Incidence, risk profile and morphological pattern of venous thromboembolism after prostate cancer surgery

Venous Thromboembolism (VTE) in Post-Prostatectomy Patients: Systematic Review and Meta-Analysis

Radical prostatectomy (RP) is one of the recommended treatments to achieve oncological outcomes in localized prostate cancer. However, a radical prostatectomy is a major abdominopelvic surgery. Venous thromboembolism (VTE) is a well-known complication associated with surgical procedures, including RP. There is a lack of consensus regarding VTE prophylaxis in urological procedures. The aim of this systematic review and meta-analysis was to investigate different aspects of VTE in post-radical prostatectomy patients. A comprehensive literature search was performed, and relevant data were extracted. The primary aim was to perform a systematic review and meta-analysis (wherever possible) of VTE occurrence in post-RP patients in relation to surgical approach, pelvic lymph node dissection, and type of prophylaxis (mechanical or combined prophylaxis). The secondary aim was to investigate the incidence and other risk factors of VTE in post-RP patients. A total of 16 studies were included for quantitative analysis. Statistical methods for analysis included the DerSimonian-Laird random effects. We were able to conclude that the overall incidence of VTE in post-radical prostatectomy is 1% (95% CI) and minimally invasive procedures (MIS), including laparoscopic, as well as robotic procedures for radical prostatectomy and RP without pelvic lymph node dissection (PLND), are associated with less risk of developing VTE. Additional pharmacological prophylaxis to mechanical methods may not be necessary in all cases and should be considered in high-risk patients only.

Risk factors for lymphorrhea and lymphocele after radical prostatectomy: a retrospective case-control study

PURPOSE

To investigate the risk factors for postoperative lymphorrhea or/and lymphocele (PLL) in patients undergoing radical prostatectomy (RP).

MATERIALS AND METHODS

The clinical data of 606 patients were retrospectively collected. The receiver operating characteristic (ROC) curve was utilized to identify the optimal cutoff value. Multivariable logistic regression analysis was used to screen the independent predictors of PLL.

RESULTS

Univariate analysis showed that nine factors differed between the PLL and non-PLL group. Multivariable logistic regression analysis showed that low preoperative fibrinogen level, extraperitoneal surgery, robot-assisted laparoscopic radical prostatectomy (RALRP), and hypoalbuminemia were risk factors and the use of fibrin glue was a protective factor. Correlation analysis showed that the scope of LN dissection (LND) and number of lymph nodes (LNs) dissected were positively correlated with PLL in the extraperitoneal approach, but were not significantly correlated with PLL in the transperitoneal approach. The use of fibrin glue was negatively associated with PLL in the overall procedure and the extraperitoneal approach, but not significantly so in the transperitoneal approach. Comparison of LNs clearance between the two surgical approaches revealed that the extent of LND and number of LNs dissected in the extraperitoneal approach were less than in the transperitoneal approach.

CONCLUSION

During RALRP, more attention should be paid to fully clotting the broken end of lymphatic vessels. The use of fibrin glue could reduce the probability of PLL. The extent of LND or number of LNs dissected were positively correlated with PLL in the extraperitoneal approach.

Evaluation of the risk factors for venous thromboembolism post splenectomy - A ten year retrospective cohort study in St James's hospital

Background

Splenectomy is a surgical intervention for a variety of indications; benign and malignant. Complications of this procedure include Venous thromboembolism (VTE) and infection. The incidence of VTE post-surgery has been reported between 0.8%-3% depending on the type of surgery. A higher incidence of abdominal VTE was reported post splenectomy (6-11%). However, there is limited literature regarding the risk factors for post splenectomy VTE and the optimal strategy for thromboprophylaxis.

Objective

The primary objective of the study was to evaluate the incidence of VTE post splenectomy and to identify the pre-operative, intra-operative and post-operative risk factors. The secondary objective was to assess the local compliance with post-splenectomy prophylactic antibiotics and vaccination protocols.

Methods

We conducted a retrospective observational study. All patients who had a splenectomy in St James's Hospital between January 2007 and June 2017 were included and reviewed. Statistical analysis was carried out using SPSS statistical package.

Results

85 patients were involved in the study. The main indications for splenectomy were benign haematology, malignant haematology, solid tumours, traumatic and spontaneous rupture. 6/85 patients developed VTE (7.06%).High BMI ≥ 30 was associated with increased risk of VTE (p = 0.007), while the use of post-operative prophylactic anticoagulation was associated with reduced risk (p = 0.005). Other factors including age >50 years, female gender, presence of active malignancy and splenomegaly were associated with increased VTE risk with no statistical significance. All VTE's occurred in elective versus emergency splenectomy. Laparoscopic splenectomy was associated with higher risk of VTE than open splenectomy. 97% of patients were prescribed prophylactic antibiotics on discharge, but only 88% had received recommended vaccinations.

