Direct Oral Anticoagulants for Venous Thromboembolism Prophylaxis Following Robot-assisted Radical Cystectomy: A Retrospective Feasibility Study at a Single Academic Medical Center

Comparison of direct oral anticoagulant (DOAC) versus low-molecular-weight heparin (LMWH) for venous thromboprophylaxis after radical cystectomy: A systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

Radical cystectomy in bladder cancer patients can result in postoperative complications, including venous thromboembolism (VTE), with an incidence reported between 3% and 11.6%. Although low-molecular-weight heparin (LMWH) is the recommended prophylactic treatment, challenges such as financial constraints and patient adherence remain. Direct Oral Anticoagulants (DOACs) present an alternative, but their comparative efficacy and safety against LMWHs in preventing VTE after radical cystectomy need further evaluation. This study aims to compare the efficacy and safety of LMWHs vs. DOACs for VTE prophylaxis following radical cystectomy.

MATERIALS AND METHODS

A systematic search was performed across 3 electronic databases to identify relevant studies utilizing DOACs and LMWHs for VTE prophylaxis after radical cystectomy. The primary outcomes of interest were VTE and bleeding events. Fixed-effect models were employed to summarize the outcomes, with results presented as odds ratios (OR) and their corresponding 95% confidence intervals (CI).

RESULTS

The analysis included a total of 541 patients from three studies. The pooled data indicated that patients on DOACs had a statistically nonsignificant lower odds of VTE (OR 0.41 [95% CI 0.13-1.36], P = 0.15) and a statistically nonsignificant higher odds of bleeding events (OR 3.03 [95% CI 0.53-17.23], P = 0.21).

CONCLUSIONS

Our findings suggest that DOACs are comparable to LMWHs in terms of VTE and bleeding events for thromboprophylaxis following radical cystectomy. The choice of prophylactic agent can be guided by patient preference and clinical judgment. However, additional randomized controlled trials with larger sample sizes are necessary to confirm these findings.

Impact of Early Detection and Varying Duration of Chemoprophylaxis on Venous Thromboembolism After Robot-Assisted Radical Cystectomy

OBJECTIVE

Venous thromboembolism (VTE) is one of the serious complications after robot-assisted radical cystectomy (RARC). This study aims to investigate the optimal duration of VTE prophylaxis and the predictive value of D-dimer measurement on the early detection of VTE.

METHODS

Retrospectively, we evaluated 86 RARC patients from July 2020 to September 2023. Thromboprophylaxis was modified two times (July 2020-; no-enoxaparin administration, June 2021-; enoxaparin for one week postoperatively, December 2022-; for two weeks), and patients were divided into three groups according to the duration. For early detection of VTE, D-dimer was measured postoperatively over time. In cases of D-dimer exceeding 10 μg/mL, contrast-enhanced CT was performed. The incidence of VTE was analyzed, and multivariate analysis was performed to identify the predictive factors.

RESULTS

Of the 40 patients who experienced postoperative D-dimer levels > 10 μg/mL, 37 underwent CT or ultrasound. VTE was observed in 10/26 cases (38%) in the no-enoxaparin group, 8/36 cases (22%) in the one-week group, and 1/24 cases (4%) in the two-week group, with a significant difference in incidence between the no-enoxaparin and 2-week groups (p = 0.005). Symptomatic VTE was observed in only one case in the no-enoxaparin group. Multivariate analyses of VTE predictive factors showed significant differences in D-dimer levels ≥ 12 on postoperative day 1 (OR = 14.2, 95% CI 2.47-81.1, p = 0.003) and enoxaparin administration for two weeks (OR = 0.10, 95% CI 0.01-0.96, p = 0.046).

CONCLUSION

Chemoprophylaxis for 2 weeks significantly reduces the risk of VTE after RARC. In addition, routine measurement of D-dimer enables early detection of asymptomatic VTE, helping to prevent the development of symptomatic VTE.

