Perioperative venous thromboembolism prophylaxis in prostate cancer surgery

• Published in: World journal of urology 2020-03, Vol.38 (3), p.593-600
• Main Authors: Klaassen, Zachary, Wallis, Christopher J. D., Lavallée, Luke T., Violette, Philippe D.
• Format: Article
• Language: English
• Subjects: Anticoagulants - therapeutic use; Bleeding; Cancer surgery; Duration of Therapy; Evidence-Based Medicine; Health risk assessment; Heparin - therapeutic use; Humans; Laparoscopy; Lymph Node Excision; Lymph nodes; Male; Medicine; Medicine & Public Health; Nephrology; Oncology; Patients; Pelvis; Perioperative Care; Postoperative Complications - prevention & control; Postoperative Hemorrhage - epidemiology; Practice Guidelines as Topic; Prophylaxis; Prostate cancer; Prostatectomy; Prostatic Neoplasms - surgery; Risk Assessment; Robotic surgery; Robotic Surgical Procedures; Stockings, Compression; Surgery; Thromboembolism; Thrombosis; Topic Paper; Urological surgery; Urology; Venous Thromboembolism - prevention & control
• ISSN: 0724-4983; 1433-8726
• DOI: 10.1007/s00345-019-02705-x

Purpose To describe a patient and procedure specific approach to selecting Venous thromboembolism (VTE) prophylaxis for men who undergo radical prostatectomy. Methods We performed a literature search and narrative review of VTE after radical prostatectomy. We describe the current paradigm of perioperative thromboprophylaxis and underlying rationale. Relevant findings from the European Association of Urology thromboprophylaxis guidelines are interpreted and summarized. Results The use of extended post-operative thromboprophylaxis for patients who undergo radical prostatectomy is appropriate when the risk of symptomatic VTE outweighs the risk of major bleeding. Patient and procedure factors impact VTE risk. Patient risk can be stratified as low, moderate or high based on 4 factors; age > 75, BMI > 35, VTE in a first degree relative, and personal history of VTE. Procedure risk of VTE and bleeding can be stratified by modality of surgery (open, laparoscopic, robotic) and extent of pelvic lymphadenectomy. Using these factors, patients at the lowest risk for VTE will have an expected incidence of VTE of 0.4–0.8% and those at highest risk from 1.5 to 15.7%. Incidence of major bleeding ranges from 0.4 to 1.4%. These ranges emphasize the need to consider the net benefit for each specific patient. Use of mechanical prophylaxis is supported by weaker evidence but has fewer harms and is likely reasonable for most patients. Conclusion Many patients who undergo radical prostatectomy will benefit from extended post-operative thromboprophylaxis. Risk of thrombosis is likely higher with open approach and extended lymph node dissection. The net benefit of treatment should be considered using patient- and procedure-specific criteria. When the net benefit is negligible or possibly harmful no pharmacological thromboprophylaxis should be used.