Venous thromboembolism after urological surgery

In-Hospital Venous Thromboembolism and Pulmonary Embolism After Major Urologic Cancer Surgery

BACKGROUND

This study aimed to test for temporal trends of in-hospital venous thromboembolism (VTE) and pulmonary embolism (PE) after major urologic cancer surgery (MUCS).

METHODS

In the Nationwide Inpatient Sample (NIS) database (2010-2019), this study identified non-metastatic radical cystectomy (RC), radical prostatectomy (RP), radical nephrectomy (RN), and partial nephrectomy (PN) patients. Temporal trends of VTE and PE and multivariable logistic regression analyses (MLR) addressing VTE or PE, and mortality with VTE or PE were performed.

RESULTS

Of 196,915 patients, 1180 (1.0%) exhibited VTE and 583 (0.3%) exhibited PE. The VTE rates increased from 0.6 to 0.7% (estimated annual percentage change [EAPC] + 4.0%; p = 0.01). Conversely, the PE rates decreased from 0.4 to 0.2% (EAPC - 4.5%; p = 0.01). No difference was observed in mortality with VTE (EAPC - 2.1%; p = 0.7) or with PE (EAPC - 1.2%; p = 0.8). In MLR relative to RP, RC (odds ratio [OR] 5.1), RN (OR 4.5), and PN (OR 3.6) were associated with higher VTE risk (all p < 0.001). Similarly in MLR relative to RP, RC (OR 4.6), RN (OR 3.3), and PN (OR 3.9) were associated with higher PE risk (all p < 0.001). In MLR, the risk of mortality was higher when VTE or PE was present in RC (VTE: OR 3.7, PE: OR  4.8; both p < 0.001) and RN (VTE: OR 5.2, PE: OR  8.3; both p < 0.001).

CONCLUSIONS

RC, RN, and PN predisposes to a higher VTE and PE rates than RP. Moreover, among RC and RN patients with either VTE or PE, mortality is substantially higher than among their VTE or PE-free counterparts.

Incidence and Risk Factors for Postoperative Venous Thromboembolism After Gender Affirming Vaginoplasty: A Retrospective Analysis of a Large Insurance Claims Database

OBJECTIVES

To investigate the incidence and associated risk factors of venous thromboembolism (VTE) after gender affirming vaginoplasty.

METHODS

We searched International Business Machines Corporation (IBM) Marketscan, a commercial claims database, for Current Procedural Terminology and International Classification of Diseases (ICD) procedure codes to identify patients who underwent gender affirming vaginoplasty from 2011-2020. We quantified deep venous thrombosis and pulmonary embolism using ICD-9 and ICD-10 codes found within 90 days after surgery. Univariate and multivariate analyses were performed to establish association between VTE events and age, residency location, and comorbidities.

RESULTS

We identified 1588 patients who underwent gender affirming vaginoplasty. Overall, 1.1% of patients experienced a VTE within 90 days following surgery. Patients who experienced postoperative VTE were older, more likely to have had a prior VTE, less likely to be from an urban area, and more likely to have a higher Charlson Comorbidity Index score. Among patients with postoperative VTE, 47.1% had previous VTE. Among patients without a postoperative VTE, 1.3% had previous VTE.

CONCLUSION

In patients undergoing gender affirming vaginoplasty, the incidence of postoperative VTE was 1.1%. Older age, rurality, increased comorbidities, and prior VTE were associated with increased risk of postoperative VTE. Current guidelines do not recommend cessation of gender affirming hormone therapy (GAHT) prior to vaginoplasty. Further research is needed to evaluate if certain high-risk patients would benefit from perioperative adjustment of GAHT or perioperative VTE prophylaxis.

Body Mass Index (BMI) Related Morbidity with Thyroid Surgery

OBJECTIVES

The increase in incidence of thyroid cancer correlates with strict increases in body mass index (BMI) and obesity in the United States. Thyroid hormone dysregulation has been shown to precipitate circulatory volume, peripheral resistance, cardiac rhythm, and even cardiac muscle health. Theoretically, thyroid surgery could precipitate injury to the cardiopulmonary system.

METHODS

The American College of Surgery National Quality Improvement Program database was queried for thyroidectomy cases in the 2007-2020 Participant User files. Continuous and categorical associations between BMI and cardiopulmonary complications were investigated as reported in the database.

RESULTS

The query resulted 186,095 cases of thyroidectomy procedures in which the mean age was 51.3 years and sample was 79.3% female. No correlation was evident in univariate and multivariate analyses between BMI and the incidence of postoperative stroke or myocardial infarction. The incidence of complications was extremely low. However, risk of deep venous thrombosis correlated with BMI in the categorical, univariate, and multivariate (OR 1.036, CI 1.014-1.057, p < 0.01) regression analysis. Additionally, increased BMI was associated with increased risk of pulmonary embolism (PE) (OR 1.050 (1.030, 1.069), p < 0.01), re-intubation (OR 1.012 (1.002, 1.023), p = 0.02), and prolonged intubation (OR 1.031 (1.017, 1.045), p < 0.01).

CONCLUSION

Despite the rarity of cardiopulmonary complications during thyroid surgery, patients with very high BMI carry a significant risk of deep venous thrombosis, PE, and prolonged intubation.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2823-2830, 2023.

Pulmonary embolism following urological non-oncological surgery: The clinical features, management, and long-term follow-up outcome from a tertiary hospital of China

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.

The Impact of Venous Thromboembolism on Mortality and Morbidity During Nephrectomy for Renal Mass

OBJECTIVES

To determine the morbidity, mortality, and costs associated with having concurrent venous thromboembolism (VTE) at the time of surgical resection of a renal mass.

PATIENTS AND METHODS

We identified 108,430 patients undergoing elective partial or radical nephrectomy for a renal mass from 2013 to 2017 using the Premier Healthcare database. The association of VTE with 90-day complication rates, mortality, ICU admission, readmission, and direct hospital costs (2019 US dollars) was determined with multivariable logistic regression and quantile regression models, respectively.

