TY - JOUR
T1 - Extended Venous Thromboembolism Prophylaxis after Radical Cystectomy
T2 - A Call for Adherence to Current Guidelines
AU - Klaassen, Zachary
AU - Arora, Karan
AU - Goldberg, Hanan
AU - Chandrasekar, Thenappan
AU - Wallis, Christopher J.D.
AU - Sayyid, Rashid K.
AU - Fleshner, Neil E.
AU - Finelli, Antonio
AU - Kutikov, Alexander
AU - Violette, Philippe D.
AU - Kulkarni, Girish S.
N1 - Publisher Copyright:
© 2018 American Urological Association Education and Research, Inc.
PY - 2018/4
Y1 - 2018/4
N2 - Purpose: Radical cystectomy is inherently associated with morbidity. We assess the timing and incidence of venous thromboembolism, review current guideline recommendations and provide evidence for considering extended venous thromboembolism prophylaxis in all patients undergoing radical cystectomy. Materials and Methods: We searched PubMed® for available literature on radical cystectomy and venous thromboembolism, focusing on incidence and timing, evidence supporting extended venous thromboembolism prophylaxis in patients undergoing radical cystectomy or abdominal oncologic surgery, current guideline recommendations, safety considerations and direct oral anticoagulants. Search terms included “radical cystectomy,” “venous thromboembolism,” “prophylaxis,” and “extended oral anticoagulants” and “direct oral anticoagulants” alone and in combination. Relevant articles were reviewed, including original research, reviews and clinical guidelines. References from review articles and guidelines were also assessed to develop a narrative review. Results: The incidence of symptomatic venous thromboembolism in short-term followup after radical cystectomy is 3% to 11.6%, of which more than 50% of cases will occur after hospital discharge. Meta-analyses of clinical trials in patients undergoing major abdominal oncologic operations suggest a decreased risk of venous thromboembolisms for patients receiving extended (4 weeks) venous thromboembolism prophylaxis. Extended prophylaxis should be considered in all radical cystectomy cases. Although the relative risk of bleeding also increases, the overall net benefit of extended prophylaxis clearly favors use for at least 28 days postoperatively. Extrarenal eliminated prophylaxis agents are preferred given the risk of renal insufficiency in radical cystectomy cases, with newer oral anticoagulants providing an alternative route of administration. Conclusions: Patients undergoing radical cystectomy are at high risk for venous thromboembolism after hospital discharge. There is strong evidence that extended prophylaxis significantly decreases the risk of venous thromboembolism in oncologic surgery cases. Use of extended prophylaxis after radical cystectomy has been poorly adopted, emphasizing the need for better adherence to current urology procedure specific guidelines as extended prophylaxis for radical cystectomy is the standard of care. Specific and rare circumstances may require case by case assessment.
AB - Purpose: Radical cystectomy is inherently associated with morbidity. We assess the timing and incidence of venous thromboembolism, review current guideline recommendations and provide evidence for considering extended venous thromboembolism prophylaxis in all patients undergoing radical cystectomy. Materials and Methods: We searched PubMed® for available literature on radical cystectomy and venous thromboembolism, focusing on incidence and timing, evidence supporting extended venous thromboembolism prophylaxis in patients undergoing radical cystectomy or abdominal oncologic surgery, current guideline recommendations, safety considerations and direct oral anticoagulants. Search terms included “radical cystectomy,” “venous thromboembolism,” “prophylaxis,” and “extended oral anticoagulants” and “direct oral anticoagulants” alone and in combination. Relevant articles were reviewed, including original research, reviews and clinical guidelines. References from review articles and guidelines were also assessed to develop a narrative review. Results: The incidence of symptomatic venous thromboembolism in short-term followup after radical cystectomy is 3% to 11.6%, of which more than 50% of cases will occur after hospital discharge. Meta-analyses of clinical trials in patients undergoing major abdominal oncologic operations suggest a decreased risk of venous thromboembolisms for patients receiving extended (4 weeks) venous thromboembolism prophylaxis. Extended prophylaxis should be considered in all radical cystectomy cases. Although the relative risk of bleeding also increases, the overall net benefit of extended prophylaxis clearly favors use for at least 28 days postoperatively. Extrarenal eliminated prophylaxis agents are preferred given the risk of renal insufficiency in radical cystectomy cases, with newer oral anticoagulants providing an alternative route of administration. Conclusions: Patients undergoing radical cystectomy are at high risk for venous thromboembolism after hospital discharge. There is strong evidence that extended prophylaxis significantly decreases the risk of venous thromboembolism in oncologic surgery cases. Use of extended prophylaxis after radical cystectomy has been poorly adopted, emphasizing the need for better adherence to current urology procedure specific guidelines as extended prophylaxis for radical cystectomy is the standard of care. Specific and rare circumstances may require case by case assessment.
KW - Administration, Oral
KW - Anticoagulants/administration & dosage
KW - Antineoplastic Agents/adverse effects
KW - Cystectomy/adverse effects
KW - Guideline Adherence
KW - Hemorrhage/etiology
KW - Humans
KW - Incidence
KW - Neoadjuvant Therapy/adverse effects
KW - Postoperative Complications/epidemiology
KW - Practice Guidelines as Topic
KW - Time Factors
KW - Urinary Bladder Neoplasms/drug therapy
KW - Venous Thromboembolism/epidemiology
UR - http://www.scopus.com/inward/record.url?scp=85042650331&partnerID=8YFLogxK
UR - https://www.webofscience.com/api/gateway?GWVersion=2&SrcApp=purepublist2023&SrcAuth=WosAPI&KeyUT=WOS:000429104000058&DestLinkType=FullRecord&DestApp=WOS
U2 - 10.1016/j.juro.2017.08.130
DO - 10.1016/j.juro.2017.08.130
M3 - Review article
C2 - 29113840
SN - 0022-5347
VL - 199
SP - 906
EP - 914
JO - Journal of Urology
JF - Journal of Urology
IS - 4
ER -