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Rich JM, Geduldig J, Elkun Y, Lavallee E, Mehrazin R, Attalla K, Wiklund P, Sfakianos JP. Thromboembolic Events After Robotic Radical Cystectomy: A Comparative Analysis of Extended and Limited Prophylaxis. Urology 2024; 190:46-52. [PMID: 38663586 DOI: 10.1016/j.urology.2024.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 03/07/2024] [Accepted: 03/29/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE To compare limited (only inpatient) venous thromboembolism (VTE) prophylaxis after robot-assisted radical cystectomy (RARC) to limited plus extended prophylaxis. There is little consensus on postoperative VTE prophylaxis regimens after RARC with data mostly extrapolated from other cancers. METHODS Retrospective review of all RARC patients at our center between 2014-2022, identifying two groups: patients after a prospectively implemented protocol (January 2018 to present) utilizing a prolonged 21-day postoperative course of either enoxaparin 40 mg daily or apixaban 2.5 mg twice daily after discharge, or patients prior to January 2018 receiving only limited VTE prophylaxis during their immediate postoperative inpatient stay. PRIMARY OUTCOME incidence of symptomatic VTE confirmed with imaging within 90-days postoperatively. SECONDARY OUTCOMES major hemorrhage, complications, readmission, and mortality within 30-days postoperatively. Descriptive statistics depicted baseline patient characteristics, operative information, and complications. Differences were compared between groups. Logistic regression was used to determine associations between variables and primary outcome. RESULTS Eighty-six patients received limited prophylaxis and 364 received extended prophylaxis. Twelve (2.7%) patients experienced VTE within 90-day postoperatively: (10 [2.7%] extended vs 2 [2.3%] limited, P = .9). Upon stratification into EAU "low-risk" or "high +intermediate-risk" groups, no statistically significant difference in VTE rates was seen between the extended or limited groups. When controlling for prophylaxis regimen, intracorporeal approach was found to be predictive of a lower with a lower risk of VTE (P = .019). CONCLUSION Limited and extended prophylaxis showed no significant differences in VTE rates among RARC patients. Further studies are necessary for RARC patients to improve guidelines.
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Affiliation(s)
- Jordan M Rich
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jack Geduldig
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yuval Elkun
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Etienne Lavallee
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kyrollis Attalla
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Urology, Karolinska University Hospital, Solna, Sweden
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY.
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Ng A, Asif A, Keane K, Ippoliti S, Nathan A, Kasivisvanathan V. The ARTS (Avoiding Risks of Thrombosis and Bleeding in Surgery) Trial: Lessons Learnt in Setting Up an International Multicentre Clinical Trial of an Investigational Medicinal Product in the UK. Eur Urol Focus 2023; 9:695-697. [PMID: 37863739 DOI: 10.1016/j.euf.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/04/2023] [Indexed: 10/22/2023]
Abstract
We describe our experience in setting up the UK arm of the ARTS trial and highlight regulatory and funding challenges in relation to an international multicentre setting for an investigational medicinal product.
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Affiliation(s)
- Alexander Ng
- Division of Surgery and Interventional Science, University College London, London, UK; British Urology Researchers in Surgical Training, London, UK.