RESULTS

Of the 108,430 patients who underwent elective partial or radical nephrectomy, 1.2% (n=1,301) of patients were diagnosed with a preoperative VTE. Patients with preoperative VTE have higher rates of minor (OR 1.47, 95% CI 1.34-1.62, p<0.0001) and major complications (OR 2.53, 95% CI 2.23-2.86, p<0.0001), mortality (OR 2.03, 95% CI 1.6-2.57, p<0.0001), and readmissions (OR 1.73, 95% CI 1.57-1.90, p<0.0001) compared to patients without preoperative VTE at the time of nephrectomy. Notably, the predicted probability for a major complication was significantly higher among patients with preoperative VTE who underwent either partial or radical nephrectomy, irrespective of the surgical approach utilized. Furthermore, rates of all types of complications except endocrine and soft tissue were significantly increased in patients undergoing nephrectomy with preoperative VTE compared to those without VTE.

CONCLUSIONS

VTE at the time of nephrectomy is associated with significantly higher rates of major complications, increased mortality, and higher overall costs. Taken together, these findings have important implications for the counseling and management of renal masses in presence of VTE.

Incidence of venous thromboembolism in benign urologic reconstructive cases

PURPOSE

To evaluate the rate of perioperative venous thromboembolism (VTE) among patients undergoing common benign urologic reconstructive cases. We hypothesize that this rate will be lower than previously described.

METHODS

We utilized the American College of Surgeons National Surgical Quality Improvement Project database from 2015 to 2019 to evaluate 30-day perioperative risk of VTE. Patients ≥ 18 years old undergoing benign urologic reconstructive cases were selected using Current Procedural Terminology (CPT) codes. Demographic, comorbidity, and operative variables were captured. The primary outcome was VTE within the 30-day postoperative period.

RESULTS

We identified 8467 patients who met inclusion criteria. The majority of patients were male (> 95%) with an average age of 65 and BMI of 29.6. There were 23 VTE events (0.27%) within the 30-day perioperative period. Fourteen (14/59) procedures had a perioperative VTE. Many of the traditional factors for VTE including operative time and obesity significantly increased risk of VTE in univariate analysis. In multivariate analysis, only BMI (OR 1.09; 95% CI 1.01-1.12) and inpatient status (OR 4.42; 95% CI 1.9-10.2) were correlated with increased perioperative VTE.

CONCLUSION

The rate of VTE among patients undergoing benign urologic reconstructive cases is low. Providers should continue to have high index of suspicion particularly for inpatients with high BMI in addition to other known risk factors for VTE.

Establishment of Prediction Models for Venous Thromboembolism in Non-Oncological Urological Inpatients - A Single-Center Experience

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.

Venous Thromboembolism Rate in Patients With Bladder Cancer According to the Type of Treatment: A Systematic Review

Bladder cancer (BC) is classified as a high-risk tumour type for venous thromboembolism (VTE). VTE presents an extra challenge in the management of patients with cancer, given the increase in morbidity and mortality on having both conditions.

To summarise the contemporary evidence on the VTE rate in patients with BC according to the stage, type of anti-cancer treatment and highlight VTE rate in the UK and other countries. A systematic review was carried out, and an electronic search for publications between January 2000 and November 2021 was done. Studies recording VTE in BC patients were included, whilst paediatric patients, case reports, studies reporting on a mix of arterial and venous thrombosis, studies reporting DVT or PE only and recorded hospitalised VTE only were excluded. The rate of VTE, country of origin, risk factors and thromboprophylaxis duration for VTE in BC patients were identified.

A total of 38 papers met the search criteria. All publications were original research papers (cohort studies). The overall VTE rate in patients with BC was estimated at 1.9% to 4.7%. For those patients undergoing cystectomy, the VTE rate ranged from 3% to 17.6%; however, the VTE rate in the metastatic stage of BC patients ranged from 3.1% to 5.1%.

The rates of VTE in BC patients are high, further increased by interventions such as surgery and chemotherapy. Thromboprophylaxis measures should be optimised. This review highlighted the fact that the VTE rate in BC varies between studies due to the heterogeneity of risk factors reported.

Incidence of Venous Thromboembolism and Safety of Perioperative Subcutaneous Heparin During Inflatable Penile Prosthesis Surgery

OBJECTIVE

To identify the incidence of venous thromboembolism (VTE) risk factors, postoperative VTE, and to assess the morbidity of perioperative pharmacologic VTE prophylaxis in men undergoing inflatable penile prosthesis (IPP) surgery.

METHODS

We retrospectively reviewed 215 patients undergoing IPP surgery between July 2017 and June 2019. Univariate and multivariate statistical analyzes were performed to assess pre-operative Caprini risk score and compare post-operative day 0 scrotal drain output, scrotal hematoma formation, and VTE in men who received subcutaneous heparin (SqH) vs those who did not receive SqH.

RESULTS

Of 215 IPP patients, 84% were classified as high or highest risk for VTE utilizing the Caprini risk score. A total of 119 (55%) received perioperative SqH with or without additional anti-thrombotics. Post-operative day 0 scrotal drain output was higher in those who received SqH compared to those who did not receive SqH, 99.9 mL vs 75.6 mL, respectively (P = .001). Minor scrotal hematomas occurred in similar rates in patients who received perioperative SqH vs those who did not, 3.8% vs 6.3%, respectively (P = .38). Similar results were found on subgroup analysis when eliminating patients who received SqH concurrently with other anti-thrombotics. The overall rate of postoperative VTE was 0.9%. No post-operative infections occurred.

CONCLUSION

Patients undergoing IPP surgery are at elevated risk for VTE. To our knowledge, this is the first study showing SqH use in the perioperative IPP surgery setting is safe when used in conjunction with a scrotal drain. Preoperative VTE risk stratification may be performed and can be used to guide clinical decision making regarding pharmacologic prophylaxis.

Incidence, risk factors, and outcome of Clostridioides difficile infection following urological surgeries

PURPOSE

To assess the incidence, risk factors, and clinical outcomes associated with (Clostridioides difficile infection) CDI following urological surgery, which is the leading cause of nosocomial diarrhea and a growing public health burden.

