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Tikkinen KAO, Cartwright R, Jensen AG, Violette PD. European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 12: Urology. Eur J Anaesthesiol 2024; 41:618-621. [PMID: 38957030 PMCID: PMC11224558 DOI: 10.1097/eja.0000000000002012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Kari A O Tikkinen
- From the Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki (KAOT), Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland (KAOT), Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada (KAOT, PDV), Departments of Gynaecology and Gender Affirmation Surgery, Chelsea and Westminster NHS Foundation Trust (RC), Department of Epidemiology and Biostatistics, Imperial College London, London, UK (RC), Department of Anesthesiology, Odense University Hospital, Odense, Denmark (AGJ), Department of Surgery, Woodstock Hospital, Woodstock, Ontario, Canada (PDV) and European Association of Urology (EAU), Arnhem, The Netherlands (KAOT, RC, PDV)
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Lavikainen LI, Guyatt GH, Luomaranta AL, Cartwright R, Kalliala IEJ, Couban RJ, Aaltonen RL, Aro KM, Cárdenas JL, Devereaux PJ, Galambosi PJ, Ge FZ, Halme ALE, Haukka J, Izett-Kay ML, Joronen KM, Karjalainen PK, Khamani N, Oksjoki SM, Pourjamal N, Singh T, Tähtinen RM, Vernooij RWM, Tikkinen KAO. Risk of thrombosis and bleeding in gynecologic cancer surgery: systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:403-416. [PMID: 37827272 DOI: 10.1016/j.ajog.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE This study aimed to provide procedure-specific estimates of the risk of symptomatic venous thromboembolism and major bleeding in the absence of thromboprophylaxis, following gynecologic cancer surgery. DATA SOURCES We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar for observational studies. We also reviewed reference lists of eligible studies and review articles. We performed separate searches for randomized trials addressing effects of thromboprophylaxis and conducted a web-based survey on thromboprophylaxis practice. STUDY ELIGIBILITY CRITERIA Observational studies enrolling ≥50 adult patients undergoing gynecologic cancer surgery procedures reporting absolute incidence for at least 1 of the following were included: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding requiring reintervention (including reexploration and angioembolization), bleeding leading to transfusion, or postoperative hemoglobin <70 g/L. METHODS Two reviewers independently assessed eligibility, performed data extraction, and evaluated risk of bias of eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine cumulative incidence at 4 weeks postsurgery stratified by patient venous thromboembolism risk factors. The GRADE approach was applied to rate evidence certainty. RESULTS We included 188 studies (398,167 patients) reporting on 37 gynecologic cancer surgery procedures. The evidence certainty was generally low to very low. Median symptomatic venous thromboembolism risk (in the absence of prophylaxis) was <1% in 13 of 37 (35%) procedures, 1% to 2% in 11 of 37 (30%), and >2.0% in 13 of 37 (35%). The risks of venous thromboembolism varied from 0.1% in low venous thromboembolism risk patients undergoing cervical conization to 33.5% in high venous thromboembolism risk patients undergoing pelvic exenteration. Estimates of bleeding requiring reintervention varied from <0.1% to 1.3%. Median risks of bleeding requiring reintervention were <1% in 22 of 29 (76%) and 1% to 2% in 7 of 29 (24%) procedures. CONCLUSION Venous thromboembolism reduction with thromboprophylaxis likely outweighs the increase in bleeding requiring reintervention in many gynecologic cancer procedures (eg, open surgery for ovarian cancer and pelvic exenteration). In some procedures (eg, laparoscopic total hysterectomy without lymphadenectomy), thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding venous thromboembolism and bleeding.
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Affiliation(s)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Anna L Luomaranta
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Rufus Cartwright
- Department of Gender Affirmation Surgery, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom; Department of Epidemiology and Biostatistics, Imperial College London, London, United Kingdom
| | - Ilkka E J Kalliala
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Rachel J Couban
- Department of Anesthesia, McMaster University, Hamilton, Canada
| | - Riikka L Aaltonen
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Karoliina M Aro
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jovita L Cárdenas
- Direction of Health Technology Assessment, National Center for Health Technology Excellence (CENETEC), Mexico City, Mexico
| | - 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; Outcomes Research Consortium, Cleveland, OH
| | - Päivi J Galambosi
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fang Zhou Ge
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Alex L E Halme
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Haukka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Matthew L Izett-Kay
- Urogynaecology Department, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Kirsi M Joronen
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi K Karjalainen
- Department of Obstetrics and Gynecology, Central Finland Central Hospital, Jyväskylä, Finland; Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Nadina Khamani
- Department of Obstetrics and Gynecology, Institute of Children's Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Negar Pourjamal
- Laboratory of Molecular Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tino Singh
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Riikka M Tähtinen
- Department of Obstetrics and Gynecology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Robin W M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - 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 Karelia Central Hospital, Lappeenranta, Finland.
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Halme ALE, Roshanov PS, Tornberg SV, Lavikainen LI, Devereaux PJ, Tikkinen KAO. Timing of Major Postoperative Bleeding Among Patients Undergoing Surgery. JAMA Netw Open 2024; 7:e244581. [PMID: 38564217 PMCID: PMC10988355 DOI: 10.1001/jamanetworkopen.2024.4581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/31/2024] [Indexed: 04/04/2024] Open
Abstract
Importance Although major bleeding is among the most common and prognostically important perioperative complications, the relative timing of bleeding events is not well established. This information is critical for preventing bleeding complications and for informing the timing of pharmacologic thromboprophylaxis. Objective To determine the timing of postoperative bleeding among patients undergoing surgery for up to 30 days after surgery. Design, Setting, and Participants This is a secondary analysis of a prospective cohort study. Patients aged 45 years or older who underwent inpatient noncardiac surgery were recruited in 14 countries between 2007 and 2013, with follow-up until December 2014. Data analysis was performed from June to July 2023. Exposure Noncardiac surgery requiring overnight hospital admission. Main Outcomes and Measures The primary outcome (postoperative major bleeding) was a composite of the timing of the following bleeding outcomes: (1) bleeding leading to transfusion, (2) bleeding leading to a postoperative hemoglobin level less than 7 g/dL, (3) bleeding leading to death, and (4) bleeding associated with reintervention. Each of the components of the composite primary outcome (1-4) and bleeding independently associated with mortality after noncardiac surgery, which was defined as a composite of outcomes 1 to 3, were secondary outcomes. Results Among 39 813 patients (median [IQR] age, 63.0 [54.8-72.5] years; 19 793 women [49.7%]), there were 5340 major bleeding events (primary outcome) in 4638 patients (11.6%) within the first 30 days after surgery. Of these events, 42.7% (95% CI, 40.9%-44.6%) occurred within 24 hours after surgery, 77.7% (95% CI, 75.8%-79.5%) by postoperative day 7, 88.3% (95% CI, 86.5%-90.2%) by postoperative day 14, and 94.6% (95% CI, 92.7%-96.5%) by postoperative day 21. Within 48 hours of surgery, 56.2% of major bleeding events, 56.2% of bleeding leading to transfusion, 56.1% of bleeding independently associated with mortality after noncardiac surgery, 51.8% of bleeding associated with hemoglobin less than 7 g/dL, and 51.8% of bleeding associated with reintervention had occurred. Conclusions and Relevance In this cohort study, of the major postoperative bleeding events in the first 30 days, more than three-quarters occurred during the first postoperative week. These findings are useful for researchers for the planning future clinical research and for clinicians in prevention of bleeding-related surgical complications and in decision-making regarding starting of pharmacologic thromboprophylaxis after surgery.
