Extended Venous Thromboembolism Prophylaxis after Radical Cystectomy: A Call for Adherence to Current Guidelines

Zachary Klaassen, Karan Arora, Hanan Goldberg, Thenappan Chandrasekar, Christopher J.D. Wallis, Rashid K. Sayyid, Neil E. Fleshner, Antonio Finelli, Alexander Kutikov, Philippe D. Violette, Girish S. Kulkarni

Research output: Contribution to journalReview article

9 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)906-914
Number of pages9
JournalJournal of Urology
Volume199
Issue number4
DOIs
StatePublished - Apr 2018

Fingerprint

Cystectomy
Venous Thromboembolism
Guidelines
Anticoagulants
Incidence
Urology
Standard of Care
PubMed
Renal Insufficiency
Meta-Analysis
Clinical Trials
Hemorrhage
Morbidity
Safety

Keywords

  • cystectomy
  • heparin
  • low-molecular-weight
  • urinary bladder neoplasms
  • venous thromboembolism

ASJC Scopus subject areas

  • Urology

Cite this

Klaassen, Z., Arora, K., Goldberg, H., Chandrasekar, T., Wallis, C. J. D., Sayyid, R. K., ... Kulkarni, G. S. (2018). Extended Venous Thromboembolism Prophylaxis after Radical Cystectomy: A Call for Adherence to Current Guidelines. Journal of Urology, 199(4), 906-914. https://doi.org/10.1016/j.juro.2017.08.130

Extended Venous Thromboembolism Prophylaxis after Radical Cystectomy : A Call for Adherence to Current Guidelines. / Klaassen, Zachary; Arora, Karan; Goldberg, Hanan; Chandrasekar, Thenappan; Wallis, Christopher J.D.; Sayyid, Rashid K.; Fleshner, Neil E.; Finelli, Antonio; Kutikov, Alexander; Violette, Philippe D.; Kulkarni, Girish S.

In: Journal of Urology, Vol. 199, No. 4, 04.2018, p. 906-914.

Research output: Contribution to journalReview article

Klaassen, Z, Arora, K, Goldberg, H, Chandrasekar, T, Wallis, CJD, Sayyid, RK, Fleshner, NE, Finelli, A, Kutikov, A, Violette, PD & Kulkarni, GS 2018, 'Extended Venous Thromboembolism Prophylaxis after Radical Cystectomy: A Call for Adherence to Current Guidelines', Journal of Urology, vol. 199, no. 4, pp. 906-914. https://doi.org/10.1016/j.juro.2017.08.130
Klaassen, Zachary ; Arora, Karan ; Goldberg, Hanan ; Chandrasekar, Thenappan ; Wallis, Christopher J.D. ; Sayyid, Rashid K. ; Fleshner, Neil E. ; Finelli, Antonio ; Kutikov, Alexander ; Violette, Philippe D. ; Kulkarni, Girish S. / Extended Venous Thromboembolism Prophylaxis after Radical Cystectomy : A Call for Adherence to Current Guidelines. In: Journal of Urology. 2018 ; Vol. 199, No. 4. pp. 906-914.
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abstract = "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{\circledR} 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.",
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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.

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