rating up was therefore not appropriate.

CONCLUSION

This work represents the first empirical application in a decision-making context of the previously suggested concept of certainty ranges and should stimulate further exploration of the associated theoretical and practical issues.

Temporal trends in venous thromboembolism after radical cystectomy

PURPOSE

To determine whether the rate of venous thromboembolism (VTE) following radical cystectomy (RC) is changing overtime.

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent RC for bladder cancer from 2011 to 2016. VTE was defined as pulmonary embolism or deep vein thrombosis within 30 days of RC. VTE rate by year was assessed using the Cochran-Armitage test for trend. Associations between patient features and VTE were evaluated with multivariable logistic regression.

RESULTS

A total of 8,241 patients undergoing RC were identified, of whom 348 (4.2%) were diagnosed with VTE. VTE was diagnosed at a median of 13 days (IQR: 7-19) after RC, with 171 (49%) occurring after hospital discharge. Notably, the rate of VTE after RC was found to significantly decrease over time, from 5.1% in 2011 to 2.8% in 2016 (P = 0.001). On multivariable analysis, clinical factors significantly associated with increased odds of VTE included congestive heart failure (odds ratio [OR] = 2.83, P = 0.01), prolonged operative time (OR: 1.48-1.56, P = 0.02-0.01), and receipt of a perioperative blood transfusion (OR = 1.27; P = 0.04). When postoperative complications were adjusted for, sepsis/septic shock (OR = 2.37, P<0.001) and perioperative infection (OR = 1.74, P<0.001) were likewise found to be associated with VTE.

CONCLUSIONS

The rate of VTE after RC significantly decreased in recent years, potentially reflecting improvements in perioperative care. The specific casual factors underlying this trend, in addition to efforts to address identified risk factors for VTE, warrant continued study.

Validating the role of ABO blood type in risk of perioperative venous thromboembolism after radical cystectomy

PURPOSE

To validate the relationship between ABO blood type and risk of VTE post-RC in a large retrospective database.

METHODS

Patients with urothelial bladder cancer (UBC) who underwent RC (intent-to-cure) for whom ABO blood type was available between 2003 and 2015 were identified from our IRB-approved database. VTE was defined as deep vein thrombosis (DVT) or pulmonary embolism (PE) within 90 days of surgery. VTE prophylaxis consisted of immediate postoperative Coumadin (2003-2009), unfractionated heparin (UFH) during hospitalization (2009-2015), and UFH during hospitalization plus 4 weeks of enoxaparin after discharge (2013-2015). Univariable and multivariable analyses of the association of ABO blood type with postoperative, symptomatic VTE and oncologic outcomes were performed.

RESULTS

Of 1341 patients, 595 (44.4%) were ABO type O and 746 (55.6%) were non-O (A, B and AB). 90 patients were diagnosed with VTE within 90 days of surgery (6.7%) (43% DVT-only, 57% PE ± DVT). On multivariable analysis non-O blood type was associated with a nearly twofold increased risk of VTE (OR = 1.94, 95% CI 1.215-3.098, p = 0.004). No difference in recurrence-free survival or overall survival was seen between ABO groups.

CONCLUSION

Non-O blood type is an independent, non-modifiable risk factor for postoperative VTE after RC. More comprehensive counseling and thromboprophylaxis should be considered in this high-risk group.

Thromboembolism in Patients with Bladder Cancer: Incidence, Risk Factors and Prevention

Patients with bladder cancer are at high risk of developing both venous and arterial thromboembolic events. Factors that contribute to this phenomenon include the hypercoagulable state induced by the malignancy itself, medical comorbidities that are common in this predominantly elderly patient population as well as treatments such as prolonged pelvic surgery and cisplatin-based chemotherapy. While formal guidelines address prevention of venous thromboembolism in patients undergoing radical cystectomy, consensus regarding the role of pharmacologic prophylaxis in patients with bladder cancer being treated with chemotherapy, either with neoadjuvant or adjuvant intent in conjunction with radical cystectomy, as part of bladder preservation protocols or for metastatic disease, has proved elusive. The present narrative review was undertaken to define the incidence of and identify risk factors for thromboembolism among patients with bladder cancer, as well as to assess the efficacy of pharmacologic prophylaxis in reducing the risk of thromboembolism in this patient population.

Perioperative venous thromboembolism in urologic oncology procedures, risk factors, and prevention

PURPOSE OF REVIEW

Venous thromboembolism (VTE) is a common complication during the perioperative period for major urologic oncology operations. The present review focuses on the risk factors, the mechanisms of hypercoagulability in this patient population, and the timing and prevention of VTE.

RECENT FINDINGS

Although the vast majority of patients undergoing major urologic oncology operations do not develop VTEs, when they do develop they can be fatal. The risk factors for VTEs are important to identify in this patient population. The timing of VTE events are also essential to understanding their prevention. Prevention focused around the perioperative period is the best way to reduce fatal complications secondary to a VTE event.

SUMMARY

VTEs are common and can potentially be fatal. Prevention in high-risk patients during the most vulnerable perioperative time period should be the focus of clinical efforts to reduce VTE complications and the associated morbidity and mortality.

Procedure-specific Risks of Thrombosis and Bleeding in Urological Non-cancer Surgery: Systematic Review and Meta-analysis

CONTEXT

Pharmacological thromboprophylaxis involves a trade-off between a reduction in venous thromboembolism (VTE) and increased bleeding. No guidance specific for procedure and patient factors exists in urology.

OBJECTIVE

To inform estimates of absolute risk of symptomatic VTE and bleeding requiring reoperation in urological non-cancer surgery.

EVIDENCE ACQUISITION

We searched for contemporary observational studies and estimated the risk of symptomatic VTE or bleeding requiring reoperation in the 4 wk after urological surgery. We used the GRADE approach to assess the quality of the evidence.

EVIDENCE SYNTHESIS

The 37 eligible studies reported on 11 urological non-cancer procedures. The duration of prophylaxis varied widely both within and between procedures; for example, the median was 12.3 d (interquartile range [IQR] 3.1-55) for open recipient nephrectomy (kidney transplantation) studies and 1 d (IQR 0-1.3) for percutaneous nephrolithotomy, open prolapse surgery, and reconstructive pelvic surgery studies. Studies of open recipient nephrectomy reported the highest risks of VTE and bleeding (1.8-7.4% depending on patient characteristics and 2.4% for bleeding). The risk of VTE was low for 8/11 procedures (0.2-0.7% for patients with low/medium risk; 0.8-1.4% for high risk) and the risk of bleeding was low for 6/7 procedures (≤0.5%; no bleeding estimates for 4 procedures). The quality of the evidence supporting these estimates was low or very low.

CONCLUSIONS

Although inferences are limited owing to low-quality evidence, our results suggest that extended prophylaxis is warranted for some procedures (eg, kidney transplantation procedures in high-risk patients) but not others (transurethral resection of the prostate and reconstructive female pelvic surgery in low-risk patients).

PATIENT SUMMARY

The best evidence suggests that the benefits of blood-thinning drugs to prevent clots after surgery outweigh the risks of bleeding in some procedures (such as kidney transplantation procedures in patients at high risk of clots) but not others (such as prostate surgery in patients at low risk of clots).