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Affiliation(s)
| | - Pavel S. Roshanov
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Outcomes Research Consortium, Cleveland, Ohio
| | - Sara V. Tornberg
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - P. J. Devereaux
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Outcomes Research Consortium, Cleveland, Ohio
- 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 Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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Lavikainen LI, Guyatt GH, Kalliala IEJ, Cartwright R, Luomaranta AL, Vernooij RWM, Tähtinen RM, Tadayon Najafabadi B, Singh T, Pourjamal N, Oksjoki SM, Khamani N, Karjalainen PK, Joronen KM, Izett-Kay ML, Haukka J, Halme ALE, Ge FZ, Galambosi PJ, Devereaux PJ, Cárdenas JL, Couban RJ, Aro KM, Aaltonen RL, Tikkinen KAO. Risk of thrombosis and bleeding in gynecologic noncancer surgery: systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:390-402. [PMID: 38072372 DOI: 10.1016/j.ajog.2023.11.1255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE This study aimed to provide procedure-specific estimates of the risk for symptomatic venous thromboembolism and major bleeding in noncancer gynecologic surgeries. DATA SOURCES We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar. Furthermore, we performed separate searches for randomized trials that addressed the effects of thromboprophylaxis. STUDY ELIGIBILITY CRITERIA Eligible studies were observational studies that enrolled ≥50 adult patients who underwent noncancer gynecologic surgery procedures and that reported the absolute incidence of at least 1 of the following: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding that required reintervention (including re-exploration and angioembolization), bleeding that led to transfusion, or postoperative hemoglobin level <70 g/L. METHODS A teams of 2 reviewers independently assessed eligibility, performed data extraction, and evaluated the risk of bias of the eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine the cumulative incidence at 4 weeks postsurgery stratified by patient venous thromboembolism risk factors and used the Grading of Recommendations Assessment, Development and Evaluation approach to rate the evidence certainty. RESULTS We included 131 studies (1,741,519 patients) that reported venous thromboembolism risk estimates for 50 gynecologic noncancer procedures and bleeding requiring reintervention estimates for 35 procedures. The evidence certainty was generally moderate or low for venous thromboembolism and low or very low for bleeding requiring reintervention. The risk for symptomatic venous thromboembolism varied from a median of <0.1% for several procedures (eg, transvaginal oocyte retrieval) to 1.5% for others (eg, minimally invasive sacrocolpopexy with hysterectomy, 1.2%-4.6% across patient venous thromboembolism risk groups). Venous thromboembolism risk was <0.5% for 30 (60%) of the procedures; 0.5% to 1.0% for 10 (20%) procedures; and >1.0% for 10 (20%) procedures. The risk for bleeding the require reintervention varied from <0.1% (transvaginal oocyte retrieval) to 4.0% (open myomectomy). The bleeding requiring reintervention risk was <0.5% in 17 (49%) procedures, 0.5% to 1.0% for 12 (34%) procedures, and >1.0% in 6 (17%) procedures. CONCLUSION The risk for venous thromboembolism in gynecologic noncancer surgery varied between procedures and patients. Venous thromboembolism risks exceeded the bleeding risks only among selected patients and procedures. Although most of the evidence is of low certainty, the results nevertheless provide a compelling rationale for restricting pharmacologic thromboprophylaxis to a minority of patients who undergo gynecologic noncancer procedures.
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Affiliation(s)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ilkka E J Kalliala
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Rufus Cartwright
- Chelsea Centre for Gender Surgery, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom; Department of Gynaecology, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom; Department of Epidemiology & Biostatistics, Imperial College London, London, United Kingdom
| | - Anna L Luomaranta
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Robin W M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Nephrology & Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Riikka M Tähtinen
- Department of Obstetrics and Gynecology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Borna Tadayon Najafabadi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tino Singh
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Negar Pourjamal
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Nadina Khamani
- Department of Obstetrics and Gynecology, Institute of Childrens' Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Päivi K Karjalainen
- Department of Obstetrics and Gynecology, Central Finland Central Hospital, Jyväskylä, Finland; Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Kirsi M Joronen
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Finland
| | - Matthew L Izett-Kay
- Urogynaecology Department, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Jari Haukka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Alex L E Halme
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Fang Zhou Ge
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Päivi J Galambosi
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P J Devereaux
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada; Outcomes Research Consortium, Cleveland, OH
| | - Jovita L Cárdenas
- National Center for Health Technology Excellence (CENETEC), Direction of Health Technologies assessment, Mexico City, Mexico
| | - Rachel J Couban
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Karoliina M Aro
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Riikka L Aaltonen
- Urogynaecology Department, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Kari A O Tikkinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; 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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Lavikainen LI, Guyatt GH, Sallinen VJ, Karanicolas PJ, Couban RJ, Singh T, Lee Y, Elberkennou J, Aaltonen R, Ahopelto K, Beilmann-Lehtonen I, Blanker MH, Cárdenas JL, Cartwright R, Craigie S, Devereaux P, Garcia-Perdomo HA, Ge FZ, Gomaa HA, Halme AL, Haukka J, Karjalainen PK, Kilpeläinen TP, Kivelä AJ, Lampela H, Mattila AK, Najafabadi BT, Nykänen TP, Pandanaboyana S, Pourjamal N, Ratnayake CB, Raudasoja A, Vernooij RW, Violette PD, Wang Y, Xiao Y, Yao L, Tikkinen KAO. Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery. Ann Surg 2024; 279:213-225. [PMID: 37551583 PMCID: PMC10782937 DOI: 10.1097/sla.0000000000006059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
OBJECTIVE To provide procedure-specific estimates of symptomatic venous thromboembolism (VTE) and major bleeding after abdominal surgery. BACKGROUND The use of pharmacological thromboprophylaxis represents a trade-off that depends on VTE and bleeding risks that vary between procedures; their magnitude remains uncertain. METHODS We identified observational studies reporting procedure-specific risks of symptomatic VTE or major bleeding after abdominal surgery, adjusted the reported estimates for thromboprophylaxis and length of follow-up, and estimated cumulative incidence at 4 weeks postsurgery, stratified by VTE risk groups, and rated evidence certainty. RESULTS After eligibility screening, 285 studies (8,048,635 patients) reporting on 40 general abdominal, 36 colorectal, 15 upper gastrointestinal, and 24 hepatopancreatobiliary surgery procedures proved eligible. Evidence certainty proved generally moderate or low for VTE and low or very low for bleeding requiring reintervention. The risk of VTE varied substantially among procedures: in general abdominal surgery from a median of <0.1% in laparoscopic cholecystectomy to a median of 3.7% in open small bowel resection, in colorectal from 0.3% in minimally invasive sigmoid colectomy to 10.0% in emergency open total proctocolectomy, and in upper gastrointestinal/hepatopancreatobiliary from 0.2% in laparoscopic sleeve gastrectomy to 6.8% in open distal pancreatectomy for cancer. CONCLUSIONS VTE thromboprophylaxis provides net benefit through VTE reduction with a small increase in bleeding in some procedures (eg, open colectomy and open pancreaticoduodenectomy), whereas the opposite is true in others (eg, laparoscopic cholecystectomy and elective groin hernia repairs). In many procedures, thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding VTE and bleeding.
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Affiliation(s)
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ville J. Sallinen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Paul J. Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rachel J. Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Tino Singh
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Yung Lee
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Riikka Aaltonen
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Kaisa Ahopelto
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ines Beilmann-Lehtonen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marco H. Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jovita L. Cárdenas
- Direction of Health Technologies Assessment, National Center for Health Technology Excellence (CENETEC), Mexico City, Mexico
| | - Rufus Cartwright
- Departments of Gynecology and Gender Affirmation Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Samantha Craigie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - P.J. Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Anesthesiology, Perioperative Medicine, and Surgical Research Group, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Outcomes Research, Outcomes Research Consortium, Cleveland, OH, USA
| | - Herney A. Garcia-Perdomo
- Department of Surgery, Division of Urology, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Fang Zhou Ge
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Huda A. Gomaa
- Department of Biostatistics, High Institute of Public Health, Alexandria University, Egypt
- Department of Medical Pharmacology, Tanta Chest Hospital, Ministry of Health and Population, Tanta, Egypt
| | - Alex L.E. Halme
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Haukka
- Health Sciences, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Päivi K. Karjalainen
- Department of Obstetrics and Gynecology, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Tuomas P. Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti J. Kivelä
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Lampela
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anne K. Mattila
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Borna Tadayon Najafabadi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Sanjay Pandanaboyana
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Negar Pourjamal
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Chathura B.B. Ratnayake
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | | | - Robin W.M. Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Philippe D. Violette
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Yuting Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yingqi Xiao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Nursing and West China School of Nursing, West China Hospital and Sichuan University, Chengdu, China
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, 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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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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8
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Smeets MJR, Touw CE, Rosendaal FR, Nemeth B, Cannegieter SC. The risk of venous thromboembolism after minor surgical procedures: A population-based case-control study. J Thromb Haemost 2023; 21:975-982. [PMID: 36696214 DOI: 10.1016/j.jtha.2022.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/11/2022] [Accepted: 11/28/2022] [Indexed: 05/26/2023]
Abstract
BACKGROUND Surgery is a well-known risk factor for venous thromboembolism (VTE). However, for several minor surgical procedures, thromboprophylaxis is not advised. OBJECTIVES These "low-risk" procedures include a wide variation of interventions for which we estimated the VTE risk to verify their "low-risk" status. PATIENTS/METHODS We used data from a large population-based case-control study (Multiple Environment and Genetic Assessment study) into causes of VTE, and linked these to the Dutch Hospital Data Registry to identify exposure to surgical procedures. Logistic regression was used to calculate odds ratios for the 90-day and 1-year relative risks of VTE following these procedures, which were adjusted for body mass index (BMI), sex, age, comorbidities, and infection/inflammation. RESULTS We included 4247 patients with VTE and 5538 control subjects. Median age and BMI were 48.5 years and 25.5 m2/kg, respectively. Nine unique procedures or groups of procedures were analyzed. One hundred twenty-three participants-90 cases and 33 controls-had undergone a minor procedure within 90 days of the index date, resulting in a 3.5-fold (OR, 3.5; 95% CI, 2.3-5.3) overall increased VTE risk. Furthermore, venous stripping (OR, 7.2; 95% CI, 2.4-21.2), open abdominal/inguinal hernia repair (OR, 3.7; 95% CI, 1.2-11.6), and laparoscopic cholecystectomy (OR, 3.2; 95% CI, 1.0-10.6) were associated with an increased risk. Other minor procedures were less strongly or not associated with an increased risk. In the 1-year period before the index date, all odds ratios were lower. CONCLUSION Of the "low-risk" procedures, we found that venous stripping, open abdominal/inguinal hernia repair, and laparoscopic cholecystectomy were associated with a clearly increased risk of VTE within 90 postoperative days.