Bleeding Risk in Patients with Cancer

The hemostatic system and cancer display a tight interconnection, and hemostatic imbalance frequently occurs in patients with cancer. While extensive knowledge about thrombotic risk has been generated, less is known about bleeding risk and associated risk factors. However, bleeding risk is of high significance as patients with cancer frequently receive therapeutic anticoagulation for various indications and/or are candidates for primary thromboprophylaxis. The risk of bleeding in patients with cancer is variable and difficult to assess in clinical practice. Certain clinical settings such as hospitalization, specific underlying risk factors (e.g., tumor type), and medications (e.g., anticoagulation) can contribute to the individual bleeding risk of a patient with cancer. In addition, some dynamic factors such as platelet count or kidney function have an impact. Particularly, data on baseline risk of bleeding are lacking to allow for risk assessment in cancer patients without anticoagulation. In contrast, risk assessment models for the prediction of bleeding events in cancer patients receiving anticoagulation have been developed; however, these have yet to be validated. The recognition of the importance of bleeding risk in cancer patients is growing, leading to an increasing number of studies investigating and reporting bleeding complications. As study designs and reporting of bleeding events vary, it is challenging to offer a clear synthesis of evidence. In this narrative review, we provide an overview of currently available data about incidence, risk factors, and clinical impact of bleeding events in patients with cancer, and critically review risk assessment models for bleeding in cancer patients during anticoagulant therapy.

Prophylactic direct oral anticoagulants vs. low molecular weight heparin after urological surgery: A systematic review and meta-analysis

Purpose

To compare the outcomes of using prophylactic direct oral anti-coagulants (DOAC) and low-molecular-weight heparin (LMWH) after major urologic surgery.

Materials and Methods

Systematic literature searches of MEDLINE, Embase, Web of Science, and Cochrane CENTRAL were performed up to 9 November 2023, and protocols were registered on PROSPERO (CRD42024494424). The primary outcomes were post-operative incidence of VTE and bleeding. The secondary outcomes included re-admissions and transfusions needed, post-operative complications and exploring the radical cystectomy sub-group. Outcomes were reported in 30 and 90 days where feasible with sub-group analysis.

Results

Searches yielded four studies that included 856 patients and the outcomes were reported within 30 and 90 days, with sub-analysis performed for each time-interval. We found no statistically significant differences between DOAC and LWMH within neither primary nor secondary outcomes; VTE events (RR 0.36; p = 0.06); bleeding events (RR 0.64; p = 0.45); re-admissions (RR 1.14; p = 0.39); transfusions (RR 0.42; p = 0.05) within 0-90 days and post-operative complications within 30 days (RR 0.76; p = 0.17). Similar results were found when exploring radical cystectomy sub-group: VTE risk (RR 0.42, p = 0.15), bleeding risk (RR 1.09; p = 0.90), and re-admissions to hospital (RR 1.18, p = 0.35). Limitations include small sample size, and difficult generalization to all urological surgery as most of the analyzed cohort underwent radical cystectomy.

Conclusion

DOACs may be a safe and possibly cost-effective alternative to LMWH as post-operative thromboprophylaxis. However, these findings should be interpreted with caution due to limitations; therefore, more randomized studies are needed to ascertain our findings.

Direct oral anticoagulants (DOACs) versus low-molecular-weight heparin (LMWH) for extended thromboprophylaxis following major abdominal/pelvic cancer-related surgery: a systematic review and meta-analysis

BACKGROUND

The use of direct oral anticoagulants (DOACs) as an alternative to low-molecular-weight heparin (LMWH) for extended thromboprophylaxis of abdominal/pelvic cancer-related postoperative thromboembolism (VTE) is unclear. We aim to investigate the efficacy and safety of DOACs vs. LMWH in these patients.

METHODS

A systematic review was conducted using EMBASE, MEDLINE, CENTRAL, and Web of science through May 19th, 2023 for all randomized controlled trials (RCTs) and observational studies that compared the outcomes with DOACs vs. LMWH for extended thromboprophylaxis among patients undergoing abdominal/pelvic cancer surgery. Primary efficacy outcome was clinical VTE, and safety outcome was clinically relevant bleeding complications reported within the 30-day postoperative period. This study was registered in PROSPERO (CRD42023413175).

RESULTS

We identified 5078 articles and selected 29 full-text articles for eligibility. A total of 9 studies (2 RCTs and 7 observational studies) encompassing 2651 patients were included for systematic review and 7 for meta-analysis. When compared with LMWH extended thromboprophylaxis, DOACs had a similar incidence of VTE (RR: 0.65 [95% CI: 0.32-1.33], I2 = 0%), major bleeding (RR: 1.68 [95% CI: 0.36-7.9], I2 = 26%), and clinically relevant non-major bleeding (RR: 0.68 [95% CI: 0.39-1.19], I2 = 0%). Subgroup analysis suggested no difference according to the study type (RCTs versus observational studies) regarding clinical VTE or major bleeding (Pinteraction = 0.43 and Pinteraction = 0.71, respectively).