METHODS

We queried the National Surgical Quality Improvement Program (NSQIP) to identify patients undergoing urological surgery in 2015-2016. We evaluated the 30-day incidence and factors associated with postoperative CDI and 30-day hospital readmission and length of stay as secondary outcomes. Among the subset of patients undergoing radical cystectomy with urinary diversion (surgery with highest CDI incidence) we used multivariable logistic regression analysis to evaluate independent clinical and demographic factors associated with postoperative CDI.

RESULTS

We identified 98,463 patients during the study period. The overall 30-day incidence of CDI was 0.31%, but varied considerably across surgery type. The risk of CDI was greatest following radical cystectomy with urinary diversion (2.72%) compared to all other urologic procedures (0.19%) and was associated with increased risk of hospital readmission (p < 0.0001), re-operation (p < 0.0001), and longer mean length of stay (p < 0.0001) in this cohort. Among patients undergoing radical cystectomy with urinary diversion, multivariable logistic regression revealed that preoperative renal failure (OR: 5.30, 95% CI 1.13-24.9, p = 0.035) and blood loss requiring transfusion (OR: 1.67, 95% CI 1.15-2.44, p = 0.0075) were independently associated with CDI.

CONCLUSIONS

In a nationally representative cohort, the incidence of CDI was low but varied substantially across surgery types. CDI was most common following radical cystectomy and associated with potentially modifiable factors such as blood transfusion and significantly longer length of stay.

Determining Perioperative Practice Patterns in Urethroplasty: A Survey of Genitourinary Reconstructive Surgeons

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.

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

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.

Significance of preoperative screening of deep vein thrombosis and its indications for patients undergoing urological surgery

Purpose

Preoperative deep vein thrombosis (pre-DVT) is a risk of symptomatic venous thromboembolism (VTE) and a serious postoperative surgical complication. However, little is known about pre-DVT in patients undergoing surgery. This study aimed to investigate the incidence and screening criteria of pre-DVT in patients undergoing urological surgery.

Materials and Methods

Between 2015 and 2017, 320 patients admitted to our hospital for urological surgery were included in this retrospective study. All patients underwent preoperative D-dimer testing. Patients with elevated D-dimer (≥1.0 µg/mL) levels underwent lower-limb compression ultrasonography (CUS). Clinical parameters were analyzed as predictors of pre-DVT, and modest cutoff value of D-dimer to predict pre-DVT were evaluated.

Results

Of 320 patients, preoperative elevated D-dimer levels and DVT were found in 81 (25.3%) and 20 (6.3%) patients, respectively. The positive predictive value (PPV) was 24.7% (20/81). ROC curve analysis revealed a cutoff D-dimer level of 1.8 µg/mL, yielding a PPV of 40.7% for pre-DVT among patients with elevated D-dimer levels. Preoperative DVT was detected in 16 (7.6%, n=210) patients with malignancy, 3 (5.7%, n=53) with adrenal tumors, and in 1 (1.8%, n=57) kidney donor. An age of >70 years was significantly associated with risk for pre-DVT (odds ratio, 2.81; 95% confidence interval, 1.12–7.19; p=0.0270). During a postoperative follow-up period of 90 days, no patient developed symptomatic VTE.

Conclusions

The incidence of pre-DVT was 6.3% in patients undergoing urological surgery. Elderly patients and/or a cutoff D-dimer level of 1.8 µg/mL might be good indications for pre-DVT screening by CUS.

Enhanced recovery after surgery of patients undergoing radical cystectomy for bladder cancer

Radical cystectomy (RC) is the standard treatment for patients diagnosed with muscle invasive bladder cancer, but is associated with significant morbidity and long hospital stays. Enhanced recovery after surgery (ERAS) is based on a variety of interventions during the peri-treatment stage. It is designed to improve morbidity, enhance recovery, and reduce hospital stays after RC. The study provides an overview of the key elements of the ERAS protocol recommended for patients undergoing RC and directions for further research. We have analyzed the rationale for 15 key elements related to the ERAS protocol: preoperative patient counseling and education, preoperative medical optimization and nutrition, mechanical bowel preparation, preoperative fasting and carbohydrate loading, pre-anesthetic medication, thromboembolic prophylaxis, minimally invasive surgical approach, resection-site drainage, preventing intraoperative hypothermia, perioperative fluid management, perioperative analgesia, urinary drainage, prevention of postoperative ileus, nausea and vomiting, early oral feeding, and early mobilization. Several studies have shown that ERAS improves the recovery of RC patients. Evidence suggests that ERAS facilitates the recovery of RC patients. However, additional randomized controlled studies or large prospective studies are needed to demonstrate the effectiveness of ERAS in RC patients.

Rethinking the one-size-fits-most approach to venous thromboembolism prophylaxis after radical cystectomy

OBJECTIVES

Empirically dosed enoxaparin is routinely given in the postoperative period for venous thromboembolism (VTE) prophylaxis after radical cystectomy (RC). Patient-specific factors may alter its pharmacokinetics, and it is unclear whether this leads to levels sufficient for antithrombosis. We sought to evaluate variability of anti-factor Xa levels in a cohort of RC patients receiving perioperative enoxaparin prophylaxis.

MATERIAL AND METHODS

Patients undergoing RC at a single institution were placed on a postoperative pathway that included enoxaparin. An anti-factor Xa level was drawn 2 to 4 hours after the third dose. The target range for prophylaxis was 0.3 IU/ml to 0.5 IU/ml.

RESULTS

The primary outcome was anti-factor Xa level. Demographics, operative time, hospital course, and 30-days post-operative VTE were compared by anti-factor Xa level group using univariate and multivariable analyses. Between January 2018 and 2019, 107 RC patients remained on pathway and were included in our analysis. Sixty-five (61%) were below target range for VTE prophylaxis.  A single VTE event (0.9%) occurred in a subprophylactic individual. The subprophylactic group had a significantly higher body mass index (P < 0.01) than those within target range.

CONCLUSIONS

Higher body mass index was associated with subprophylactic enoxaparin dosing after RC. Nearly two-thirds of patients had below target anti-factor Xa levels. This suggests that dosing could be further individualized, but given the low incidence of VTE, implications of dose-adjusted prophylaxis on VTE prevention remain unknown.