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Affiliation(s)
- Mark J R Smeets
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Carolina E Touw
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Banne Nemeth
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Orthopedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Internal Medicine, section Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
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9
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Azawi NH, Tolouee S, Dabestani S. Incidence and associated risk factors of venous thromboembolism after open and laparoscopic partial nephrectomy in patients administered short-period thromboprophylaxis: a Danish nationwide population-based cohort study. Scand J Urol 2023; 57:81-85. [PMID: 36703546 DOI: 10.1080/21681805.2023.2171112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To report the risk of venous thromboembolism (VTE) after partial nephrectomy in Denmark. MATERIALS AND METHODS A nationwide population-based registry was used to conduct a retrospective cohort study. All partial nephrectomies from January 2010 to August 2018 were assessed for postoperative VTE events. Univariable and multivariable analyses were used to evaluate the odds of postoperative VTE within 4 weeks and 4 months after partial nephrectomy in patients who received standard-of-care thromboprophylaxis. RESULTS Among 2355 patients, postoperative VTE risk was 0.6% and 0.9%, at 4 weeks and 4 months, respectively. In multivariate analysis, prior VTE (OR = 24.9, p < 0.001) and length of hospital stay (OR = 0.89, p < 0.001) were predictors of postoperative VTE within 4 months after partial nephrectomy. Limitations included the retrospective and registry-based study design and the absence of BMI data. CONCLUSION Incidence of postoperative VTE is rare, but patients with prior VTE and those with a greater length of hospital stay are at greater long-term risk and should be evaluated when considering thromboprophylaxis.
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Affiliation(s)
- Nessn H Azawi
- Department of Urology, Zealand University Hospital, Roskilde, Denmark.,Institute of Clinical Medicine, Copenhagen University, Denmark
| | - Sara Tolouee
- Department of Urology, Zealand University Hospital, Roskilde, Denmark
| | - Saeed Dabestani
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Sweden
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10
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Wu Z, Liu X, Zhu Q, Li H, Li K, Wang G, Tang Z, Wang Z. Pulmonary embolism following urological non-oncological surgery: The clinical features, management, and long-term follow-up outcome from a tertiary hospital of China. Front Surg 2022; 9:930968. [PMID: 36132209 PMCID: PMC9483021 DOI: 10.3389/fsurg.2022.930968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To evaluate the clinical features, treatment, and outcomes of pulmonary embolism (PE) after urological non-oncological surgery in a tertiary hospital of China. Methods A total of eight patients who suffered from PE after urological non-oncological surgery from 2016 to 2019 were recruited to the study. Clinical data such as symptoms, vital signs, electrocardiogram, echocardiography, and computed tomographic pulmonary arteriography (CTPA) were reviewed. In addition, the management and long-term follow-up outcome of PE were reported. Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire was applied for five patients to evaluate health-related quality of life after PE. Results All patients survived during their hospitalization, and five patients were contacted during follow-up. Five of the eight patients were anticoagulated regularly until the re-examination results of CTPA and lower extremities ultrasound were normal. The period of anticoagulant sustained at least one month for each patient. The long-term follow-up outcomes showed that PE had little impact on the patients' quality of life. Conclusions The study demonstrated that the prognosis of PE patients was not as terrible as feared when treated immediately in the ward. Early diagnosis and treatment of PE is vital for prognosis. However, further verifications based on the results of large studies are still needed.
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Affiliation(s)
- Ziqiang Wu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Xuesong Liu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, China
| | - Quan Zhu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Haozhen Li
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Kaixuan Li
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Guilin Wang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhengyan Tang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
- Provincial Laboratory for Diagnosis and Treatment of Genitourinary System Disease, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Correspondence: Zhengyan Tang Zhao Wang
| | - Zhao Wang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Correspondence: Zhengyan Tang Zhao Wang
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11
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Zhang S, Wu QJ, Liu SX. A methodologic survey on use of the GRADE approach in evidence syntheses published in high-impact factor urology and nephrology journals. BMC Med Res Methodol 2022; 22:220. [PMID: 35948868 PMCID: PMC9367121 DOI: 10.1186/s12874-022-01701-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background To identify and describe the use of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for rating the certainty of systematic reviews (SRs) evidence published in urology and nephrology journals. Methods SRs that were published in the top ten "urology and nephrology" journals with the highest impact factor according to the 2020 Journal Citation Reports (covering 2016–2020) were systematically searched and evaluated using the GRADE approach. Results A total of 445 SRs were researched. Sixty SRs of randomized control trials (RCTs) and/or non-randomized studies (NRSs) were evaluated using the GRADE approach. Forty-nine SRs (11%) rated the outcome-specific certainty of evidence (n = 29 in 2019–2020). We identified 811 certainty of evidence outcome ratings (n = 544 RCT ratings) as follows: very low (33.0%); low (32.1%); moderate (24.5%); and high (10.4%). Very low and high certainty of evidence ratings accounted for 55.0% and 0.4% of ratings in SRs of NRSs compared to 23.0% and 15.3% in SRs of RCTs. The certainty of evidence for RCTs and NRSs was downgraded most often for risk of bias and imprecision. Conclusions We recommend increased emphasis on acceptance of the GRADE approach, as well as optimal use of the GRADE approach, in the synthesis of urinary tract evidence. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01701-x.
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Affiliation(s)
- Shuang Zhang
- Department of Nephrology, Dalian Municipal Central Hospital, No.826, Xinan Road, Dalian, Liaoning, 116033, China.,Dalian Key Laboratory of Intelligent Blood Purification, Dalian Municipal Central Hospital, No.826, Xinan Road, Dalian, Liaoning, 116033, China
| | - Qi-Jun Wu
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shu-Xin Liu
- Department of Nephrology, Dalian Municipal Central Hospital, No.826, Xinan Road, Dalian, Liaoning, 116033, China. .,Dalian Key Laboratory of Intelligent Blood Purification, Dalian Municipal Central Hospital, No.826, Xinan Road, Dalian, Liaoning, 116033, China.
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12
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Li K, Yu M, Li H, Zhu Q, Wu Z, Wang Z, Tang Z. Establishment of Prediction Models for Venous Thromboembolism in Non-Oncological Urological Inpatients - A Single-Center Experience. Int J Gen Med 2022; 15:3315-3324. [PMID: 35360703 PMCID: PMC8961164 DOI: 10.2147/ijgm.s354288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/10/2022] [Indexed: 12/20/2022] Open
Abstract
Purpose Venous thromboembolism (VTE) comprises deep venous thrombosis (DVT) and pulmonary embolism (PE), which can lead to death. VTE is an insidious disease with no specific symptoms and overlooked readily. We aimed to establish prediction models for VTE in non-oncological urological inpatients to aid urologists to better identify VTE patients. Patients and Methods A retrospective analysis of 1453 inpatients was carried out. The risk factors for VTE had been clarified in our previous study. A stepwise regression method was used to screen the relevant influencing factors for VTE and construct a logistic regression prediction model to predict VTE. To validate the accuracy of the model, data from 291 patients from another cohort were used for external validation. Results A total of 1453 inpatients were enrolled. Five potential risk factors (previous VTE; treatment with anticoagulants or anti-platelet agents before hospital admission; D-dimer ≥0.89 μg/mL; lower-extremity swelling; chest symptoms) were selected by multivariable analysis with p < 0.05. These five risk factors were used to build a logistic regression prediction model. When p < 0.1 in the multivariable logistic regression model, two additional risk factors were added: Caprini score ≥5 and complications, and all seven risk factors were used to build another prediction model. Internal verification showed the cutoff values, sensitivity, and specificity of the two models to be 0.02474, 0.941, 0.816 (model 1) and 0.03824, 0.941, and 0.820 (model 2), respectively. Both models had good predictive ability, but prediction accuracy was 43.0% for both when using the data of the additional 291 inpatients in the two models. Conclusion Two novel prediction models were built to predict VTE in non-oncological urological inpatients. This is a new method for VTE screening, and internal validation showed a good performance. External validation results were suboptimal but may provide clues for subsequent VTE screening.
