Venous thromboembolism (<scp>VTE</scp>) prophylaxis and urological pelvic cancer surgery: a <scp>UK</scp> national audit

Pridgeon, Simon; Allchorne, Paula; Turner, Bruce; Peters, John; Green, James S. A.

doi:10.1111/bju.12693

Cited by 31 publications

(27 citation statements)

References 16 publications

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“…It is widely becoming acknowledged that RP procedures are becoming less invasive, favouring laparoscopic and robot‐assisted approaches over conventional open techniques. In 2012, 69% of RP cases were performed either robotically or laparoscopically , with only 31% being performed open.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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Rishi Naik and Indrajeet Mandal are joint first authors. ObjectivesVenous thromboembolism (VTE), consisting of both pulmonary embolism (PE) and deep vein thromboses (DVT), remains a well-recognised complication of major urological cancer surgery. Several international guidelines recommend extended thromboprophylaxis (ETP) with LMWH, whereby the period of delivery is extended to the post-discharge period, where the majority of VTE occurs. In this literature review we investigate whether ETP should be indicated for all patients undergoing major urological cancer surgery, as well procedure specific data that may influence a clinician's decision. MethodsWe performed a search of six databases (PubMed, Cochrane, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and British Nursing Index (BNI)) from inception to June 2019, for studies looking at adult patients who received VTE prophylaxis after surgery for a major urological malignancy. ResultsEighteen studies were analysed. VTE risk is highest in open and robotic Radical Cystectomy (RC) (2.6-11.6%) and ETP demonstrates a significant reduction in risk of VTE, but not a significant difference in Pulmonary Embolism (PE) or mortality. Risk of VTE in open Radical Prostatectomy (RP) (0.8-15.7%) is comparable to RC, but robotic RP (0.2-0.9%), open partial/radical nephrectomy (1.0-4.4%) and robotic partial/radical nephrectomy (0.7-3.9%) were lower risk. It has not been shown that ETP reduces VTE risk specifically for RP or nephrectomy. ConclusionThe decision to use ETP is a fine balance between variables such as VTE incidence, bleeding risk and perioperative morbidity/mortality. This balance should be assessed for each specific procedure type. While ETP still remains of net benefit for open RP as well as open and robotic RC, the balance is closer for minimally invasive RP as well as radical and partial nephrectomy. Due to a lack of procedure specific evidence for the use of ETP, adherence with national guidelines remains poor. Therefore, we advocate further studies directly comparing ETP vs standard prophylaxis, for specific procedure types, in order to allow clinicians to make a more informed decision in future.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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“…The Level 1 evidence supporting the use of extended thromboprophylaxis has largely been from studies of non-urologic cancer [34–36]. This combined with the variable recommendations for extended prophylaxis and provider concerns of post-operative hemorrhage might explain the lower compliance and slow uptake of extended thromboprophylaxis treatment for bladder cancer patients [37, 38]. …”

Section: Discussionmentioning

confidence: 99%

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

Brennan

Karim

d’Oiron

et al. 2018

BLC

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Background:Chemotherapy and major pelvic surgery are established risk factors for venous thromboembolism (VTE). We evaluate the incidence rate, timing, and factors associated with VTE in patients with bladder cancer who underwent radical cystectomy and peri-operative chemotherapy in routine clinical practice.Methods:Electronic records of treatment were linked to the population-based Ontario Cancer Registry to identify all patients who underwent cystectomy for bladder cancer in Ontario 1994–2013. VTE events within 6 months of before or after cystectomy were identified using diagnostic codes recorded on hospital admissions and emergency department visits. Multivariable logistic regression was used to analyze factors associated with VTE prior to surgery, within 90-days of cystectomy, and 120-days after the start of adjuvant chemotherapy.Results:4205 patients had cystectomy and 26% (1084/4205) received peri-operative chemotherapy. The overall incidence rate of VTE within 6 months of cystectomy was 9% (363/4205). VTE rate was highest among those patients treated with neoadjuvant chemotherapy (NACT) compared to patients treated with no chemotherapy or only adjuvant chemotherapy (ACT) (12% vs 8% vs 9%, p = 0.002). Among all VTE events, 10%, 28%, and 61% occurred before, during, and after hospitalization for cystectomy. Pre-operative VTE rate was highest among cases treated with NACT (4%) compared to patients with no chemotherapy (<1%) or ACT (<1%) (p < 0.001). VTE within 90 days of surgery was associated with greater length of hospital admission (p < 0.001) across all treatment groups.Conclusions:A substantial proportion of patients treated with peri-operative chemotherapy will develop VTE. The majority of these occur after discharge from hospital following cystectomy. Extended thromboprophylaxis treatment in high-risk patients including those who receive peri-operative chemotherapy should be considered.

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“…A recent national survey conducted in the UK among 64 pelvic cancer centres reported that, after radical cystectomy, all centres routinely use LMWH in the peri-operative period and 67% do so after discharge [6]. Similarly, for radical prostatectomy, 98% used peri-operative prophylaxis while 61% also used it after discharge.…”

Section: Variations In the Use Of Venous Thromboembolism Prophylaxis mentioning

confidence: 99%

“…When comparing the thromboprophylaxis guidelines a spectrum of recommendations appear (Table 3). This divergence of recommendations contributes significantly to the heterogeneity of practice among urologists [4][5][6].…”

Section: Trade-off Of Bleeding and Venous Thromboembolism Risk For Pamentioning

confidence: 99%

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Guideline of guidelines: thromboprophylaxis for urological surgery

Violette¹,

Cartwright

Briel

et al. 2016

BJU International

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Decisions regarding thromboprophylaxis in urologic surgery involve a trade-off between decreased risk of venous thromboembolism (VTE) and increased risk of bleeding. Both patient-and procedure-specific factors are critical in making an informed decision on the use of thromboprophylaxis. Our systematic review of the literature revealed that existing guidelines in urology are limited. Recommendations from national and international guidelines often conflict and are largely based on indirect as opposed to procedure-specific evidence. These issues have likely contributed to large variation in the use of VTE prophylaxis within and between countries. The majority of existing guidelines typically suggest prolonged thromboprophylaxis for high-risk abdominal or pelvic surgery, without clear clarification of what these procedures are, for up to 4 weeks post-discharge. Existing guidance may result in the undertreatment of procedures with low risk of bleeding and the over-treatment of oncological procedures with low risk of VTE. Guidance for patients who are already anticoagulated are not specific to urological procedures but generally involve evaluating patient and surgical risks when deciding on bridging therapy. The European Association of Urology Guidelines Office has commissioned an ad hoc guideline panel that will present a formal thromboprophylaxis guideline for specific urological procedures and patient risk factors.

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Venous thromboembolism (VTE) prophylaxis and urological pelvic cancer surgery: a UK national audit

Cited by 31 publications

References 16 publications

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

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

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

Guideline of guidelines: thromboprophylaxis for urological surgery

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