| | - Aqua Asif
- Division of Surgery and Interventional Science, University College London, London, UK; British Urology Researchers in Surgical Training, London, UK
| | - Kevin Keane
- British Urology Researchers in Surgical Training, London, UK; Department of Urology, St. James' Hospital, Dublin, Ireland
| | - Simona Ippoliti
- British Urology Researchers in Surgical Training, London, UK; Urology Department, Hull University Teaching Hospitals, Hull, UK
| | - Arjun Nathan
- Division of Surgery and Interventional Science, University College London, London, UK; British Urology Researchers in Surgical Training, London, UK
| | - Veeru Kasivisvanathan
- Division of Surgery and Interventional Science, University College London, London, UK; British Urology Researchers in Surgical Training, London, UK
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Singh T, Lavikainen LI, Halme ALE, Aaltonen R, Agarwal A, Blanker MH, Bolsunovskyi K, Cartwright R, García-Perdomo H, Gutschon R, Lee Y, Pourjamal N, Vernooij RWM, Violette PD, Haukka J, Guyatt GH, Tikkinen KAO. Timing of symptomatic venous thromboembolism after surgery: meta-analysis. Br J Surg 2023; 110:553-561. [PMID: 36912116 PMCID: PMC10364527 DOI: 10.1093/bjs/znad035] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/12/2023] [Accepted: 01/22/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND The timing at which venous thromboembolism (VTE) occurs after major surgery has major implications for the optimal duration of thromboprophylaxis. The aim of this study was to perform a systematic review and meta-analysis of the timing of postoperative VTE up to 4 weeks after surgery. METHODS A systematic search of MEDLINE, Scopus, and CINAHL databases was performed between 1 January 2009 and 1 April 2022. Prospective studies that recruited patients who underwent a surgical procedure and reported at least 20 symptomatic, postoperative VTE events by time were included. Two reviewers independently selected studies according to the eligibility criteria, extracted data, and evaluated risk of bias. Data were analysed with a Poisson regression model, and the GRADE approach was used to rate the certainty of evidence. RESULTS Some 6258 studies were evaluated, of which 22 (11 general, 5 urological, 4 mixed, and 2 orthopaedic postoperative surgical populations; total 1 864 875 patients and 24 927 VTE events) were eligible. Pooled evidence of moderate certainty showed that 47.1 per cent of the VTE events occurred during the first, 26.9 per cent during the second, 15.8 per cent during the third, and 10.1 per cent during the fourth week after surgery. The timing of VTE was consistent between individual studies. CONCLUSION Although nearly half of symptomatic VTE events in first 4 weeks occur during the first postoperative week, a substantial number of events occur several weeks after surgery. These data will inform clinicians and guideline developers about the duration of postoperative thromboprophylaxis.
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Affiliation(s)
- Tino Singh
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | | | - Alex L E Halme
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Riikka Aaltonen
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Arnav Agarwal
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Kostiantyn Bolsunovskyi
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Raseborg Health Centre, City of Raseborg, Raseborg, Finland
| | - Rufus Cartwright
- Departments of Gynaecology and Gender Affirmation Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | - Herney García-Perdomo
- Division of Urology/Uro-oncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Rachel Gutschon
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, Woodstock Hospital, Woodstock, Ontario, Canada
| | - Yung Lee
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Negar Pourjamal
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Robin W M Vernooij
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Philippe D Violette
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, Woodstock Hospital, Woodstock, Ontario, Canada
| | - Jari Haukka
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kari A O Tikkinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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Sharma G, Krishna M, Pareek T, Bora GS, Mavuduru RS, Mete UK, Singh SK, Patel HRH. Current practice patterns in the perioperative management of patients undergoing radical cystectomy: Results from a global survey. Urol Oncol 2022; 40:196.e1-196.e9. [PMID: 35279359 DOI: 10.1016/j.urolonc.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 12/06/2021] [Accepted: 01/01/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine current practice patterns and adherence to various components of enhanced recovery after surgery in cystectomy (ERAC) protocol for peri-operative management of radical cystectomy patients through a global survey. METHODS A survey containing 25 questions and addressing 15 of the 22 items of the ERAC protocol was developed and disseminated through Email to the urologists with recent bladder cancer publications. The mailing list was generated by retrieving Email-ids of corresponding authors of articles using the keyword "cystectomy" in Scopus from January 2018 to October 2020. RESULTS The survey was completed by 443 respondents across the globe. About 51.5% of respondents used some form of bowel preparation. A minority used carbohydrate loading (29.8%) and Alvimopan (13.3%). A short duration of nil by mouth was practised by 28.9%. For antibiotic prophylaxis, 51.7% used one, and 42% used two antibiotics. Duration of antibiotics was 24 hours, 48 hours, and >48 hours for 47.6%, 16.9%, and 35.4%, respectively. For peri-operative analgesia, 43.6% used non-steroidal anti-inflammatory drugs, 9.3% opioids and 40.6% combination of both. Pharmacological thrombo-prophylaxis was routinely used by 74.7% respondents. There was significant variability in ERAC and non-ERAC components according to region of practice; The open surgical approach was most commonly used in Africa (92%), whereas it was the robotic approach in North America (or America?) (41%). The use of bowel preparation was higher in Asia (58%) and Africa (65%). Alvimopan use was more common in North America (58%). Most used 1 or 2 prophylactic antibiotics but the duration was shorter (<24 hours) in the Americas and European (58%-83%) compared to Asia and Africa (15%-35%). CONCLUSION There is high variability in the use of different ERAC components. Other than the timely removal of the abdominal drain and the use of thromboprophylaxis, the overall adherence of ERAC components is low.