Conclusion

Venous thromboembolism is common post splenectomy. Our data showed that BMI ≥30 was associated with a statistically significant increased risk of VTE, while the use of prophylactic anticoagulation was associated with reduced risk. Further prospective studies with larger samples are warranted and a splenectomy care plan may be helpful.

Preoperative Parameters to Predict the Development of Symptomatic Lymphoceles after Radical Prostatectomy

INTRODUCTION

Symptomatic lymphoceles (SLs) represent the most common complication after radical prostatectomy (RP) and pelvic lymph node dissection (PLND). To date, preoperative risk factors are missing.

METHODS

Clinical and pathological data of 592 patients who underwent RP and PLND were evaluated. Included parameters were age, BMI, prostate-specific antigen (PSA), PSA ratio, PSA density, number of resected and/or positive lymph nodes, previous abdominal surgery/pelvic radiotherapy, anticoagulation, and surgical approach.

RESULTS

Fifty-nine patients (10%) developed an SL, of which 57 underwent open retropubic radical prostatectomy (RRP) and 2 underwent robot-assisted radical prostatectomy (RARP). Multivariate logistic regression revealed the following parameters as statistically significant risk factors: PSA (odds ratio [OR] = 2.23; 95% CI [1.25; 5.04], p = 0.04), number of resected lymph nodes (OR = 1.47; 95% CI [1.10; 1.97], p < 0.01), previous abdominal surgery (OR = 2.58; 95% CI [1.38; 4.91], p < 0.01), and surgical approach (OR = 0.08; 95% CI [0.01; 0.27], p < 0.01). Previous oral anticoagulation showed almost statistically significant results (OR = 2.39 [0.92; 5.51], p = 0.05).

CONCLUSION

The risk for SL might be predictable considering preoperative risk factors such as PSA, previous abdominal surgery and anticoagulation. To avoid SL, RARP should be the procedure of choice. If RRP is considered, patients at risk for SL may benefit from peritoneal fenestration during RP.

Evaluation and analysis of incidence and risk factors of lower extremity venous thrombosis after urologic surgeries: A prospective two-center cohort study using LASSO-logistic regression

BACKGROUND

Deep vein thrombosis (DVT) is among the most frequent complications of surgery. This study aimed to analyse the incidence and risk factors of lower extremity venous thrombosis after urologic surgery.

MATERIALS AND METHODS

This prospective two-centre study was conducted from August 2019 to January 2020. Patients who underwent urological procedures were enrolled. The primary endpoint was the detection of asymptomatic or symptomatic DVT of the lower extremity within 7 days after surgery. Univariate and least absolute shrinkage and selection operator (LASSO) logistic regression analyses were performed.

RESULTS

Fifty-six of 1011 patients developed DVT. In the univariate analysis, Barthel Index ≤40, d-dimer level ≥0.5 mg/L and age ≥60 years (p < 0.001) were identified as the most significant risk factors. The LASSO logistic regression model identified nine factors: age, history of DVT, lymph node dissection, perioperative steroid use, Caprini score, Barthel Index, D-dimer level, cystectomy, and prostatectomy.

CONCLUSION

Our study used the LASSO logistic regression model to provide reliable data on the risk factors for DVT after comprehensive urologic surgery. The incidence of DVT in this group was 5.54%. This might facilitate individualised anticoagulant management in patients undergoing urological procedures.

High BMI, Aggressive Tumours and Long Console Time Are Independent Predictive Factors for Symptomatic Lymphocele Formation after Robot-Assisted Radical Prostatectomy and Pelvic Lymph Node Dissection

INTRODUCTION

Lymphocele (LC) formation is a common complication which may cause severe symptoms after robot-assisted radical prostatovesiculectomy (RARP) with concomitant pelvic lymph node dissection (PLND). Compared to open radical prostatectomy, the amount of data on potential risk factors for LC formation is still limited. The aim of the present study was to identify risk factors for symptomatic LC formation (sLC) after RARP with PLND.

METHODS

We used the data of a prospective multicentre series of 232 RARP patients which were treated between March 2017 and December 2017. The primary endpoint was the presence of sLC within 90 days. Asymptomatic LC (aLC) formation was also recorded. We evaluated clinical, perioperative, and histopathological criteria and compared their distribution in patients with and without post-operative sLC. Uni- and multivariable logistic regression analyses (MVAs) were performed to identify potential predictors for LC formation. Regarding the influence of patients' BMI, 2 models were calculated: BMI continuously (model 1) and BMI dichotomized with cut-off 30 kg/m2 (WHO definition, model 2).