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Affiliation(s)
- Kaixuan Li
- Department of Urology, Xiangya Hospital of Central South University, Changsha, 410008, People's Republic of China
| | - Meihong Yu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, People's Republic of China.,Research Center of Digestive Disease, Central South University, Changsha, Hunan, 410011, People's Republic of China
| | - Haozhen Li
- Department of Urology, Xiangya Hospital of Central South University, Changsha, 410008, People's Republic of China
| | - Quan Zhu
- Department of Urology, Xiangya Hospital of Central South University, Changsha, 410008, People's Republic of China
| | - Ziqiang Wu
- Department of Urology, Xiangya Hospital of Central South University, Changsha, 410008, People's Republic of China
| | - Zhao Wang
- Department of Urology, Xiangya Hospital of Central South University, Changsha, 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Changsha, 410008, People's Republic of China
| | - Zhengyan Tang
- Department of Urology, Xiangya Hospital of Central South University, Changsha, 410008, People's Republic of China.,Provincial Laboratory for Diagnosis and Treatment of Genitourinary System Disease, Changsha, 410000, People's Republic of China
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13
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Zheng Z, Wu Z, Li K, Zhu Q, Li H, Liu X, Wang G, Tang Z, Wang Z. Incidence and Risk Factors of Venous Thromboembolism in Patients After Transurethral Resection of the Prostate (TURP). Front Surg 2022; 8:744244. [PMID: 35198593 PMCID: PMC8858983 DOI: 10.3389/fsurg.2021.744244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
Objective Venous thromboembolism (VTE) in patients following transurethral resection of the prostate (TURP) has been overlooked for many years. This research was aimed to investigate the incidence and risk factors of VTE in patients after TURP. Methods A total of 451 patients who underwent TURP between January 2017 and December 2020 were retrospectively analyzed. Clinical data of the patients were collected, such as basic demographic data, prostate volume, creatinine values, hemoglobin values, surgery duration, Caprini score, international prostate symptom score (IPSS), quality of life (QOL) score, plasma D-dimer levels, and so on. Univariate analysis and multivariate logistic regression were performed to identify the potential risk factors of VTE. Venous ultrasonography of lower extremities was performed routinely to detect VTE for patients after TURP. Results In total, 36 (8%) out of the 451 patients suffered from VTE. A total of 12 (2.7%) patients were confirmed with deep venous thrombosis (DVT). Two patients (0.4%) were identified with pulmonary embolism (PE). Twenty-two (4.9%) patients were suffered from superficial venous thrombosis. Furthermore, according to the results of multivariate stepwise logistic regression analysis, having a history of VTE (adjusted odds ratio [aOR] = 10.980, 95% CI = 2.265–53.223), complicated with postoperative bladder hematoma (aOR = 6.302, 95% CI = 2.265–17.532), D-dimer >1.25 mg/L (aOR = 4.402, 95% CI = 1.798–10.774), and age >65 (aOR = 3.106, 95% CI = 1.084–8.893) were independent risk factors of VTE after TURP. In addition, the nomogram prediction model is a useful auxiliary prevention tool of VTE. Conclusion The incidence of VTE is severely underestimated in patients following TURP. A lot of asymptomatic VTEs have been overlooked. Early detection and diagnosis of VTE are essential. Nevertheless, further verifications based on the results of large-scaled studies are still needed.
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Affiliation(s)
- Zhihuan Zheng
- Xiangya Hospital, Central South University, Changsha, China
| | - Ziqiang Wu
- Xiangya Hospital, Central South University, Changsha, China
| | - Kaixuan Li
- Xiangya Hospital, Central South University, Changsha, China
| | - Quan Zhu
- Xiangya Hospital, Central South University, Changsha, China
| | - Haozhen Li
- Xiangya Hospital, Central South University, Changsha, China
| | - Xuesong Liu
- Xiangya Hospital, Central South University, Changsha, China
| | - Guilin Wang
- Xiangya Hospital, Central South University, Changsha, China
| | - Zhengyan Tang
- Xiangya Hospital, Central South University, Changsha, China.,Provincial Laboratory for Diagnosis and Treatment of Genitourinary System Disease, Changsha, China
| | - Zhao Wang
- Xiangya Hospital, Central South University, Changsha, China
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14
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Violette P. Editorial Comment on END-2021-0762-OR.R1. J Endourol 2022; 36:598-599. [PMID: 35021892 DOI: 10.1089/end.2022.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Philippe Violette
- Western University, Urology, St. Joseph's Hospital, 268 Grosvenor Street, London, Ontario, Canada, N6A 4V2;
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15
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Wang Z, Li K, Zhu Q, Li H, Wu Z, Liu X, Tang Z. Incidence and risk factors of in-hospital venous thromboembolism in non-oncological urological inpatients: A single center experience. Asian J Urol 2021. [DOI: 10.1016/j.ajur.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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16
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Liao Y, Chen T. A commentary on "Evaluation and analysis of incidence and risk factors of lower extremity venous thrombosis after urologic surgeries: A prospective two-center cohort study using LASSO-logistic regression" (Int. J. Surg. 2021 (89) 105948). Int J Surg 2021; 95:106139. [PMID: 34634510 DOI: 10.1016/j.ijsu.2021.106139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Yang Liao
- Department of Urology, Chongqing Jiangjin District Central Hospital, Chongqing, 402260, China
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17
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Lavikainen LI, Guyatt GH, Lee Y, Couban RJ, Luomaranta AL, Sallinen VJ, Kalliala IEJ, Karanicolas PJ, Cartwright R, Aaltonen RL, Ahopelto K, Aro KM, Beilmann-Lehtonen I, Blanker MH, Cárdenas JL, Craigie S, Galambosi PJ, Garcia-Perdomo HA, Ge FZ, Gomaa HA, Huang L, Izett-Kay ML, Joronen KM, Karjalainen PK, Khamani N, Kilpeläinen TP, Kivelä AJ, Korhonen T, Lampela H, Mattila AK, Najafabadi BT, Nykänen TP, Nystén C, Oksjoki SM, Pandanaboyana S, Pourjamal N, Ratnayake CBB, Raudasoja AR, Singh T, Tähtinen RM, Vernooij RWM, Wang Y, Xiao Y, Yao L, Haukka J, Tikkinen KAO. Systematic reviews of observational studies of Risk of Thrombosis and Bleeding in General and Gynecologic Surgery (ROTBIGGS): introduction and methodology. Syst Rev 2021; 10:264. [PMID: 34625092 PMCID: PMC8499502 DOI: 10.1186/s13643-021-01814-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 09/12/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) and bleeding are serious and potentially fatal complications of surgical procedures. Pharmacological thromboprophylaxis decreases the risk of VTE but increases the risk of major post-operative bleeding. The decision to use pharmacologic prophylaxis therefore represents a trade-off that critically depends on the incidence of VTE and bleeding in the absence of prophylaxis. These baseline risks vary widely between procedures, but their magnitude is uncertain. Systematic reviews addressing baseline risks are scarce, needed, and require innovations in methodology. Indeed, systematic summaries of these baseline risk estimates exist neither in general nor gynecologic surgery. We will fill this knowledge gap by performing a series of systematic reviews and meta-analyses of the procedure-specific and patient risk factor stratified risk estimates in general and gynecologic surgeries. METHODS We will perform comprehensive literature searches for observational studies in general and gynecologic surgery reporting symptomatic VTE or bleeding estimates. Pairs of methodologically trained reviewers will independently assess the studies for eligibility, evaluate the risk of bias by using an instrument developed for this review, and extract data. We will perform meta-analyses and modeling studies to adjust the reported risk estimates for the use of thromboprophylaxis and length of follow up. We will derive the estimates of risk from the median estimates of studies rated at the lowest risk of bias. The primary outcomes are the risk estimates of symptomatic VTE and major bleeding at 4 weeks post-operatively for each procedure stratified by patient risk factors. We will apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate evidence certainty. DISCUSSION This series of systematic reviews, modeling studies, and meta-analyses will inform clinicians and patients regarding the trade-off between VTE prevention and bleeding in general and gynecologic surgeries. Our work advances the standards in systematic reviews of surgical complications, including assessment of risk of bias, criteria for arriving at the best estimates of risk (including modeling of the timing of events and dealing with suboptimal data reporting), dealing with subgroups at higher and lower risk of bias, and use of the GRADE approach. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021234119.
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Affiliation(s)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Rachel J Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Anna L Luomaranta
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville J Sallinen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilkka E J Kalliala
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Paul J Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rufus Cartwright
- Department of Obstetrics and Gynaecology, LNWH NHS Trust, London, UK
| | - Riikka L Aaltonen
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Kaisa Ahopelto
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karoliina M Aro
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ines Beilmann-Lehtonen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jovita L Cárdenas
- National Center for Health Technology Excellence (CENETEC) Direction of Health Technologies assessment, Mexico City, Mexico
| | - Samantha Craigie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Päivi J Galambosi
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Herney A Garcia-Perdomo
- Division of Urology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Fang Zhou Ge
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - Huda A Gomaa
- High Institute of Public Health, Alexandria University, Alexandria, Egypt
- Tanta Chest Hospital, Ministry of Health and Population, Tanta, Egypt
| | - Linglong Huang
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Matthew L Izett-Kay
- Urogynaecology Department, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Kirsi M Joronen
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi K Karjalainen
- Department of Obstetrics and Gynecology, Central Finland Central Hospital, Jyväskylä, Finland
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Nadina Khamani
- Department of Obstetrics and Gynecology, Institute of Childrens' Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti J Kivelä
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tapio Korhonen
- Experts by Experience, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Hanna Lampela
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anne K Mattila
- Central Finland Central Hospital, Department of Surgery, Jyväskylä, Finland
| | - Borna Tadayon Najafabadi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Carolina Nystén
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Sanjay Pandanaboyana
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Negar Pourjamal
- Laboratory of Molecular Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Chathura B B Ratnayake
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Auckland City Hospital, Auckland, New Zealand
| | | | - Tino Singh
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Riikka M Tähtinen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Robin W M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Nephrology & Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yuting Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yingqi Xiao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- West China School of Nursing/Department of Nursing, West China Hospital, Sichuan University, Chengdu, China
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Jari Haukka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
| | - 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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18
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Sforza S, Grosso AA, Di Maida F, Viola L, Tuccio A, Mari A, Cito G, Cocci A, Carini M, Minervini A, Masieri L. A comparative study of anticoagulant/antiplatelet therapy among men undergoing robot-assisted radical prostatectomy: a prospective single institution study. J Robot Surg 2021; 16:849-857. [PMID: 34546522 DOI: 10.1007/s11701-021-01308-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
The present study aimed to assess the safety and efficacy of robot-assisted radical prostatectomy (RARP) in patients with prostate cancer (PCa) under anticoagulant (AC) and/or antiplatelet (AP) therapy, as compared to a control group, and to establish possible differences in postoperative-related morbidity. Data of all consecutive patients submitted to elective RARP for PCa from June 2017 to May 2020 at our institution were prospectively collected. Patients were divided according to the use of AC/AP therapy at surgery. The primary endpoint was to determine differences in 90-day postoperative complication rate, while secondary endpoints included differences in transfusion rate, readmission rate and postoperative oncological outcomes between the two groups. Sub-groups analysis was separately performed for patients undergoing pelvic lymphadenectomy and nerve-sparing procedures. Overall, 822 patients were included in the study and divided in 704 control-group patients (group A) and 118 patients under AC/AP therapy at surgery (group B). Despite the higher estimated blood loss between AC/AP takers and the control group, we did not find a significant difference in terms of 90-day postoperative complication rate, transfusion rate, readmission rate and postoperative oncological outcomes (all p > 0.05). In the cohort of patients undergoing nerve-sparing prostatectomy, a higher rate of complications and transfusions were found. At multivariate analysis, ASA score and ongoing medications were independently associated with complication in this sub-group. RARP can be safely and effectively performed in patients with PCa and ongoing AC/AP agents. Attention has to be paid in candidates for nerve-sparing procedures.
