3 years ago

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

Radical cystectomy (RC) is an inherently morbid procedure. The purpose of this review is to assess the timing and incidence of venous thromboembolism (VTE), review current guideline recommendations, and provide evidence for considering extended VTE prophylaxis among all patients undergoing RC. Materials and Methods We conducted a PubMed search of available literature for RC and VTE, focusing on: incidence and timing, evidence supporting extended VTE prophylaxis (among RC and abdominal surgical oncology patients), current guideline recommendations, safety considerations, and direct oral anticoagulants. The search terms used included radical cystectomy, venous thromboembolism, prophylaxis, extended, and direct oral anticoagulants alone or 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 VTE in short-term follow-up after RC is 3-11.6% of patients, of which more than 50% will occur after hospital discharge. Meta-analyses of clinical trials for patients undergoing major abdominal surgical oncology procedures suggests decreased risk of VTEs for patients receiving extended (4 weeks) VTE prophylaxis. Extended prophylaxis should be considered for all RC patients; although the relative risk of bleeding also increases, the overall net benefit of extended prophylaxis clearly favors use for at least 28 days post-operatively. Extra-renal eliminated prophylaxis agents are preferred given the risk of renal insufficiency in RC patients, with newer oral anticoagulants providing an alternative route of administration. Conclusions Patients undergoing RC are at high risk for VTE after hospital discharge. There is strong evidence that extended prophylaxis significantly decreases the risk of VTEs in surgical oncology patients. The use of extended prophylaxis post-RC has been poorly adopted, emphasizing the need for better adherence to current urology procedure specific guidelines, as extended prophylaxis for RC is the standard of care. Specific and typically rare circumstances may require case-by-case assessment.

Publisher URL: www.sciencedirect.com/science

DOI: S0022534717778172

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