RESULTS

Post-operative sLC was present in 21 patients (9.1%), while aLC was detected in 49 patients (21.1%) 90 days after RARP with PLND. Patients with sLC showed higher median baseline PSA levels (9.8 vs. 8.1 ng/mL), higher prevalence of obesity (BMI >30; 42.9 vs. 19.9%), and longer median console time (180 vs. 165 min) compared to patients without sLC. On MVA higher BMI {model 1: OR 1.145 (confidence interval [CI] 1.025-1.278); model 2: OR 2.761 (1.045-7.296)}, longer console time (model 1: OR 1.013 [1.005-1.021]; model 2: OR 1.013 [1.005-1.020]) and an ISUP grade ≥3 (model 1: OR 3.247 [1.182-8.917]; model 2: OR 2.791 [1.050-7.423]) were identified as independent predictors for sLC development.

CONCLUSION

Patients with aggressive tumours and higher BMI should be informed about a potentially increased risk for sLC formation. In case of a long console time, a close and regular follow-up should be considered to check for LC development.

Venous thromboembolism and prostate cancer: what about genetic markers?

Aim & methods: To review the existing literature concerning the relationship between venous thromboembolism (VTE) and prostate cancer (PC) and explore the putative biological and clinical implications of VTE genetic markers on PC patients by screening the PubMed database. Results: Considering the roles of VTE genome-wide association studies-identified genetic determinants in disease development in the general population, these variants might also underlie the susceptibility for PC-related VTE. Therefore, they could help to identify those with a positive benefit-to-harm ratio for thromboprophylaxis approaches during cancer therapy management, thereby improving patient's prognosis. Conclusion: Future studies are mandatory to explore the relationship between VTE and PC and dissect the predictive value of VTE genome-wide association studies-identified genetic determinants in PC patients, given their clinical implications.

Improving follow-up of incomplete lower extremity venous duplex ultrasound examinations performed for deep and superficial vein thromboses

OBJECTIVE

A lower extremity venous duplex ultrasound (LEVDUS) examination is the standard diagnostic test to evaluate patients for lower extremity deep vein thrombosis (DVT). However, some studies will be incomplete for a variety of reasons, including patient-related factors such as pain, edema, a large leg circumference, or the presence of overlying bandages or orthopedic devices. We previously reported that the frequency of obtaining a follow-up examination after an incomplete and negative (I/N) LEVDUS examination was low but that the rates of DVT found on the follow-up studies of initially I/N LEVDUS studies were similar to the rates of DVT found with initially complete LEVDUS examinations. Therefore, we recommended process improvements to increase follow-up LEVDUS studies after an I/N LEVDUS examination. In the present study, we have described the results of appending a recommendation to obtain a follow-up LEVDUS study to preliminary and final reports of I/N LEVDUS.

METHODS

Starting in January 2019 through December 2019, a recommendation to obtain a repeat LEVDUS examination after an I/N study was appended to the preliminary and final reports of all I/N LEVDUS examination of patients who did not, otherwise, have an indication for anticoagulation (group 2). The patients were identified on an ongoing basis through the study period and entered into an Excel database (Microsoft Corp, Redmond, Wash). Group 2 was compared with a previously reported historic control cohort of patients identified from January 2017 to December 2017 (group 1). We compared groups 1 and 2 with respect to the frequency of the repeat studies performed within 4 weeks after an I/N LEVDUS examination and the DVT rates found from the follow-up LEVDUS examinations after an I/N LEVDUS study.

RESULTS

Of the patients in groups 1 and 2, 187 and 229 had had I/N LEVDUS examinations, with 28% and 40.2% of group 1 and 2 studies having follow-up LEVDUS examinations (P < .01). Previously unidentified lower extremity thrombi were discovered in 21% of the group 2 follow-up examinations. Also, the rate of new thrombi detected was not different between groups 2 and 1 (historic controls; DVT, 14.3% vs 18.5% [P = .25]; SVT, 6.3% vs 3.3% [P = .15]). A definitive finding of either positive or negative for DVT and SVT with a complete examination in 50% of the group 2 patients with follow-up examinations.

CONCLUSIONS

A recommendation to obtain a follow-up examination appended to the preliminary and final I/N LEVDUS reports was associated with an increased rate of follow-up examinations, which revealed many previously undetected DVTs and SVTs or had allowed for definitive exclusion of DVT.

Extended versus inpatient thromboprophylaxis with heparins following major open abdominopelvic surgery for malignancy: a systematic review of efficacy and safety

Background

Patients undergoing open abdominopelvic procedures for malignancy are at high risk of postoperative venous thromboembolism (VTE). This risk can be mitigated with prophylaxis; however, optimum duration in this population remains unknown. Our objective was to conduct a systematic review of contemporary literature on the use of heparin thromboprophylaxis following major open pelvic surgery for malignancy, comparing the efficacy and safety of extended duration to inpatient treatment.