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Affiliation(s)
- Simone Sforza
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Largo Brambilla, 3, 70134, Florence, Italy.
| | - Antonio Andrea Grosso
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Largo Brambilla, 3, 70134, Florence, Italy
| | - Fabrizio Di Maida
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Largo Brambilla, 3, 70134, Florence, Italy
| | - Lorenzo Viola
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Largo Brambilla, 3, 70134, Florence, Italy
| | - Agostino Tuccio
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Largo Brambilla, 3, 70134, Florence, Italy
| | - Andrea Mari
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Largo Brambilla, 3, 70134, Florence, Italy
| | - Gianmartin Cito
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Largo Brambilla, 3, 70134, Florence, Italy
| | - Andrea Cocci
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Largo Brambilla, 3, 70134, Florence, Italy
| | - Marco Carini
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Largo Brambilla, 3, 70134, Florence, Italy
| | - Andrea Minervini
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Largo Brambilla, 3, 70134, Florence, Italy
| | - Lorenzo Masieri
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Largo Brambilla, 3, 70134, Florence, Italy
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19
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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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20
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Padayachee WPR, Haffejee M, Nel M. Evaluating post-operative venous thromboembolism risk in urology patients using a validated risk assessment model. AFRICAN JOURNAL OF UROLOGY 2021. [DOI: 10.1186/s12301-021-00237-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Venous thromboembolism (VTE) is an important cause of post-surgical morbidity and mortality. This study aimed to apply a validated risk assessment model to evaluate the risk of post-operative VTE in urology patients.
Methods
This prospective descriptive observational study used the Caprini risk assessment model to evaluate VTE risk in patients planned for elective urology surgery at a tertiary Johannesburg hospital from January to June 2020.
Results
Two hundred and twenty-six patients with a mean age of 52 years were evaluated for post-operative VTE risk. The population was generally overweight, with a mean BMI of 26.3 kg/m2. The mean Caprini score was 4.42, reflecting a population at high risk for post-operative VTE. There was no statistically significant difference between males and females in this regard. On average, participants had three risk factors for post-operative VTE. Fifteen per cent of all patients were at low risk for VTE, while 40.3% of participants were categorised as moderate risk. The category with the highest percentage of participants (44.7%) was the high-risk category (Caprini score ≥ 5). High-risk patients undergoing oncology surgery comprised 16.8% of the population, and these patients may require extended duration pharmacological thromboprophylaxis to prevent VTE. The most clinically significant risk factors for post-operative VTE included age, obesity, malignancy and HIV infection.
Conclusion
Venous thromboembolism may be difficult to diagnose, and clinicians may underestimate the risk for it to develop. Risk assessment models, such as the Caprini score, are objective and a practical tool to guide the application of thromboprophylaxis. The application of the Caprini RAM in the elective urological surgery population at Chris Hani Baragwanath Academic Hospital yields similar results to studies performed elsewhere on similar surgical populations. Further research is required to evaluate whether the actual incidence of VTE correlates with the risk assessment in this population. Clinician compliance with the use of RAMs as well as the corresponding recommendations for prophylaxis may need to be evaluated. A validated risk assessment model which accounts for procedure-specific risks in urology may be useful.
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21
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Morgano GP, Wiercioch W, Anderson DR, Brożek JL, Santesso N, Xie F, Cuker A, Nieuwlaat R, Akl EA, Darzi A, Yepes-Nuñez JJ, Exteandia-Ikobaltzeta I, Rahman M, Rajasekhar A, Rogers F, Tikkinen KAO, Yates AJ, Dahm P, Schünemann HJ. A modeling approach to derive baseline risk estimates for GRADE recommendations:Concepts, development, and results of its application to the American Society of Hematology 2019 guidelines on prevention of venous thromboembolism in surgical hospitalized patients. J Clin Epidemiol 2021; 140:69-78. [PMID: 34284102 DOI: 10.1016/j.jclinepi.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/18/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The goal of this study was to develop an approach that can be used where baseline risk estimates that are directly applicable to prioritized patient-important outcomes are not available from published studies. STUDY DESIGN The McMaster University GRADE Centre and the ASH guideline panel for the prevention of VTE in surgical patients developed a modeling approach based on explicit assumptions about the distribution of symptoms, anatomical location, and severity of VTE events. RESULTS We applied the approach to derive modeled estimates of baseline risk. These estimates were used to calculated absolute measures of anticipated effects that informed the discussion of the evidence and the formulation of 30 guideline recommendations. CONCLUSIONS Our approach can assist guideline developers facing a lack of information about baseline risk estimates that directly apply to outcomes of interest. The use of modeled estimates increases transparency in the process and makes the baseline risk used by guideline experts explicit during their decision-making.
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Affiliation(s)
- Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | | | - Jan L Brożek
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Nancy Santesso
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, USA
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Lebanon
| | - Andrea Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Juan José Yepes-Nuñez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada; School of Medicine, Universidad de los Andes, Colombia
| | | | - Maryam Rahman
- Lillian S. Wells Department of Neurosurgery, University of Florida, USA
| | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, USA
| | - Frederick Rogers
- Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, USA
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Finland,; Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
| | - Adolph J Yates
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, USA
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, USA; Department of Urology, University of Minnesota, USA
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada; Department of Medicine, McMaster University, Canada.
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22
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Hoare DT, Doiron RC, Rourke KF. Determining Perioperative Practice Patterns in Urethroplasty: A Survey of Genitourinary Reconstructive Surgeons. Urology 2021; 156:263-270. [PMID: 34186137 DOI: 10.1016/j.urology.2021.05.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/13/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To better delineate perioperative urethroplasty practice patterns among reconstructive urologists given that management strategies in reconstructive urology have generally been poorly described. METHODS An online survey examining perioperative management of anterior urethroplasty patients was administered to Society of Genitourinary Reconstructive Surgeons (GURS) members between August-October 2019. Questions pertained to tissue transfer, pharmacologic prophylaxis, catheter use, follow-up, and post-operative care. RESULTS A total of 248 GURS members were invited to participate, with a response rate of 57.2% (n = 142). Most participants performed >20 urethroplasties per year (n = 108, 76.1%). Almost all respondents (97.9%, n = 139) used intraoperative intravenous antibiotics. A minority of surgeons used intraoperative pharmacologic thromboembolism prophylaxis (n = 57, 40.1%). Surgeons prefer buccal mucosa for grafting (n = 138, 97.2%) with many leaving the donor site open (n = 76, 53.5%). Only 21.8% (n = 31) of surgeons prescribe bedrest for patients and 25.4% (n = 36) routinely place drains. Postoperatively, oral antimicrobials are routinely administered (n=100, 70.4%), with most continuing until the urinary catheter is removed (70, 72.2%). Patients commonly had a urethral catheter for 2-3 (n = 72, 58.5%) or 3-4 weeks (n = 37, 30.1%). At catheter removal, surgeons routinely perform urethral imaging with contrast (n=96, 67.6%). Most surgeons prefer some form of objective investigation (n = 111, 78.2%) (uroflowmetry [n = 91, 82.0%], post-void residual [n = 88, 79.3%]). Cystoscopy is also commonly performed (n = 64, 57.7%). These investigations are routinely performed at 2-3 (n = 49, 44.2%) or 4-6 months (n = 38, 34.2%) postoperatively. CONCLUSION Despite general consensus on urethroplasty management options, heterogeneity remains in the areas of antibiotic use, VTE prophylaxis, donor site management, catheter management, and follow-up assessment.