Venous thromboprophylaxis in urological cancer surgery

Venous thromboembolism (VTE) represents a major complication of cancer and its treatment, contributing to increased morbidity and mortality. The appropriate choice of thromboprophylaxis method and duration is, therefore, of utmost importance. We conducted an extensive review of the literature concerning VTE in patients undergoing surgery for urological cancers. Special attention was paid to risk factors, different types of surgery (transurethral, pelvic, abdominal-open, laparoscopic and robot-assisted) and different medications used (heparins, vitamin K antagonists and new oral anticoagulants). Original papers, reviews and guidelines were identified in Medline database. The available data were then summarised for the purpose of this article. Venous thromboprophylaxis is obligatory in urological cancer patients undergoing surgical treatment. Unless individual contraindications are recognised, the available guidelines should be followed. The variety of clinical scenarios and patients' comorbidities necessitate cooperation with other specialists (cardiologists, neurologists, etc.) in choosing the optimal management. Thrombosis risk must be carefully weighed against bleeding risk.

[Rate of thrombosis and bleeding after urological surgery under standardized anticoagulation]

BACKGROUND

According to the current definition of the German guideline for prevention of venous thromboembolism, urological surgery includes a high number of high-risk patients. All patients undergoing urological surgery between 2012 and 2016 were analyzed with regard to complications (bleeding or thrombosis).

MATERIALS AND METHODS

This study is a retrospective and monocentric cohort study. Included were all patients who underwent surgery between 2012 and 2016 at the Urological Department at the University Hospital of Luebeck. Information was collected relating to anticoagulation, patient-specific and surgery-specific risk factors, and complications.

RESULTS

In all, 3609 surgeries were analyzed: 77.8% of patients received no medical prophylaxis, 10.2% received an aggregation inhibitor, and 8.5% synthetic, unfractionated or low molecular weight heparin. Heparin was administered to 80.4% of patients after surgery. During an average hospital stay of 4.5 days, 93.3% of the patients received no change in anticoagulation. Merely 0.8% of all patients suffered from clinical thomboembolic events within 28 days. In contrast the number of bleedings was higher with 20.3% (minor: 4.8%, major: 15.5%).

CONCLUSION

We found a slight risk for postoperative thromboembolism (0.8%). The risk for postoperative bleeding in contrast was 20.3%, including 15.5% major bleedings. The results are discussed in relation to the current guidelines.

Assessment of hypercoagulability using thromboelastography predicts advanced status in renal cell carcinoma

Background

Thromboelastography (TEG) has been established as a sensitive method to assess the whole coagulation process. The aim of the study was to evaluate the diagnosis significance of TEG on hypercoagulability in patients suffering renal mass.

Methods

A total of 478 patients were diagnosed with renal tumor by histolopathologic examination and were assigned to three groups. Group A: 79 patients with benign renal tumor; Group B: 317 patients with renal cell carcinoma (RCC, Fuhrman grades I and II); Group C: 82 patients with high‐risk RCC (Fuhrman grades III and IV). Subgroup analysis was performed in malignant renal tumor patients according to the TMN classification. The clinical data, whole blood TEG, and conventional coagulation tests were reviewed.

Results

There was no statistically significant difference between subgroups in respect to conventional coagulation tests. Hypercoagulablity was marked in Group C according to the TEG parameters. The elevated platelets and fibrinogen is linked with hypercoagulability in renal tumor. The positive correlation was between fibrinogen and MA value (r = .663, P < .05). The pathologic tumor stages were also associated with the TEG parameters.

Conclusion

Patients suffering advanced RCC are hypercoagulable which can be identified by TEG. MA value could be potential diagnosis indicators for detecting high‐grade RCC.

Use of venous-thrombotic-embolic prophylaxis in patients undergoing surgery for renal tumors: a questionnaire survey in the Nordic countries (The NORENCA-2 study)

Purpose

To examine the variation in venous thromboembolism prophylactic treatment (VTEP) among renal cancer patients undergoing surgery.

Materials and methods

An Internet-based questionnaire on renal tumor management before and after surgery was mailed to all Nordic departments of urology. The questions focused on the use of VTEP and were subdivided into different surgical modalities.

Results

Questionnaires were mailed to 91 institutions (response rate 53%). None of the centers used VTEP before surgery, unless the patient had a vena caval tumor thrombus. Overall, the VTEP utilized during hospitalization for patients undergoing renal surgery included early mobilization (45%), compression stockings (52%) and low-molecular-weight heparin (89%). In patients undergoing open radical Nx, 80% of institutions used VTEP during their hospitalization (23% compression stockings and 94% low-molecular-weight heparin). After leaving the hospital, the proportion and type of VTEP received varied considerably across institutions. The most common interval, used in 60% of the institutions, was for a period of 4 weeks. The restriction to the Nordic countries was a limitation and, therefore, may not reflect the practice patterns elsewhere. It is a survey study and, therefore, cannot measure the behaviors of those institutions that did not participate.

Conclusion

We found variation in the type and duration of VTEP use for each type of local intervention for renal cancer. These widely disparate variations in care strongly argue for the establishment of national and international guidelines regarding VTEP in renal surgery.

Temporal trends in venous thromboembolism after radical cystectomy

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Analysis of National Trends in Hospital Acquired Conditions Following Major Urologic Surgery Before and After Implementation of the Hospital Acquired Condition Reduction Program

OBJECTIVE

To define the rates of common hospital acquired conditions (HACs) in patients undergoing major urologic surgery over a period of time encompassing the implementation of the Hospital Acquired Condition Reduction program, and to evaluate whether implementation of the HAC reimbursement penalties in 2008 was associated with a change in the rate of HACs.

METHODS

Using American College of Surgeons National Surgical Quality Improvement Program data, we determined rates of HACs in patients undergoing major inpatient urologic surgery from 2005 to 2012. Rates were stratified by procedure type and approach (open vs laparoscopic and/or robotic). Multivariable logistic regression was used to determine the association between year of surgery and HACs.