Methods

A study protocol describing search strategy and inclusion and exclusion criteria was developed and registered with PROSPERO. A literature review was conducted in accordance with the protocol.

Results

Literature review identified only 4 studies directly comparing extended and inpatient duration prophylaxis, with a combined population of 3198 and 3135 patients for VTE rate and bleeding events, respectively. Despite many studies reporting lower VTE rates in patients receiving extended prophylaxis, no statistically significant difference in rates of postoperative VTE (p = 0.18) or bleeding complications (p = 0.43) was identified between patients receiving extended duration prophylaxis and those receiving inpatient only prophylaxis.

Conclusion

On the review of contemporary literature, no significant difference was found in rates of postoperative VTE or bleeding complications between patients receiving extended duration heparin VTE prophylaxis and those receiving inpatient prophylaxis after open abdominopelvic surgery for malignancy.

This raises the question of how extended duration prophylaxis has become common practice in this population, and whether this needs to be re-evaluated.

Venous thromboembolism after radical cystectomy and urinary diversion: a single-center experience with 1737 consecutive patients

Background: To investigate the incidence, timing, and risk factors of venous thromboembolic events (VTE) following radical cystectomy and urinary diversion in a large cohort of patients.Patients and Methods: The electronic data base of patients underwent radical cystectomy and urinary diversion in a tertiary referral center between January 2004 and February 2014 was retrospectively reviewed. Patients developed VTE namely deep vein thrombosis (DVT) and pulmonary embolism (PE) within 90 days after surgery were identified and compared to those without VTE. Univariate and multivariate analyses were used to evaluate the predictors of the VTE.Results: Out of 1737 patients, 77 VTE have occurred in 70 (4%) patients. DVT and PE occurred in 34 (2%) and 43 (2.5%) patients, respectively. PE was the leading cause of mortality in 17 patients. The median (range) time for VTE was 11 days (1-92) with 39 (50.6%) events developed after the stoppage of thrombo-prophylaxis. On multivariate analysis, older age ≥60 years (OR = 1.9; p = 0.009), female gender (OR = 1.9; p = 0.02), morbid obesity (BMI ≥35 kg/m²) (OR = 2.4; p = 0.008) and preoperative platelet count (≥300.000/cc) (OR = 1.6; p = 0.045) were significant predictors for developing VTE.Conclusion: The overall incidence of VTE is 4% with more than half of events occurred after the stoppage of thromboprophylaxis highlighting the necessity of adopting an extended protocol. Independent predictors included older age, female gender, morbid obesity and preoperative thrombocytosis. These group of patients require particular attention for the prevention of this complication.

Long-lasting prothrombotic state implied by changes of plasma von Willebrand factor parameters after radical prostatectomy for prostate malignancy

OBJECTIVES

Thromboembolic complications are present in 0.8%-16.8% of the cases after radical prostatectomy (RP). Association between elevated plasma von Willebrand factor (VWF) levels-as an endothelial activation marker-and increased risk of thrombotic events has been evidenced. We aimed to elicit new data on the VWF after RP in prostate cancer patients and explore the role of it as a thrombotic risk factor. Upon perioperative plasma VWF levels (VWF:Ag) its collagen-binding (CB) activity (VWF:CB), multimerization, and cleaving enzyme (ADAMTS13 [a disintegrin and metalloprotease with thrombospondin type repeats, motif 1, type 13]) of the VWF multimers were quantitated along with Factor VIII and routine laboratory parameters in this observational pilot study.

METHODS

Plasma samples of 24 prostate cancer patients were collected before (-1 day; D-1) and after RP (1 hour, 6 days, 1 month, and 10 months; H1, D6, M1, and M10). VWF:Ag, VWF:CB, ADAMTS13:Ag were measured by ELISA, and the multimer distribution by electrophoresis and quantitative densitometry. Factor VIII, fibrinogen, D-dimer, and other routine laboratory parameters were determined as well. Preoperative values served as baselines which were compared to controls (24 healthy individuals).

RESULTS

VWF:Ag and CB elevated by 122% and 143% respectively at H1 after RP then plateaued at D6 compared to baseline values. ADAMTS13/VWF:Ag ratio reduced by 41% at H1, and by 46% at D6, meanwhile the ratio of high molecular weight multimers increased as well. Values returned to baseline at M1 and further reduced to the levels of the controls at M10. All of the 24 patients at H1 and D6 and 14 at M10 were in potential prothombotic state according ROC analysis of the VWF parameters as indicators.