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Affiliation(s)
- Dylan T Hoare
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta
| | - R Christopher Doiron
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta; Department of Urology, Queen's University, Kingston, Ontario
| | - Keith F Rourke
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta.
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23
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Ortiz RM, Golijanin B, O'Rourke TK, Sobel DW, Pillsbury L, T Tucci C, Caffery P, Golijanin D. Direct Oral Anticoagulants for Venous Thromboembolism Prophylaxis Following Robot-assisted Radical Cystectomy: A Retrospective Feasibility Study at a Single Academic Medical Center. Urology 2021; 156:154-162. [PMID: 34171347 DOI: 10.1016/j.urology.2021.04.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/11/2021] [Accepted: 04/15/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To evaluate the use of direct oral anticoagulants following radical cystectomy for venous thromboembolism prophylaxis. We compared the experience of those who received venous thromboembolism prophylaxis following a robot-assisted radical cystectomy with either a direct oral anticoagulant or enoxaparin. METHODS Medical records of 66 patients who underwent robot-assisted radical cystectomy between July 2017 and May 2020 at a single academic institution were reviewed retrospectively. Patients received extended prophylaxis with either a direct oral anticoagulant or enoxaparin before or following surgical discharge. Venous thromboembolic events and complications resulting in emergency department visits and readmissions were reviewed over a 90-day postoperative period. RESULTS A total of 4 venous thromboembolic events within 90 days of surgery were observed. Among patients taking enoxaparin, 5% (2/37) developed a deep vein thrombosis and 3% (1/37) developed a pulmonary embolism. Among patients taking direct oral anticoagulants, 3% (1/29) developed a deep vein thrombosis. Zero patients in the enoxaparin group and 3% (1/29) of patients in the direct oral anticoagulant group experienced bleeding that required an emergency department visit. CONCLUSION Direct oral anticoagulants performed comparably to enoxaparin in this feasibility study following robot-assisted radical cystectomy in 66 patients. No significant differences in the number of venous thromboembolisms or bleeding complications were observed. These data encourage future studies and support the prospect of direct oral anticoagulants as a potentially suitable oral alternative to injectable low molecular weight heparins for venous thromboembolism prophylaxis following radical cystectomy.
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Affiliation(s)
- Rebecca M Ortiz
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI
| | - Borivoj Golijanin
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI
| | - Timothy K O'Rourke
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI
| | - David W Sobel
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI
| | - Lauren Pillsbury
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI
| | - Christopher T Tucci
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI
| | - Philip Caffery
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI
| | - Dragan Golijanin
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI.
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24
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Tang G, Qi L, Sun Z, Liu J, Lv Z, Chen L, Huang B, Zhu S, Liu Y, Li Y. Evaluation and analysis of incidence and risk factors of lower extremity venous thrombosis after urologic surgeries: A prospective two-center cohort study using LASSO-logistic regression. Int J Surg 2021; 89:105948. [PMID: 33892158 DOI: 10.1016/j.ijsu.2021.105948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/19/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Deep vein thrombosis (DVT) is among the most frequent complications of surgery. This study aimed to analyse the incidence and risk factors of lower extremity venous thrombosis after urologic surgery. MATERIALS AND METHODS This prospective two-centre study was conducted from August 2019 to January 2020. Patients who underwent urological procedures were enrolled. The primary endpoint was the detection of asymptomatic or symptomatic DVT of the lower extremity within 7 days after surgery. Univariate and least absolute shrinkage and selection operator (LASSO) logistic regression analyses were performed. RESULTS Fifty-six of 1011 patients developed DVT. In the univariate analysis, Barthel Index ≤40, d-dimer level ≥0.5 mg/L and age ≥60 years (p < 0.001) were identified as the most significant risk factors. The LASSO logistic regression model identified nine factors: age, history of DVT, lymph node dissection, perioperative steroid use, Caprini score, Barthel Index, D-dimer level, cystectomy, and prostatectomy. CONCLUSION Our study used the LASSO logistic regression model to provide reliable data on the risk factors for DVT after comprehensive urologic surgery. The incidence of DVT in this group was 5.54%. This might facilitate individualised anticoagulant management in patients undergoing urological procedures.
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Affiliation(s)
- Guyu Tang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Lin Qi
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Zepeng Sun
- Department of Statistics, School of Mathematics and Statistics, Beijing Technology and Business University, Haidian, Beijing, 100048, China
| | - Jing Liu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Zhengtong Lv
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Lingxiao Chen
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Bin Huang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Shuai Zhu
- Department of Urology, Hunan Cancer Hospital, Central South University, Changsha, Hunan, 410013, China
| | - Yao Liu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Yuan Li
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China; Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
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25
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Batagello CA, Vicentini FC, Monga M, Miller AW, Marchini GS, Torricelli FCM, Danilovic A, Coelho RF, Srougi M, Nahas WC, Mazzucchi E. Tranexamic acid in patients with complex stones undergoing percutaneous nephrolithotomy: a randomised, double-blinded, placebo-controlled trial. BJU Int 2021; 129:35-47. [PMID: 33630393 DOI: 10.1111/bju.15378] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To assess the efficacy and safety of single-dose tranexamic acid on the blood transfusion rate and outcomes of patients with complex kidney stones undergoing percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS In a randomised, double-blinded, placebo-controlled trial, 192 patients with complex kidney stone (Guy's Stone Scores III-IV) were prospectively enrolled and randomised (1:1 ratio) to receive either one dose of tranexamic acid (1 g) or a placebo at the time of anaesthetic induction for PCNL. The primary outcome measure was the occurrence rate of perioperative blood transfusion. The secondary outcome measures included blood loss, operative time, stone-free rate (SFR), and complications. ClinicalTrials.gov identifier: NCT02966236. RESULTS The overall risk of receiving a blood transfusion was reduced in the tranexamic acid group (2.2% vs 10.4%; relative risk, 0.21, 95% confidence interval [CI] 0.03-0.76, P = 0.033; number-needed-to-treat: 12). Patients randomised to the tranexamic acid group had a higher immediate and 3-month SFR compared with those in the placebo group (29% vs 14.7%, odds ratio [OR] 2.37, 95% CI 1.15-4.87, P = 0.019, and 46.2% vs 28.1%, OR 2.20, 95% CI 1.20-4.02, P = 0.011, respectively). Faster haemoglobin recovery occurred in patients in the tranexamic acid group (mean, 21.3 days; P = 0.001). No statistical differences were found in operative time and complications between groups. CONCLUSIONS Tranexamic acid administration is safe and reduces the need for blood transfusion by five-times in patients with complex kidney stones undergoing PCNL. Moreover, tranexamic acid may contribute to better stone clearance rate and faster haemoglobin recovery without increasing complications. A single dose of tranexamic acid at the time of anaesthetic induction could be considered standard clinical practice for patients with complex kidney stones undergoing PCNL.
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Affiliation(s)
- Carlos A Batagello
- Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fabio C Vicentini
- Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Endourology, Hospital Brigadeiro, Sao Paulo, Brazil
| | - Manoj Monga
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Stevan B. Streem Center for Endourology and Stone Disease, Cleveland Clinic, Cleveland, OH, USA.,Urology Division, University of California San Diego, San Francisco, CA, USA
| | - Aaron W Miller
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Stone Translational Research Laboratory, Cleveland Clinic, Cleveland, OH, USA.,Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Giovanni S Marchini
- Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fabio C M Torricelli
- Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alexandre Danilovic
- Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Rafael F Coelho
- Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Miguel Srougi
- Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Willian C Nahas
- Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Eduardo Mazzucchi
- Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
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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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Azawi NH, Subhi Y, Tolouee S, Geertsen L, Bjerrum SN, Laier GH, Dahl C, Lund L, Dabestani S. 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. Urology 2020; 143:112-116. [PMID: 32569656 DOI: 10.1016/j.urology.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/03/2020] [Accepted: 06/09/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Nessn H Azawi
- Department of Urology, Zealand University Hospital, Roskilde, Denmark; Institute of Clinical Medicine, Copenhagen University, Copenhagen, Denmark.
