Heparin prophylaxis and the risk of venous thromboembolism after robotic‐assisted laparoscopic prostatectomy

Abstract

Study Type – Therapy (case series)Level of Evidence 4What’s known on the subject? and What does the study add?The incidence of deep venous thrombosis (DVT) in major urological surgery has decreased over time with the introduction of pharmacological prophylaxis, early mobilization, and the use of sequential mechanical compression devices. We examined the value of heparin prophylaxis in robotic assisted laparoscopic prostatectomy (RALP), where the risk of DVT is already low.The rate of thromboemolic events within 30 days was 0.6% in this series. Heparin did not influence estimated blood loss, haematrocrit change, or length of stay. The incidence of thromboembolism is low after RALP, which may obviate the use of heparin prophylaxis. However, its use appears to be safe and does not affect surgical outcomes.OBJECTIVE• The incidence of venous thromboembolism (VTE) after robotic‐assisted laparoscopic prostatectomy (RALP) in patients receiving perioperative heparin prophylaxis was compared with those who did not receive such prophylaxis.MATERIALS AND METHODS• Between July 2007 to February 2010, a total of 307 RALPs were performed at our institution by two surgeons. A total of 187 patients operated on by surgeon 1 received perioperative heparin prophylaxis, whereas 120 patients operated on by surgeon 2 did not receive any.• All demographic, clinical and pathological data were prospectively recorded, whereas the incidence of venous thromboembolism within 30 days of the operation was retrospectively reviewed. Evaluation for potential VTE was based on clinical symptoms.RESULTS• Cohorts were comparable with respect to PSA, clinical stage, preoperative Gleason score, body mass index, smoking status, pathological stage, path Gleason score and margin status. A total of two thromboemoblic events occurred (0.6%) within 30 days of surgery (one in each arm of the study).• Heparin prophylaxis did not influence estimated blood loss (P= 0.076) or haematocrit change from preoperative levels (P= 0.378). Length of stay was comparable between the two groups (1.4 vs 1.3 days; P= 0.159).CONCLUSION• The incidence of thromboembolism is low after RALP, which may obviate the need for heparin prophylaxis. However, its use is safe and does not impact surgical outcomes. Larger series are needed to confirm the results obtained in the present study.

Dabigatran for thromboprophylaxis after robotic assisted laparoscopic prostatectomy: Retrospective analysis of safety profile and effect on blood coagulation

“…The results seem to support the conclusion from the registration trials with hip and knee surgery that dabigatran is also both effective and safe after prostate cancer surgery. In keeping with the earlier reports suggesting that VTE is rare after minimally invasive prostate cancer surgery [2,3], only one clinically evident VTE was detected in this cohort, translating to an incidence of only 0.25%. The observed low VTE risk could suggest that the prophylactic policy was even too extensive.…”

“…A VTE rate of only 0.5% was reported after laparoscopic prostatectomy or robotic assisted laparoscopic prostatectomy (RALP) in a large multiinstitutional retrospective analysis of almost 6000 patients across the USA and Europe [2]. A recent single-institution comparative cohort analysis found a low VTE rate that was not affected by the use of heparin [3]. Thus, some authors have suggested that thromboprophylaxis using heparin may not be justified after minimally invasive prostate cancer surgery [2][3][4].…”

“…A recent single-institution comparative cohort analysis found a low VTE rate that was not affected by the use of heparin [3]. Thus, some authors have suggested that thromboprophylaxis using heparin may not be justified after minimally invasive prostate cancer surgery [2][3][4]. A thorough analysis from the Prostate Cancer Database Sweden (PCBaSe) Sweden (n = 45 065) stated, however, that all surgical procedures in prostate cancer patients were associated with increased thromboembolic complication rates.…”

The Role of Cryosurgery of the Prostate for Nonsurgical Candidates

“…4,15,18 Although only 1% of patients in our series required transfusions, we observed that blood transfusion and not simply blood loss appeared to increase the risk of VTEs. This observation is similar to observations in studies of other cancer types that have noted this relationship and found increased risk per unit transfused, suggesting a mechanism from the transfusion itself.…”

Venous thromboembolism prophylaxis in cancer patients — guidelines focus on surgical patients

“…In both groups the incidence of symptomatic VTE was comparable (1.0% vs. 0.7%) [221]. The other authors also report relatively low incidence of symptomatic VTE (0.5-0.6%) in laparoscopic or robotic prostatectomy [220,222]. On the other hand, some reports suggest higher risk for such complications despite of antithrombotic prophylaxis administration in this clinical settings.…”