CONCLUSIONS

Prostate malignancy and then surgical stress, and inflammatory reactions induced release of VWF from the endothelial cells, along with an increasing amount of large multimers and relative reduction of ADAMTS13 level. Because these changes mark a prothrombotic state even at M1 after RP, more than 1 month follow-up and prophylactic targeting through the thrombotic and inflammatory activity of the VWF is proposed. Evaluation of VWF parameters provides new information about the long-term disturbances of primary hemostasis after radical pelvic oncologic surgery like RP and might improve the understanding the physiological and pathological recovery.

The role of extended venous thromboembolism prophylaxis for major urological cancer operations

OBJECTIVES

Venous thromboembolism (VTE), consisting of both pulmonary embolism (PE) and deep vein thromboses (DVT), remains a well-recognised complication of major urological cancer surgery. Several international guidelines recommend extended thromboprophylaxis (ETP) with LMWH, whereby the period of delivery is extended to the post-discharge period, where the majority of VTE occurs. In this literature review we investigate whether ETP should be indicated for all patients undergoing major urological cancer surgery, as well procedure specific data that may influence a clinician's decision.

METHODS

We performed a search of six databases (PubMed, Cochrane, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and British Nursing Index (BNI)) from inception to June 2019, for studies looking at adult patients who received VTE prophylaxis after surgery for a major urological malignancy.

RESULTS

Eighteen studies were analysed. VTE risk is highest in open and robotic Radical Cystectomy (RC) (2.6-11.6%) and ETP demonstrates a significant reduction in risk of VTE, but not a significant difference in Pulmonary Embolism (PE) or mortality. Risk of VTE in open Radical Prostatectomy (RP) (0.8-15.7%) is comparable to RC, but robotic RP (0.2-0.9%), open partial/radical nephrectomy (1.0-4.4%) and robotic partial/radical nephrectomy (0.7-3.9%) were lower risk. It has not been shown that ETP reduces VTE risk specifically for RP or nephrectomy.

CONCLUSION

The decision to use ETP is a fine balance between variables such as VTE incidence, bleeding risk and perioperative morbidity/mortality. This balance should be assessed for each specific procedure type. While ETP still remains of net benefit for open RP as well as open and robotic RC, the balance is closer for minimally invasive RP as well as radical and partial nephrectomy. Due to a lack of procedure specific evidence for the use of ETP, adherence with national guidelines remains poor. Therefore, we advocate further studies directly comparing ETP vs standard prophylaxis, for specific procedure types, in order to allow clinicians to make a more informed decision in future.

Incidence, risk factors, and outcomes of venous thromboembolism after oncologic surgery: A systematic review and meta-analysis

BACKGROUND

The risk and prognosis of VTE associated with oncologic surgery need to be quantified to guide patient management. We aimed to examine the availability of data and to report the incidence of venous thromboembolism (VTE) in cancer patients after surgery, as well as the clinical outcomes of VTE following oncologic surgery.

METHODS

We searched multiple databases for terms related to VTE after oncologic surgery from inception to November 1, 2017. A random-effects meta-analysis was done to calculate the pooled incidence of VTE.

RESULTS

Of the 8611 citations identified, 136 studies including 1,481,659 patients met the eligibility criteria. The overall incidence of VTE was estimated to be 2.3% (95% CI 2.1-2.5). Bone and soft tissue cancer (10.6%, 95% CI 2.9-18.2) and lung cancer (8.1%, 95% CI 3.7-12.6) were associated with the highest and second highest risk of postoperative VTE, respectively. Age (standardized mean difference [SMD] = 0.46, 95% CI 0.40-0.53; I² = 93.8%), radiation (OR 1.29, 95% CI 1.03-1.62; I² = 34.6%), transfusion (OR 1.96, 95% CI 1.48-2.59; I² = 57.0%), and operative time (SMD = 1.12, 95% CI 1.07-1.16; I² = 100%) were possible risk factors for postoperative VTE. Patients with VTE versus those without had increased odds of all-cause fatal events (11.15, 95% CI 4.07-30.56; I² = 92.0%).

CONCLUSIONS

The risk of VTE after oncologic surgery remains high, and this risk varied according to the cancer type, study region, surgical location, and thromboprophylactic strategy. VTE is associated with increased mortality at the early stage of cancer surgery.

Postoperative D-dimer predicts venous thromboembolism in patients undergoing urologic tumor surgery

PURPOSE

We examined the incidence of pulmonary thromboembolism (PE) and deep venous thromboembolism (DVT) in patients who underwent urologic tumor surgery. The aim of this study was to investigate the postoperative D-dimer for prediction of venous thromboembolism events (VTE), as well as to identify other risk factors associated with the occurrence of thromboembolisms.