RESULTS

We identified 39,257 patients undergoing major urologic surgery, of whom 2300 (5.9%) had at least one hospital acquired condition. Urinary tract infection (2.6%) was the most common, followed by surgical site infection (2.5%) and venous thrombotic events (0.7%). Multivariable logistic regression analysis demonstrated that open surgical approach, diabetes, congestive heart failure, chronic obstructive pulmonary disease, weight loss, and American Society of Anesthesiology class were among the variables associated with higher likelihood of HAC. We observed a nonsignificant secular trend of decreasing rates of HAC from 7.4% to 5.8% HACs during the study period, which encompassed the implementation of the Hospital Acquired Condition Reduction program.

CONCLUSION

HACs occurred at a rate of 5.9% after major urologic surgery, and are significantly affected by procedure type and patient health status. The rate of HAC appeared unaffected by National Reduction program in this cohort. Better understanding of the factors associated with HACs is critical in developing effective reduction programs.

Improving quality through clinical registries in urology

PURPOSE OF REVIEW

In this review, we highlight the use of clinical registries for quality improvement and research purposes in urology. We focus on national and regional clinical database registries, such as the National Surgical Quality Improvement Programme, the Cancer of the Prostate Strategic Urologic Research Endeavor, the Michigan Urological Surgery Improvement collaborative and the American Urological Association Quality Registry programme.

RECENT FINDINGS

It is widely known that claims-based and institutional databases are limited in their capacity to provide granular, real-time data for quality improvement purposes. As a result, clinical registries have emerged as an attractive alternative given their ability to capture large amounts of data across networks of health records. Another added benefit of Federally Qualified Clinical Data Registries (QCDRs) is the ability to meet emerging Medicare quality reporting standards, such as Physician Quality Reporting System and Meaningful Use. Despite the enthusiasm for QCDRs in the field of urology, however, myriad challenges remain in their implementation and widespread adoption including integration of existing health-information technology infrastructure, the accurate measurement of quality measures and the availability of clinically relevant quality measures in subspecialty practices.

SUMMARY

Quality measurement and improvement have become important aspects of modern clinical practice. Advances in health information technology have ushered in new tools, such as clinical registries, which simultaneously improve the quality of scientific research and clinical care while assisting eligible professionals in meeting federally mandated reporting requirements.

Postoperative D-dimer predicts venous thromboembolism in patients undergoing urologic tumor surgery

PURPOSE

We examined the incidence of pulmonary thromboembolism (PE) and deep venous thromboembolism (DVT) in patients who underwent urologic tumor surgery. The aim of this study was to investigate the postoperative D-dimer for prediction of venous thromboembolism events (VTE), as well as to identify other risk factors associated with the occurrence of thromboembolisms.

PATIENTS AND METHODS

This was a prospective observational cohort study, which included 1,269 patients who underwent major urologic tumor surgery, from August 2015 to February 2017, at our center. Data comprising age, sex, body mass index, Charlson comorbidity index, type of surgery, Caprini score, postoperative D-dimer levels, and other laboratory tests were collected for analyses. Lower limb venous ultrasound was performed before surgery and the day before hospital discharge to measure DVT. Computerized tomography or ventilation/perfusion lung scan was applied to detect PE.

RESULTS

The overall incidence of VTE was 2.4% (31 cases) in 1,269 patients, consisting of 23 PE events and 9 DVT events. Patients undergoing radical cystectomy were most likely to suffer VTE (4.3%). The optimal cutoff value for postoperative D-dimer was 0.98μg/ml, according to the receiver operating characteristic curve analysis, with a sensitivity of 83.9%, and a specificity of 80.0%. On multivariate analysis, hypertension (odds ratio, OR = 2.5, 95% CI: 1.1-5.7; P = 0.026), Charlson comorbidity index ≥ 2 (OR = 5.6, 95% CI: 2.2-14.6; P<0.001), and D-dimer lever ≥ 1μg/ml on postoperative day 1 (OR = 12.52, 95% CI: 4.6-35.2; P<0.001) were independently associated with VTE after urologic tumor surgery.

CONCLUSIONS

The overall incidence of urologic-tumor-surgery-associated VTE in an Asian population is similar to those reported in European and North American series. Elevated D-dimer early after operation is an independent predictor of VTE in patients undergoing urologic tumor surgery. In addition, hypertension and the Charlson comorbidity index are both important clinical risk factors. The Caprini score recommended by the guideline is inadequate in this study population. The postoperative D-dimer plasma level is a more reliable marker for identifying patients at high-risk of developing venous thromboembolisms.

Enhanced Recovery After Surgery for Radical Cystectomy

Even with advances in perioperative medical care, anesthetic management, and surgical techniques, radical cystectomy (RC) continues to be associated with a high morbidity rate as well as a prolonged length of hospital stay. In recent years, there has been great interest in identifying multimodal and interdisciplinary strategies that help accelerate postoperative convalescence by reducing variation in perioperative care of patients undergoing complex surgeries. Enhanced recovery after surgery (ERAS) attempts to evaluate and incorporate scientific evidence for modifying as many of the factors contributing to the morbidity of RC as possible, and optimize how patients are cared for before and after surgery. In this chapter, we review the preoperative, intraoperative and postoperative elements of using an ERAS protocol for RC.

The postoperative venous thromboembolism (TREVO) study - risk and case mortality by surgical specialty

INTRODUCTION AND OBJECTIVES

Venous thromboembolism, risk of which is increased in surgical patients, is a preventable cause of morbidity and death. The primary objective of this study was to estimate the incidence of symptomatic postoperative venous thromboembolism in adults at a tertiary university hospital, overall and by surgical specialty. The secondary objective was to analyze severity of and mortality from thromboembolic events.

METHODS

We performed a retrospective study to identify cases of in-hospital postoperative venous thromboembolism, encoded by the International Classification of Diseases, Ninth Revision, according to the Joint Commission International criteria. Adult patients admitted for surgery in 2008-2012 were included.

RESULTS

Among 67 635 hospitalizations, 90 cases of postoperative symptomatic venous thromboembolism were identified, corresponding to an incidence of 1.33/1000 admissions (95% confidence interval [CI] 1.1-1.6/1000). Neurosurgery had the highest risk (4.07/1000), followed by urological surgery and general surgery (p<0.001). There were 50 cases of pulmonary embolism, 11 of which were fatal. Of the 90 cases, 12.2% occurred under neuraxial anesthesia and 55.1% in patients with American Society of Anesthesiology III physical status. At least 37.7% of patients with events received a prophylactic dose of injectable anticoagulant postoperatively. The overall risk decreased from 2008 to 2012. Venous thromboembolism-associated mortality during hospitalization was 21.1% (95% CI 13.6-30.4).