| | - Yousif Subhi
- Department of Ophthalmology, Zealand University Hospital, Roskilde, Denmark
| | - Sara Tolouee
- Department of Urology, Zealand University Hospital, Roskilde, Denmark
| | - Louise Geertsen
- Department of Urology, Odense University Hospital, Odense, Denmark
| | | | | | - Claus Dahl
- Department of Urology, Zealand University Hospital, Roskilde, Denmark
| | - Lars Lund
- Department of Urology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Saeed Dabestani
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
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Violette PD, Vernooij RWM, Aoki Y, Agarwal A, Cartwright R, Arai Y, Tailly T, Novara G, Baldeh T, Craigie S, Breau RH, Guyatt GH, Tikkinen KAO. An International Survey on the Use of Thromboprophylaxis in Urological Surgery. Eur Urol Focus 2020; 7:653-658. [PMID: 32561453 DOI: 10.1016/j.euf.2020.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/15/2020] [Accepted: 05/27/2020] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Philippe D Violette
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Robin W M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Nephrology & Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yoshitaka Aoki
- Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
| | - Arnav Agarwal
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rufus Cartwright
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK; Department of Urogynecology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Yoichi Arai
- Department of Urology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Thomas Tailly
- Division of Urology, Department of Surgery, University Hospital Ghent, Ghent, Belgium
| | - Giacomo Novara
- Department of Surgical, Oncological, and Gastroenterological Sciences, Urology Clinic, University of Padua, Padua, Italy
| | - Tejan Baldeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Samantha Craigie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Rodney H Breau
- Division of Urology, The Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Kari A O Tikkinen
- Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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Branchu B, Léon P, Fournier R, Lasserre T, Tambwe R, Hoquetis L, Joncour C, Larré S. [Impact of antiplatelet and anticoagulant treatments on bleeding complications in patients treated with HoLEP]. Prog Urol 2020; 30:639-645. [PMID: 32409241 DOI: 10.1016/j.purol.2020.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/10/2020] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION We aimed to assess the impact of antiplatelet and anticoagulation therapy for patients undergoing HoLEP. METHODS We performed a study during the learning curve on a consecutive series of patients who underwent HoLEP surgery from 2015 to 2018. The patients were divided into 3 groups: a control group, patients with antiplatelet therapy and patients with anticoagulation therapy. RESULTS A total of 223 patients underwent HoLEP surgery during this period: 124 in the control group, 63 in the antiplatelet group and 36 in the anticoagulant group. In the anticoagulant group, we observe significant differences with the control group for the catheterization time (2.05 days vs 5.17 days; P<0.001), the hospital length of stay (1.5 nights vs 4.49 nights; P<0.001) and complications (8.9% vs 58%; P<0.001). No difference between the control and antiplatelet groups in terms of catheterization time, hospital length of stay and complications (2.05 days vs 2.68 days; 1.5 nights vs 1.6 nights) but variation in terms of complications and bleeding complications (8.9% vs 21%; P<0,001; 8.1% vs 19%; P<0,001) CONCLUSION: Our study shows that HoLEP is therefore associated with a higher risk of bleeding for patients treated with anticoagulation therapy. Complications increase morbidity with longer catheterization time, hospitalization times and higher transfusion's rates, revision surgery and readmission. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- B Branchu
- Service d'urologie, CHU de Reims, rue Cognacq-Jay, 51100 Reims, France.
| | - P Léon
- Service d'urologie, clinique Pasteur, 17200 Royan, France
| | - R Fournier
- Service d'urologie, CHU de Reims, rue Cognacq-Jay, 51100 Reims, France
| | - T Lasserre
- Service d'urologie, CHU de Reims, rue Cognacq-Jay, 51100 Reims, France
| | - R Tambwe
- Service d'urologie, CHU de Reims, rue Cognacq-Jay, 51100 Reims, France
| | - L Hoquetis
- Service d'urologie, CHU de Reims, rue Cognacq-Jay, 51100 Reims, France
| | - C Joncour
- Service d'urologie, CHU de Reims, rue Cognacq-Jay, 51100 Reims, France
| | - S Larré
- Service d'urologie, CHU de Reims, rue Cognacq-Jay, 51100 Reims, France
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30
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Perioperative antithrombotic (antiplatelet and anticoagulant) therapy in urological practice: a critical assessment and summary of the clinical practice guidelines. World J Urol 2020; 38:2761-2770. [DOI: 10.1007/s00345-020-03078-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/02/2020] [Indexed: 01/28/2023] Open
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Anderson DR, Morgano GP, Bennett C, Dentali F, Francis CW, Garcia DA, Kahn SR, Rahman M, Rajasekhar A, Rogers FB, Smythe MA, Tikkinen KAO, Yates AJ, Baldeh T, Balduzzi S, Brożek JL, Ikobaltzeta IE, Johal H, Neumann I, Wiercioch W, Yepes-Nuñez JJ, Schünemann HJ, Dahm P. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv 2019; 3:3898-3944. [PMID: 31794602 PMCID: PMC6963238 DOI: 10.1182/bloodadvances.2019000975] [Citation(s) in RCA: 270] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/22/2019] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Charles W Francis
- Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA
| | - Susan R Kahn
- Department of Medicine, McGill University and Lady Davis Institute, Montreal, QC, Canada
| | | | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL
| | - Frederick B Rogers
- Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA
| | - Maureen A Smythe
- Department of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI
- Department of Pharmacy Practice, Wayne State University, Detroit, MI
| | - Kari A O Tikkinen
- Department of Urology and
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Adolph J Yates
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tejan Baldeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sara Balduzzi
- Department of Diagnostic, Clinical, and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Jan L Brożek
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | | | - Herman Johal
- Center for Evidence-Based Orthopaedics, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, MN; and
- Department of Urology, University of Minnesota, Minneapolis, MN
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Doménech López P, Robles García JE, Gutiérrez Castañé C, Chiva San Román S, García Cortés A, Ancizu Marckert FJ, Tamariz Amador LE, Andrés Boville G, Villacampa Aubá F, de Fata Chillón FR, Diez-Caballero Alonso F, Torres Roca M, Rosell Costa D, Miñana López B, Pascual Piedrola JI, Páramo Fernández JA. Surgical thromboprophylaxis in daily urologic surgery: Beyond bridge therapy. Actas Urol Esp 2019; 43:455-466. [PMID: 31351747 DOI: 10.1016/j.acuro.2019.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/05/2019] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- P Doménech López
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España.
| | - J E Robles García
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - C Gutiérrez Castañé
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - S Chiva San Román
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - A García Cortés
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - F J Ancizu Marckert
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - L E Tamariz Amador
- Departamento de Hematología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - G Andrés Boville
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - F Villacampa Aubá
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - F R de Fata Chillón
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | | | - M Torres Roca
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - D Rosell Costa
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - B Miñana López
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - J I Pascual Piedrola
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - J A Páramo Fernández
- Departamento de Hematología Clínica, Universidad de Navarra, Pamplona, Navarra, España
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McAlpine K, Breau RH, Knee C, Carrier M, Violette PD, van Walraven C, McIsaac DI, Mallick R, Cagiannos I, Morash C, Lavallée LT. Venous thromboembolism and transfusion after major abdominopelvic surgery. Surgery 2019; 166:1084-1091. [PMID: 31377000 DOI: 10.1016/j.surg.2019.05.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/16/2019] [Accepted: 05/27/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Thromboprophylaxis aims to reduce venous thromboembolism but has the potential to increase bleeding. We sought to evaluate the risk of venous thromboembolism and transfusion after major abdominopelvic procedures and to quantify the association of the procedure with venous thromboembolism. METHODS The American College of Surgeons' National Surgical Quality Improvement Program was queried for patients who received an abdominopelvic surgery between 2005 and 2016. Patient factors, operative factors, and outcomes were collected. Multivariable analyses were used to determine the association between individual procedures and venous thromboembolism. Area under the curve analyses were performed to assess whether addition of the procedure to Caprini score improved the association of the model with venous thromboembolism. The primary outcome was risk of venous thromboembolism within 30 days of surgery. Secondary outcomes were the risk of transfusion within 30 days and the association between operative time with venous thromboembolism. RESULTS There were 896,441 patients who received an abdominopelvic procedure. The overall risk of venous thromboembolism was 1.9% (n = 16,665). Procedures with the highest risk of venous thromboembolism were esophagectomy (5.5%) and partial esophagectomy (5.3%). The overall risk of transfusion was 9.5% (n = 84,889). Procedures with the highest risk of transfusion were pelvic exenteration (53.6%) and radical cystectomy (37.7%). On multivariable analyses, individual procedures were independently associated with venous thromboembolism, despite adjusting for Caprini score. Area under the curve analyses indicated risk prediction of the baseline model (area under the curve 0.59) improved when procedures were added (area under the curve 0.68). CONCLUSION Patients undergoing abdominopelvic surgery are at a high risk of venous thromboembolism and transfusion. Improved risk stratification may be possible by including more procedural information in scoring systems.
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Affiliation(s)
- Kristen McAlpine
- Division of Urology, University of Ottawa and The Ottawa Hospital, ON, Canada
| | - Rodney H Breau
- Division of Urology, University of Ottawa and The Ottawa Hospital, ON, Canada; Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Christopher Knee
- Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Marc Carrier
- Ottawa Hospital Research Institute, University of Ottawa, ON, Canada; Department of Medicine, University of Ottawa and The Ottawa Hospital, ON, Canada
| | - Philippe D Violette
- Departments of Health Research Methods, Evidence, and Impact and Surgery, McMaster University, Hamilton, ON, Canada
| | - Carl van Walraven
- Ottawa Hospital Research Institute, University of Ottawa, ON, Canada; Department of Medicine, University of Ottawa and The Ottawa Hospital, ON, Canada
| | - Daniel I McIsaac
- Ottawa Hospital Research Institute, University of Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, ON, Canada
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Ilias Cagiannos
- Division of Urology, University of Ottawa and The Ottawa Hospital, ON, Canada; Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Christopher Morash
- Division of Urology, University of Ottawa and The Ottawa Hospital, ON, Canada; Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Luke T Lavallée
- Division of Urology, University of Ottawa and The Ottawa Hospital, ON, Canada; Ottawa Hospital Research Institute, University of Ottawa, ON, Canada.