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Affiliation(s)
- Gopal Sharma
- Department of Urology, PGIMER, Chandigarh, India
| | | | - Tarun Pareek
- Department of Urology, PGIMER, Chandigarh, India
| | | | | | - Uttam K Mete
- Department of Urology, PGIMER, Chandigarh, India
| | | | - Hitendra R H Patel
- Adjunct Professor, University of Rochester Medical and Dental School, Rochester, NY
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Violette PD, Cartwright R, Devereaux PJ, Gross PL, Kaukonen KM, Sandset PM, Kilpeläinen TP, Lavikainen LI, Sallinen V, Horstia S, Guyatt GH, Tikkinen KAO. ARTS: A Large, International Trial of Thromboprophylaxis in Intra-abdominal, Gynecologic, and Urologic Surgery. Eur Urol Focus 2021; 7:1222-1225. [PMID: 34556452 DOI: 10.1016/j.euf.2021.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
ARTS will be the first trial to compare anticoagulation with a direct oral anticoagulant (apixaban) versus no anticoagulation among patients undergoing intra-abdominal, gynecologic, or urologic surgery at sufficiently similar risk of deep vein thrombosis or pulmonary embolism and major bleeding.
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Affiliation(s)
- Philippe D Violette
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Surgery, Woodstock General Hospital, Woodstock, Canada
| | - Rufus Cartwright
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK; Department of Obstetrics and Gynaecology, LNWH NHS Trust, London, UK
| | - P J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Peter L Gross
- Department of Medicine, McMaster University, Hamilton, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Canada
| | - Kirsi-Maija Kaukonen
- Department of Diagnostics and Therapeutics, Anesthesiology and Intensive care, University of Helsinki, Helsinki, Finland; Pharmacovigilance Unit, Finnish Medicines Agency, Helsinki, Finland
| | - Per Morten Sandset
- Department of Haematology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Ville Sallinen
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Saana Horstia
- Faculty of Medicine, University of Helsinki, Helsinki, Finland; Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland.
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Urinary diversions for benign and oncologic indications: what did we learn about short term complications in the last 24 months? Curr Opin Urol 2021; 31:556-561. [PMID: 34265842 DOI: 10.1097/mou.0000000000000927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF THE REVIEW Urinary diversion (UD) with or without cystectomy is a procedure with high short term complication rates. In this review, we summarize the most relevant findings of the last 2 years. RECENT FINDINGS The use of a prophylactic mesh decreases the risk of parastomal hernia after ileal conduit (IC) surgery without adding mesh-related complications according to a recent randomized multicentre trial. Robot-assisted surgery is increasingly applied for UD and is evolving from extra- to intra-corporeal reconstruction in both continent and incontinent diversions, but there is still a need for appropriately designed studies assessing both short- and long-term complications. Promising techniques to decrease ureterointestinal stricture rates have been reported from small series, such as retrosigmoid placement of the proximal IC to avoid transpositioning of the left ureter, or in robot-assisted surgery the use of indocyanine green with near-infrared light to improve visualisation of distal ureteral viability. SUMMARY Most recent reports derive from observational data. Appropriate randomized studies are warranted for the evaluation of new techniques to be implemented in a surgical area that still is associated with high complication rates.
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Tikkinen KA, Guyatt GH. Baseline Risks of Venous Thromboembolism and Major Bleeding are Crucial in Decision-making on Thromboprophylaxis. Eur Urol 2020; 78:369-370. [DOI: 10.1016/j.eururo.2020.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 11/29/2022]
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