CONCLUSIONS

The incidence of postoperative symptomatic venous thromboembolism was 1.33/1000. Neurosurgery showed the greatest risk. Mortality was 21.1%.

Venous thromboembolism after nephrectomy: incidence, timing and associated risk factors from a national multi-institutional database

PURPOSE

To evaluate the rate of venous thromboembolism (VTE) after nephrectomy with specific focus on event timing and location (before or after hospital discharge) in order to identify modifiable risk factors and establish benchmarks for preventive interventions.

METHODS

Using the ACS-NSQIP database, we identified patients undergoing nephrectomy from 2006 to 2012. Patients were analyzed in two cohorts: collectively and by surgical approach [open vs. lap/robotic (MIS)]. Rates of deep vein thrombosis (DVT) and pulmonary embolus (PE) were assessed and time to each event was established in relation to discharge status. Logistic regression analysis was performed to assess association between preoperative risk factors, surgical variables, and VTE.

RESULTS

In total, 13,208 patients met inclusion criteria. The overall rate of VTE was 1.2% (PE = 0.5% and DVT = 0.8, 0.1% DVT and PE). Using regression analysis, diabetes, dependent functional status, and longer operative time were associated with higher odds of DVT. For PE, dyspnea, disseminated cancer, and longer operative time were significant associations. The rate of VTE was higher in open surgery compared to MIS (2 vs. 0.8%, p < 0.001). Median times to DVT and PE were 8.5 and 6 days, respectively, with 53.3% of DVTs and 63.1% of PEs occurring prior to discharge.

CONCLUSIONS

The overall rate of VTE after nephrectomy is low, occurs roughly one week after surgery, and is associated with longer hospital stays. Certain patient factors, open surgical approach, and longer operative times were associated with higher odds of post-operative VTE; these patients may benefit from more aggressive prophylaxis.

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

CONTEXT

Pharmacological thromboprophylaxis involves balancing a lower risk of venous thromboembolism (VTE) against a higher risk of bleeding, a trade-off that critically depends on the risks of VTE and bleeding in the absence of prophylaxis (baseline risk).

OBJECTIVE

To provide estimates of the baseline risk of symptomatic VTE and bleeding requiring reoperation in urological cancer surgery.

EVIDENCE ACQUISITION

We identified contemporary observational studies reporting symptomatic VTE or bleeding after urological procedures. We used studies with the lowest risk of bias and accounted for use of thromboprophylaxis and length of follow-up to derive best estimates of the baseline risks within 4 wk of surgery. We used the GRADE approach to assess the quality of the evidence.

EVIDENCE SYNTHESIS

We included 71 studies reporting on 14 urological cancer procedures. The quality of the evidence was generally moderate for prostatectomy and cystectomy, and low or very low for other procedures. The duration of thromboprophylaxis was highly variable. The risk of VTE in cystectomies was high (2.6-11.6% across risk groups) whereas the risk of bleeding was low (0.3%). The risk of VTE in prostatectomies varied by procedure, from 0.2-0.9% in robotic prostatectomy without pelvic lymph node dissection (PLND) to 3.9-15.7% in open prostatectomy with extended PLND. The risk of bleeding was 0.1-1.0%. The risk of VTE following renal procedures was 0.7-2.9% for low-risk patients and 2.6-11.6% for high-risk patients; the risk of bleeding was 0.1-2.0%.

CONCLUSIONS

Extended thromboprophylaxis is warranted in some procedures (eg, open and robotic cystectomy) but not others (eg, robotic prostatectomy without PLND in low-risk patients). For "close call" procedures, decisions will depend on values and preferences with regard to VTE and bleeding.

PATIENT SUMMARY

Clinicians often give blood thinners to patients to prevent blood clots after surgery for urological cancer. Unfortunately, blood thinners also increase bleeding. This study provides information on the risk of clots and bleeding that is crucial in deciding for or against giving blood thinners.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Risk factors associated with venous thromboembolism in patients undergoing spine surgery

OBJECTIVE

Patients undergoing spinal surgery are at risk for developing venous thromboembolism (VTE). The authors sought to identify risk factors for VTE in these patients.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project database for the years 2006–2010 was reviewed for patients who had undergone spinal surgery according to their primary Current Procedural Terminology code(s). Clinical factors were analyzed to identify associations with VTE.

RESULTS

Patients who underwent spinal surgery (n = 22,434) were identified. The rate of VTE in the cohort was 1.1% (pulmonary embolism 0.4%; deep vein thrombosis 0.8%). Multivariate binary logistic regression analysis revealed 13 factors associated with VTE. Preoperative factors included dependent functional status, paraplegia, quadriplegia, disseminated cancer, inpatient status, hypertension, history of transient ischemic attack, sepsis, and African American race. Operative factors included surgery duration > 4 hours, emergency presentation, and American Society of Anesthesiologists Class III–V, whereas postoperative sepsis was the only significant postoperative factor. A risk score was developed based on the number of factors present in each patient. Patients with a score of ≥ 7 had a 100-fold increased risk of developing VTE over patients with a score of 0. The receiver-operating-characteristic curve of the risk score generated an area under the curve of 0.756 (95% CI 0.726–0.787).

CONCLUSIONS

A risk score based on race, preoperative comorbidities, and operative characteristics of patients undergoing spinal surgery predicts the postoperative VTE rate. Many of these risks can be identified before surgery. Future protocols should focus on VTE prevention in patients who are predisposed to it.

Adverse Event Rates, Timing of Complications, and the Impact of Specialty on Outcomes Following Adrenal Surgery: An Analysis of 30-Day Outcome Data From the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP)

OBJECTIVE

To report on 30-day adverse event rates and timing of complications following adrenal surgery; further, to investigate the impact of specialty (general surgery vs urology) on these outcomes using a large prospective multi-institutional data registry.