PATIENTS AND METHODS

This was a prospective observational cohort study, which included 1,269 patients who underwent major urologic tumor surgery, from August 2015 to February 2017, at our center. Data comprising age, sex, body mass index, Charlson comorbidity index, type of surgery, Caprini score, postoperative D-dimer levels, and other laboratory tests were collected for analyses. Lower limb venous ultrasound was performed before surgery and the day before hospital discharge to measure DVT. Computerized tomography or ventilation/perfusion lung scan was applied to detect PE.

RESULTS

The overall incidence of VTE was 2.4% (31 cases) in 1,269 patients, consisting of 23 PE events and 9 DVT events. Patients undergoing radical cystectomy were most likely to suffer VTE (4.3%). The optimal cutoff value for postoperative D-dimer was 0.98μg/ml, according to the receiver operating characteristic curve analysis, with a sensitivity of 83.9%, and a specificity of 80.0%. On multivariate analysis, hypertension (odds ratio, OR = 2.5, 95% CI: 1.1-5.7; P = 0.026), Charlson comorbidity index ≥ 2 (OR = 5.6, 95% CI: 2.2-14.6; P<0.001), and D-dimer lever ≥ 1μg/ml on postoperative day 1 (OR = 12.52, 95% CI: 4.6-35.2; P<0.001) were independently associated with VTE after urologic tumor surgery.

CONCLUSIONS

The overall incidence of urologic-tumor-surgery-associated VTE in an Asian population is similar to those reported in European and North American series. Elevated D-dimer early after operation is an independent predictor of VTE in patients undergoing urologic tumor surgery. In addition, hypertension and the Charlson comorbidity index are both important clinical risk factors. The Caprini score recommended by the guideline is inadequate in this study population. The postoperative D-dimer plasma level is a more reliable marker for identifying patients at high-risk of developing venous thromboembolisms.

The postoperative venous thromboembolism (TREVO) study - risk and case mortality by surgical specialty

INTRODUCTION AND OBJECTIVES

Venous thromboembolism, risk of which is increased in surgical patients, is a preventable cause of morbidity and death. The primary objective of this study was to estimate the incidence of symptomatic postoperative venous thromboembolism in adults at a tertiary university hospital, overall and by surgical specialty. The secondary objective was to analyze severity of and mortality from thromboembolic events.

METHODS

We performed a retrospective study to identify cases of in-hospital postoperative venous thromboembolism, encoded by the International Classification of Diseases, Ninth Revision, according to the Joint Commission International criteria. Adult patients admitted for surgery in 2008-2012 were included.

RESULTS

Among 67 635 hospitalizations, 90 cases of postoperative symptomatic venous thromboembolism were identified, corresponding to an incidence of 1.33/1000 admissions (95% confidence interval [CI] 1.1-1.6/1000). Neurosurgery had the highest risk (4.07/1000), followed by urological surgery and general surgery (p<0.001). There were 50 cases of pulmonary embolism, 11 of which were fatal. Of the 90 cases, 12.2% occurred under neuraxial anesthesia and 55.1% in patients with American Society of Anesthesiology III physical status. At least 37.7% of patients with events received a prophylactic dose of injectable anticoagulant postoperatively. The overall risk decreased from 2008 to 2012. Venous thromboembolism-associated mortality during hospitalization was 21.1% (95% CI 13.6-30.4).

CONCLUSIONS

The incidence of postoperative symptomatic venous thromboembolism was 1.33/1000. Neurosurgery showed the greatest risk. Mortality was 21.1%.

Surgical operative time increases the risk of deep venous thrombosis and pulmonary embolism in robotic prostatectomy

Background and Objectives:

To evaluate the effect of operative time on the risk of symptomatic venous thromboembolic events (VTEs) in patients undergoing robot-assisted radical prostatectomy (RARP).

Methods:

We reviewed the records of all patients at our institution who underwent RARP by a single surgeon from January 2007 until April 2011. Clinical and pathologic information and VTE incidence were recorded for each patient and analyzed by use of logistic regression to evaluate for association with VTE risk. All patients had mechanical prophylaxis, and beginning in February 2008, a single dose of unfractionated heparin, 5000 U, was administered before surgery.

Results:

A total of 549 consecutive patients were identified, with a median follow-up period of 8 months. During the initial 30 days postoperatively, 10 patients (1.8%) had a VTE (deep venous thrombosis in 7 and pulmonary embolism in 3). The median operative time was 177 minutes (range, 121–360 minutes). An increase in operative time of 30 or 60 minutes was associated with 1.6 and 2.8 times increased VTE risks. A 5-point increase in body mass index and need for blood transfusion were also associated with increased risk of VTEs (odds ratios of 2.0 and 11.8, respectively). Heparin prophylaxis was not associated with a significant VTE risk reduction but also was not associated with a significant increase in estimated blood loss (P = .23) or transfusion rate (P = .37).