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Boeri L, Montanari E, Salonia A. Reply to Vincent Misraï, Kevin C. Zorn, and Helene Charbonneau's Letter to the Editor re: Luca Boeri, Paolo Capogrosso, Eugenio Ventimiglia, et al. Clinical Comparison of Holmium Laser Enucleation of the Prostate and Bipolar Transurethral Enucleation of the Prostate in Patients Under Either Anticoagulation or Antiplatelet Therapy. Eur Urol Focus. In press. https://doi.org/10.1016/j.euf.2019.03.002. Perioperative Assessment of Transurethral Surgery for Benign Prostatic Obstruction in Patients Taking Oral Anticoagulants or Antiplatelet Agents: A Plea to Improve the Quality of Data. Eur Urol Focus 2019; 7:223-224. [PMID: 31060853 DOI: 10.1016/j.euf.2019.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Luca Boeri
- Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Urology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.
| | - Emanuele Montanari
- Department of Urology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Andrea Salonia
- Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
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35
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Klaassen Z, Wallis CJD, Lavallée LT, Violette PD. Perioperative venous thromboembolism prophylaxis in prostate cancer surgery. World J Urol 2019; 38:593-600. [DOI: 10.1007/s00345-019-02705-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 02/25/2019] [Indexed: 01/31/2023] Open
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Becker B, Netsch C, Hansen J, Böhme A, Gross AJ, Zacharias M, Lehrich K. Perioperative Safety in Patient Under Oral Anticoagulation During Holmium Laser Enucleation of the Prostate. J Endourol 2019; 33:219-224. [PMID: 30516393 DOI: 10.1089/end.2018.0693] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES To evaluate the safety of holmium laser enucleation of the prostate (HoLEP) in patients on oral anticoagulation (OA) with respect to intra- and postoperative bleeding complications. METHODS Between January 2013 and October 2016, 2178 patients were included in this study, of whom 94 received direct oral anticoagulants (DOACs) and 151 received vitamin K antagonists (VKAs) before HoLEP. All patients either ceased OA (DOACs) or were bridged subtherapeutically (VKAs, international normalized ratio <2) during surgery. These patients were compared to a sample size of 1933 nonanticoagulated patients. RESULTS A significant longer postoperative stay was noted for the patients on DOACs (5.2 [4-6] days) and VKAs (5.3 [4-5] days) compared to the control group (4.5 [4-4] days). The mean drop in hemoglobin was significantly higher in the VKA group compared to the DOAC and control group. There was a significantly higher rate of postoperative bladder tamponades/secondary coagulation in patients on OA with 6 (7.9%)/3 (3.9%) patients in the DOAC group, 10 (7.4%)/6 (4.4%) patients in the VKA group compared to 37 (2.2%)/21 (2.1%) patients in the control group, respectively (p < 0.001). Eight patients required blood transfusions with a distribution of 1 (1.3%), 3 (2.2%), and 4 (0.2%) patients in the DOAC, VKA, and control group, respectively (p < 0.001). CONCLUSIONS Our findings indicate that bridged patients who's DOACs and VKAs were ceased before HoLEP are at higher risk of intra- and postoperative bleeding complications. Nonetheless, HoLEP appears to be a safe and effective procedure in those patients.
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Affiliation(s)
- Benedikt Becker
- 1 Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany
| | | | - Jens Hansen
- 2 Department of Urology, Auguste Viktoria Hospital, Berlin, Germany
| | - Axel Böhme
- 2 Department of Urology, Auguste Viktoria Hospital, Berlin, Germany
| | - Andreas J Gross
- 1 Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Mario Zacharias
- 2 Department of Urology, Auguste Viktoria Hospital, Berlin, Germany
| | - Karin Lehrich
- 2 Department of Urology, Auguste Viktoria Hospital, Berlin, Germany
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Coscarella M, Motte S, Dalati MF, Oliveira-E-Silva T, Entezari K, Roumeguere T. New oral anti-coagulation drugs and prostate biopsy: a call for guidelines. Ther Adv Urol 2018; 10:437-443. [PMID: 30574204 PMCID: PMC6295786 DOI: 10.1177/1756287218811037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 10/11/2018] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Mathieu Coscarella
- Department of Urology, Erasme Hospital, University Clinics of Brussels, Route de Lennik 808, 1070 Brussels, Belgium Department of Urology, CHU St Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Serge Motte
- Department of Vascular Diseases, University Clinics of Brussels, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Mohamad-Fadi Dalati
- Department of Urology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Tania Oliveira-E-Silva
- Department of Urology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Kim Entezari
- Department of Urology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Roumeguere
- Department of Urology, University Clinics of Brussels, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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McAlpine K, Lavallée LT. Decreasing rates of venous thromboembolism after radical cystectomy: an encouraging trend and more work is still needed. Transl Androl Urol 2018; 7:982-983. [PMID: 30505737 PMCID: PMC6256039 DOI: 10.21037/tau.2018.07.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Kristen McAlpine
- 1Division of Urology, 2The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Luke T Lavallée
- 1Division of Urology, 2The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Tikkinen KAO, Craigie S, Schünemann HJ, Guyatt GH. Certainty ranges facilitated explicit and transparent judgments regarding evidence credibility. J Clin Epidemiol 2018; 104:46-51. [PMID: 30145323 DOI: 10.1016/j.jclinepi.2018.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 07/29/2018] [Accepted: 08/17/2018] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Kari A O Tikkinen
- Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, 00029 Helsinki, Finland.
| | - Samantha Craigie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada; Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada; Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
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Packiam VT, Pariser JJ. Ongoing efforts to reduce perioperative morbidity of radical cystectomy: towards widespread adoption of extended-duration thromboprophylaxis. Transl Androl Urol 2018; 7:S81-S82. [PMID: 29645005 PMCID: PMC5881201 DOI: 10.21037/tau.2018.02.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 01/29/2018] [Indexed: 11/06/2022] Open
Affiliation(s)
- Vignesh T. Packiam
- Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joseph J. Pariser
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
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Rieken M, Bachmann A. Risk of Bleeding Versus Venous Thromboembolism in Urological Surgery-Finding the Right Balance Is Not Always Easy! Eur Urol 2017; 73:252-253. [PMID: 28890251 DOI: 10.1016/j.eururo.2017.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/23/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Malte Rieken
- alta uro AG, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | - Alexander Bachmann
- alta uro AG, Basel, Switzerland; University of Basel, Basel, Switzerland
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Ramos JD, Wingate JT, Gulati R, Plimack ER, Harshman LC, Powles T, Crabb SJ, Niegisch G, Bellmunt J, Ladoire S, De Giorgi U, Hussain S, Alva AS, Baniel J, Agarwal N, Rosenberg JE, Vaishampayan UN, Galsky MD, Yu EY. Venous Thromboembolism Risk in Patients With Locoregional Urothelial Tract Tumors. Clin Genitourin Cancer 2017; 16:S1558-7673(17)30242-2. [PMID: 28923700 PMCID: PMC5826750 DOI: 10.1016/j.clgc.2017.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/05/2017] [Accepted: 08/13/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is common in cancer patients, but there is limited data on patients with urothelial tract tumors (UTT). We previously identified several associative factors for increased VTE rates in patients with metastatic UTT. In this study, we assessed the frequency, associative factors, and impact on survival of VTE in patients with locoregional UTT. METHODS Patients with locoregional bladder, upper urinary tract, or urethral cancer were included in this multi-center study from 29 academic institutions. Patients with < cT2, > N1, or M1 disease at diagnosis were excluded. Patients with incomplete clinical staging or miscoded/missing data were excluded. Cumulative, unadjusted VTE incidence was calculated from time of diagnosis of muscle-invasive disease, excluding VTEs diagnosed in the metastatic setting. χ2 statistics tested differences in VTE rates across baseline and treatment-related factors. Significant covariates were incorporated into a multivariate, logistic regression model. Overall survival stratified by VTE was estimated using Kaplan-Meier methods and evaluated using the log-rank test. RESULTS A total of 1732 patients were eligible. There were 132 (7.6%) VTEs. On multivariate analysis, non-urothelial histology (P < .001), clinical Nx stage (P < .001), cardiovascular disease (P = .01), and renal dysfunction (P = .04) were statistically significant baseline factors associated with VTE. Using surgery alone as reference, surgery with perioperative chemotherapy (P = .04) and radiation with concurrent chemotherapy (P = .04) also were significant. CONCLUSIONS The VTE incidence of 7.6% in locoregional disease is comparable with our previously reported rate in the metastatic setting (8.2%). Similar to our findings in metastatic UTT, non-urothelial histology, renal dysfunction, and CVD was associated with increased VTE risk.
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Affiliation(s)
- Jorge D Ramos
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Roman Gulati
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | - Thomas Powles
- Barts and the London School of Medicine, London, England
| | | | - Guenter Niegisch
- Medical Faculty, Department of Urology, Heinrich-Heine-University, Düsseldorf, Germany
| | | | - Sylvain Ladoire
- Georges François Leclerc Center, Dijon, France; Université de Bourgogne, Dijon, France
| | - Ugo De Giorgi
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | | | | | | | | | | | | | | | - Evan Y Yu
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA.
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