MATERIALS AND METHODS

Within the American College of Surgeons National Surgical Quality Improvement Program (2005-2012), patients undergoing adrenalectomy were identified (CPT-codes: 60540, 60545, 60650). Outcomes evaluated included complications, blood transfusion, length of stay, reintervention, readmission, and mortality. Complications were further evaluated in relation to discharge status (pre-/postdischarge). Multivariable regression models assessed association between specialty and 30-day morbidity/mortality.

RESULTS

During the study period, 4844 patients underwent adrenalectomy (95.7% general surgery). The overall complication rate was 7.5% (n = 363); 43.2% of the complications occurred postdischarge with a substantial proportion of major complications, including cardiac, pulmonary, renal, neurologic, septic, and deep venous thrombosis/pulmonary embolism also occurring postdischarge (29.9%). The overall blood transfusion, reintervention, readmission, and mortality rates were 3.9%, 2.0%, 6.4%, and 0.6%, respectively. In adjusted analyses, specialty did not have an effect on any of the outcomes (P  >  .05 all).

CONCLUSION

One in 13 patients suffers a complication postadrenalectomy. Approximately 40% of these complications occur postdischarge, primarily within the first 2 weeks of surgery. Accurate knowledge regarding 30-day adverse event rates and timing of complications that this study provides may facilitate improved patient-physician communication and encourage early patient follow-up in this critical window. Lastly, specialty does not seem to affect outcomes in American College of Surgeons National Surgical Quality Improvement Program participant hospitals.

Causes of hospital readmissions after urologic cancer surgery

OBJECTIVES

The Hospital Readmissions Reduction Program mandates reimbursement reductions to hospitals with higher than expected rates of readmissions. We examine causes and predictors of readmissions following major procedures in urologic oncology.

MATERIALS AND METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, patients undergoing radical prostatectomy (RP), radical (RN) or partial nephrectomy (PN), and radical cystectomy (RC) during the year 2012 were abstracted. Rates of unplanned readmission within 30 days after surgery, as well as causes of readmission, were identified. Multivariable logistic regression models were fitted to examine the association between patient perioperative factors and odds of readmission.

RESULTS

Overall, we observed a 5.5% unplanned 30-day readmission rate. Readmission rates for patients treated with RP, RN, PN, and RC were 4.1%, 5.2%, 4.5%, and 15.9%, respectively. For each procedure, approximately two-third of readmissions occurred within the first 10 days following hospital discharge. Commonest causes of readmission after RP included thromboembolic (13.6%), wound (12.2%), renal/genitourinary (12.2%), and gastrointestinal (11.8%); after RN, wound (12.9%) and gastrointestinal (12.9%); after PN, renal/genitourinary (19.6%), cardiovascular (9.8%), and bleeding/hematoma (9.8%); and after RC, renal/genitourinary (15.5%), wound (14.8%), and sepsis/infection (14.1%). RC was significantly associated with readmission. Patients undergoing open RP or PN were more likely to be readmitted relative to their minimally invasive counterparts (odds ratio = 1.53, 95% CI: 1.12-2.08, P = 0.007 and odds ratio = 2.51, 95% CI: 1.38-4.55, P = 0.003, respectively).

CONCLUSIONS

Readmissions are relatively common following major urologic oncology procedures. Compared with RP, RN, or PN, RC patients experience the highest burden of readmission. Venous thromboembolism is a common modifiable cause of readmission following urologic cancer surgery. Minimally invasive approach is associated with decreased odds of readmission following RP and PN.

Heart failure and risk of venous thromboembolism: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism is a major global health problem that is often secondary to other clinical situations. Many studies have investigated the association between venous thromboembolism and heart failure, but have yielded inconsistent findings. We aimed to quantify the absolute and relative risks (RR) for venous thromboembolism in patients with heart failure after hospital admission. We also assessed rates of venous thromboembolism in patients in different settings.

METHODS

In this systematic review and meta-analysis, we searched for studies investigating the risk of venous thromboembolism in patients in hospital with heart failure. We searched for studies published between Jan 1, 1955, and March 31, 2015, in PubMed, Embase, Evidence-Based Medicine Reviews, Allied and Complementary Medicine Database, Ovid HealthSTAR, Global Health, Ovid Nursing Database, Web of Science, CINAHL Plus, ProQuest Central, Conference Papers Index, BIOSIS Previews, and ClinicalTrials.gov. All cohort studies and subgroup analyses of randomised controlled trials (RCTs) were eligible for inclusion if they reported venous thromboembolism rates (number of events per follow-up period) or RR estimates. We extracted data from published reports and contacted the corresponding authors of records with insufficient quantitative data. RRs and 95% CIs were pooled using a random-effects model. This study is registered with PROSPERO, number CRD42014015504.

FINDINGS

Of 8673 records identified, we included 71 studies with data from 88 cohorts in our analysis, with 59 cohorts included in the assessment of venous thromboembolism rates and 46 cohorts included in the meta-analysis of heart failure and risk of venous thromboembolism. Venous thromboembolism rates varied widely in patients in hospital with heart failure from different settings. The overall median symptomatic venous thromboembolism rate was 2·48% (IQR 0·84-5·61); rates was were 3·73% (1·05-7·31) for patients who did not receive thromboprophylaxis and 1·47% (0·64-3·54) for those who did. Overall, patients with heart failure in hospital had an RR of 1·51 (1·36-1·68) for venous thromboembolism. The overall I(2) statistic was 96·1% and there was no evidence of publication bias (Egger's test, p=0·46).

INTERPRETATION

Heart failure is a common independent risk factor for venous thromboembolism. Thromoboprophylaxis should be considered in clinical practice for high-risk patients.

FUNDING

National Natural Science Foundation.

Incidence and risk factors of venous thromboembolism after pelvic uro-oncologic surgery--a single center experience

OBJECTIVE

To determine the incidence and assess risk factors for the development of VTE among patients undergoing major pelvic surgery for prostate and bladder cancer in an Australian tertiary referral center.

PATIENTS AND METHODS

Consecutive patients undergoing major pelvic uro-oncologic surgery, namely radical cystectomy and radical prostatectomy over a five-year period (2009-2013) were identified. Patient variables and types of thromboprophylaxis (pharmacological and/or mechanical) used in this patient cohort were collected for analyses as predictive factors.