Conclusion:

A prolonged operative time increases the risk of symptomatic VTEs after RARP. Future studies are needed to evaluate the best VTE prophylactic approach in patients at risk.

Risk of thromboembolic disease in men with prostate cancer undergoing androgen deprivation therapy

OBJECTIVES

To investigate the risk of thromboembolic disease (TED) in men with prostate cancer (PCa) on androgen deprivation therapy (ADT), while accounting for known TED risk factors.

MATERIALS AND METHODS

We assessed TED risk for 42 263 men with PCa who were receiving ADT compared with a matched cohort of 190 930 without PCa. The associations between ADT and deep vein thrombosis (DVT) or pulmonary embolism (PE) were analysed using multivariate Cox proportional hazard regression models, while accounting for previous PCa-related surgeries and the following proxies for disease progression: transurethral resection of the prostate, palliative radiotherapy and nephrostomy.

RESULTS

Between 1997 and 2013, 11 242 men with PCa received anti-androgen monotherapy, 26 959 men received gonadotropin-releasing hormone (GnRH) agonists, 1 091 men received combined androgen blockade and 3 789 men underwent orchiectomy. When accounting for previous surgeries and proxies of disease progression, GnRH agonist users and surgically castrated men had a higher risk of TED than the comparison cohort: hazard ratios (HRs) 1.67 (95% confidence interval [CI] 1.40-1.98) and 1.61 (95% CI 1.15-2.28), respectively. Men on anti-androgen monotherapy had a lower risk: HR for DVT 0.49 (95% CI 0.33-0.74). TED risk was highest among those who switched from anti-androgen to GnRH agonists: HR for PE 2.55 (95% CI 1.76-3.70). This increased from 2.52 (95% CI 1.54-4.12) in year 1, to 4.05 (95% CI 2.51-6.55) in year 2.

CONCLUSION

The incidence of TED among men on ADT increased with the duration of therapy and the risk was highest for those who switched regimen, suggesting that disease progression as well as ADT contribute to the propagation of TED risk. Nonetheless, these findings support the hypothesis that only men with a relevant indication should receive systemic ADT.

Highest risk of symptomatic venous thromboembolic events after radical cystectomy occurs in patients with obesity or nonurothelial cancers

CONTEXT

Venous thromboembolism (VTE) is a common cause of postoperative morbidity and mortality in cystectomy patients.

AIMS

The aim of this study is to identify variables associated with risk of developing deep venous thrombosis (DVT) or pulmonary embolism (PE) within 90 days after radical cystectomy (RC).

SETTING AND DESIGN

Retrospective chart review of patients undergoing RC from 2004 to 2011 at the University of Wisconsin.

SUBJECTS AND METHODS

Clinical variables collected for all RC patients. All patients received mechanical prophylaxis, and routine heparin prophylaxis began in 2010.

STATISTICAL ANALYSIS USED

Univariate and multivariate analyses were used to evaluate VTE association with known risk factors.

RESULTS

A total of 241 patients were identified with median age of 67.1 (interquartile range: 57.8-74.3) years. Body mass index (BMI) was ≥30 in 36.8% of patients. Median blood loss was 950 (600-1500) mL and 157/241 (65.2%) patients received a blood transfusion.

CONCLUSIONS

Patients with BMI ≥30 or nonurothelial cancer are at highest risk for postoperative VTE and should be considered for extended heparin prophylaxis.

How to minimize lymphoceles and treat clinically symptomatic lymphoceles after radical prostatectomy

The development of a lymphocele after pelvic surgery is a well-documented complication, especially where pelvic lymph node dissection (PLND) is part of the operation. However, not all lymphoceles are symptomatic and require treatment. Most lymphoceles spontaneously resolve, and even lymphoceles that become symptomatic may resolve without any intervention. Robotic assisted radical prostatectomy (RARP) is a common operation in urology where PLND is likely to be performed in intermediate and high-risk prostate cancer patients. The rationale for performing a PLND in prostate cancer is for accurate staging and potential therapeutic benefits. However, due to potential intraoperative and postoperative complications there is still a debate regarding the value of PLND in prostate cancer. In this review, we will discuss the potential risk factors to be aware of in pelvic surgery in order to minimize the formation of a lymphocele, along with the management for clinically significant lymphoceles.

National estimated costs of never events following radical prostatectomy

OBJECTIVE

To examine the Centers for Medicare and Medicaid Services, which since 2008 has identified and not reimbursed 10 common postoperative complications deemed "never events" or hospital-acquired conditions (HACs). Prostate cancer, the most frequent cancer among U.S. men, is most often treated with radical prostatectomy (RP). Therefore, its complications in total may represent significant costs to hospitals and providers if not reimbursed. We evaluated the potential effect of these unreimbursed HACs following RP on clinical outcomes and costs.