CONCLUSION

Our results suggest that DOACs for extended thromboprophylaxis were an effective and safe alternative to LMWH after major abdominal/pelvic cancer-related surgery.

Efficacy and safety of direct oral anticoagulants versus low-molecular-weight heparin for thromboprophylaxis after cancer surgery: a systematic review and meta-analysis

BACKGROUND

Direct oral anticoagulants (DOACs) used as an alternative to low-molecular-weight heparin (LMWH) for thromboprophylaxis after cancer surgery for venous thromboembolic events (VTE) remains unclear. This study aimed to investigate the efficacy and safety of DOACs versus LMWH in these patients.

MATERIALS AND METHODS

A search of EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science was carried out and included all randomized controlled trials (RCTs) and observational studies that directly compared DOACs with LMWH for thromboprophylaxis in patients after cancer surgery through July 25, 2023. The primary efficacy and safety outcomes were VTE, major bleeding, and clinically relevant non-major bleeding (CRNMB) within 30 days of surgery. The risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB2) tool for RCTs and ROBINS-I tool for non-randomized studies. This study was registered in PROSPERO (CRD42023445386).

RESULTS

We retrieved 5149articles, selected 27 for eligibility, and included 10 studies (three RCTs and seven observational studies) encompassing 3054 patients who underwent postoperative thromboprophylaxis with DOACs (41%) or LMWH (59%). Compared to LMWH thromboprophylaxis, DOACs had a comparable risk of VTE (RR:0.69[95% CI:0.46-1.02], I2 = 0%), major bleeding (RR:1.55 [95% CI:0.82-2.93], I2 = 2%), and CRNMB (RR, 0.89 [95% CI, 0.4-1.98], I2 = 31%) during the 30-day postoperative period. Subgroup analysis of VTE and major bleeding suggested no differences according to study type, extended thromboprophylaxis, tumor types, or different types of DOAC.

CONCLUSION

DOACs are potentially effective alternatives to LMWH for thromboprophylaxis in patients undergoing cancer surgery, without increasing the risk of major bleeding events.

Outcomes from a prospectively implemented protocol using apixaban after robot-assisted radical cystectomy

OBJECTIVES

To compare the safety and efficacy of oral apixaban with that of injectable enoxaparin after robot-assisted radical cystectomy (RARC) for venous thromboembolism (VTE) thromboprophylaxis.

MATERIALS AND METHODS

We conducted a retrospective review of prospectively collected data for all RARC patients treated at our tertiary care centre between 2018 and 2022. The study included two groups: patients who were subject to a prospectively implemented protocol from October 2021 to the present, comprising a 21-day postoperative course of apixaban 2.5 mg twice daily after discharge, and patients treated prior to October 2021 who received enoxaparin 40 mg daily. Baseline demographics and clinical characteristics, such as VTE (defined as deep vein thrombosis and pulmonary embolism), were analysed. The primary outcome was incidence of symptomatic VTE confirmed with definitive imaging within 90 days of RARC. Secondary outcomes included major bleeding, complications, readmission, and mortality within 30 days postoperatively. Descriptive statistics included baseline patient characteristics, operative information and complications. Differences in baseline characteristics and postoperative data were compared between groups. Multivariate logistic regression was used to determine associations between variables and the primary outcome.

RESULTS

A total of 124 patients received apixaban and 250 patients received enoxaparin prophylaxis. Ten patients (2.7%) experienced a VTE within 90 days postoperatively (two [1.6%] apixaban group vs eight [3.2%] enoxaparin group; P = 0.5). After patient stratification into European Association of Urology risk groups, no statistically significant difference in VTE rates was seen between groups in the apixaban (2.7% high- + intermediate-risk group vs 1.1% low-risk group; P = 0.5) and enoxaparin cohorts (4.3% high- + intermediate-risk group vs 2.5% low-risk group; P = 0.5). On multivariate logistic regression, no variables were associated with the development of the primary outcome.

CONCLUSION

Prophylaxis with apixaban and enoxaparin showed no statistically significant differences in VTE rates among RARC patients. Apixaban appears to be safe and effective for VTE prophylaxis after RARC.