RESULTS

The overall incidence of VTE was 1.8%. Patients undergoing radical cystectomy were more likely to suffer a VTE event compared to patients having radical prostatectomy. In this cohort, the risk factors for VTE include, prolonged operative time of greater than 4 hours (h), lymph node dissection (LND) and patients requiring blood transfusions.

CONCLUSION

Patients undergoing major pelvic uro-oncologic surgery have an approximately 1.8% risk of developing VTE. Risk factors identified in this study should be used to guide the use of early and prolonged thromboprophylaxis.

Morbidity of urologic surgical procedures: an analysis of rates, risk factors, and outcomes

OBJECTIVE

To quantify national complication rates, perioperative outcomes, and predictors for a broad range of urologic procedures to demonstrate background rates and discuss benchmarking.

METHODS

Urologic procedures from the National Surgical Quality Improvement Program (2006-2011) were analyzed to identify 30-day rates of 21 complications; outcomes (length of stay, reoperation, and death); and predictors including resident involvement for 18 specific procedures. Multivariate logistic regression models assessed predictors for any complication and for Clavien grade IV or V complication.

RESULTS

A total of 39,700 procedures were included with abdominopelvic operations more morbid than endoscopic, scrotal, incontinence, or prolapse procedures. Cystectomy had the highest morbidity (10.8 days length of stay and 3.2% mortality), with 56% experiencing any complication followed by nephrectomy (21%), retroperitoneal lymph node dissection (20%), and radical retropubic prostatectomy (19%). Transurethral resection of bladder tumor (11%) and transurethral resection of the prostate (10%) had the highest rates for endoscopic procedures. Older age, American Society of Anesthesiologists class, dependent functional status, acute kidney injury (odds ratio [OR], 2.70 [1.89-3.87]), and ≥5 units preoperative transfusion (OR, 4.44 [3.40-5.80]) were the strongest predictors of any complication. Higher ORs of similar predictors along with chronic obstructive pulmonary disorder (OR, 1.52 [1.21-1.92]) and steroid use (OR, 1.51 [1.07-2.14]) were associated with Clavien grade IV or V complication. Resident involvement increased odds of any complication (OR, 1.18 [1.09-1.29]), mostly for abdominopelvic and urogynecologic procedures, but not Clavien grade IV or V complication (P = .55).

CONCLUSION

Complication rates of urologic procedures based on the retrospective experience of few surgeons do not allow for appropriate benchmarking. Baseline rates and benchmarks derived from the National Surgical Quality Improvement Program may help hospitals better track deficient areas and improvements in quality of care. Many predictors were similar across procedures, although magnitudes differed, and resident trainees did not impact rates of serious complications (Clavien-Dindo grade IV or V).

Clinical factors associated with venous thromboembolism risk in patients undergoing craniotomy

OBJECT

Patients undergoing craniotomy are at risk for developing venous thromboembolism (VTE). The safety of anticoagulation in these patients is not clear. The authors sought to identify risk factors predictive of VTE in patients undergoing craniotomy.

METHODS

The authors reviewed a national surgical quality database, the American College of Surgeons National Surgical Quality Improvement Program. Craniotomy patients were identified by current procedural terminology code. Clinical factors were analyzed to identify associations with VTE.

RESULTS

Four thousand eight hundred forty-four adult patients who underwent craniotomy were identified. The rate of VTE in the cohort was 3.5%, including pulmonary embolism in 1.4% and deep venous thrombosis in 2.6%. A number of factors were found to be statistically significant in multivariate binary logistic regression analysis, including craniotomy for tumor, transfer from acute care hospital, age ≥ 60 years, dependent functional status, tumor involving the CNS, sepsis, emergency surgery, surgery time ≥ 4 hours, postoperative urinary tract infection, postoperative pneumonia, on ventilator ≥ 48 hours postoperatively, and return to the operating room. Patients were assigned a score based on how many of these factors they had (minimum score 0, maximum score 12). Increasing score was predictive of increased VTE incidence, as well as risk of mortality, and time from surgery to discharge.

CONCLUSIONS

Patients undergoing craniotomy are at low risk of developing VTE, but this risk is increased by preoperative medical comorbidities and postoperative complications. The presence of more of these clinical factors is associated with progressively increased VTE risk; patients possessing a VTE Risk Score of ≥ 5 had a greater than 20-fold increased risk of VTE compared with patients with a VTE score of 0.

Systematic reviews of observational studies of risk of thrombosis and bleeding in urological surgery (ROTBUS): introduction and methodology

BACKGROUND

Pharmacological thromboprophylaxis in the peri-operative period involves a trade-off between reduction in venous thromboembolism (VTE) and an increase in bleeding. Baseline risks, in the absence of prophylaxis, for VTE and bleeding are known to vary widely between urological procedures, but their magnitude is highly uncertain. Systematic reviews and meta-analyses addressing baseline risks are uncommon, needed, and require methodological innovation. In this article, we describe the rationale and methods for a series of systematic reviews of the risks of symptomatic VTE and bleeding requiring reoperation in urological surgery.

METHODS/DESIGN

We searched MEDLINE from January 1, 2000 until April 10, 2014 for observational studies reporting on symptomatic VTE or bleeding after urological procedures. Additional studies known to experts and studies cited in relevant review articles were added. Teams of two reviewers, independently assessed articles for eligibility, evaluated risk of bias, and abstracted data. We derived best estimates of risk from the median estimates among studies rated at the lowest risk of bias. The primary endpoints were 30-day post-operative risk estimates of symptomatic VTE and bleeding requiring reoperation, stratified by procedure and patient risk factors.

DISCUSSION

This series of systematic reviews will inform clinicians and patients regarding the trade-off between VTE prevention and bleeding. Our work advances standards in systematic reviews of surgical complications, including assessment of risk of bias, criteria for arriving at best estimates of risk (including modeling of timing of events and dealing with suboptimal data reporting), dealing with subgroups at higher and lower risk of bias, and use of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate certainty in estimates of risk. The results will be incorporated in the upcoming European Association Urology Guideline on Thromboprophylaxis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014010342.