METHODS AND MATERIALS

Using the Nationwide Inpatient Sample, we selected a weighed, national, estimated sample of 451,707 men with prostate cancer who underwent RP between 2002 and 2009. Baseline sociodemographic and hospital characteristics are described. We calculated estimated frequencies and costs of HACs and the predictors of in-hospital mortality, prolonged length of stay, and increased total hospital costs.

RESULTS

Overall, HACs were infrequent at 0.08%, with pressure ulcer development (0.02%) and foreign object retained at surgery (0.02%) being the most common. HAC occurrence was not affected by hospital teaching status or surgical volume, but larger hospital size was related to more HACs. Those experiencing an HAC were much more likely to have a prolonged length of stay (odds ratio = 6.68, 95% CI: 5.34-8.36) and increased hospital costs (odds ratio = 5.03, 95% CI: 4.05-6.24). HACs after RP cost an estimated nearly $1 million annually in the United States.

CONCLUSION

In a robust sample of patients who underwent RP in the United States, HACs were very uncommon and contributed approximately $1 million in additional expenditures. As the U.S. government continues to expand quality improvement programs and develop incentives to avoid complications, efforts to monitor unnecessary complications should continue as well.

The cost of thromboembolic events in hospitalized patients with breast or prostate cancer in France

AIMS

The aim of the present study was to determine the number of admissions and the cost of hospital management of venous thromboembolism (VTE) events occurring in patients with breast cancer (BC) or prostate cancer (PC).

METHODS

The French national hospital database (PMSI) was analyzed to identify patients diagnosed with BC or PC in 2010 and followed for 2 years. The number of admissions for VTE (or with VTE occurring during hospitalization) and the corresponding number of patients hospitalized were determined using disease-specific International Classification of Diseases, 10th revision (ICD-10) codes. Associated hospital costs were estimated from the healthcare payer perspective, using the French official tariffs.

RESULTS

62,365 and 45,551 patients diagnosed with BC and PC, respectively, in 2010 were identified from PMSI data; 1,271 (2.0%) and 997 (2.2%) were hospitalized for or had VTE during hospitalization. During the 2 years of follow-up, 346 patients (15%) presented a recurrence of thrombosis requiring hospitalization. A total of 1,604 and 1,210 inpatient VTE-related admissions (stays) in the BC and PC cohorts, respectively, were analyzed. Pulmonary embolism (PE) was the most frequent diagnosis leading to hospital admission in those cancer patients, followed by deep venous thrombosis. Mean cost per admission was €3,302 and €2,916 for first event and recurrence, respectively, in BC patients (total cost €1.98 million over 2 years) and €3,611 and €3,363 for first event and recurrence in PC patients (total cost €1.43 million over 2 years). In patients who had at least one recurrence, mean hospitalization cost was €5,545 and €5,692 in BC and PC, respectively.

CONCLUSION

The burden of VTE in cancer patients is important; costs should be reduced by decreasing the occurrence of thrombotic recurrences. In this respect, better prevention and follow-up measures may reduce recurrence and VTE costs.

Deep venous thrombosis after major abdominal surgery in a Ugandan hospital: a prospective study

Background

Deep venous thrombosis (DVT) is a major cause of morbidity and mortality among postoperative patients. Its incidence has been reported to range between 16% and 38% among general surgery patients and may be as high as 60% among orthopaedic patients. The most important clinical outcome of DVT is pulmonary embolism, which causes about 10% of hospital deaths. In over 90% of patients, occurrence of DVT is silent and presents no symptoms until onset of pulmonary embolism and/or sudden death. The only effective way of guarding against this fatal condition is therefore prevention/prophylaxis. However, prophylaxis programs are usually based on the estimated prevalence of DVT in that particular community. There is currently no data concerning rates of postoperative DVT in Uganda.

The purpose of the study was therefore to determine the prevalence of DVT among postoperative patients at Mulago Uganda’s National Referral Hospital.

Methods

A cross sectional descriptive study was conducted between March and June 2011. Eligible patients were identified and screened and patient details were collected. Clinical examinations were done on postoperative days (PODs) 1, 2, and 4 and Doppler ultrasounds were done on POD 7 and POD 21 to assess for DVT. Patients found with DVT were treated appropriately according to local treatment guidelines.

Results

A total of 82 patients were recruited, 4/82 (5%) had DVT. The most common risk factor was cancer. The overall mean age was 45 years (range 20–83 years). The male to female ratio was 1.6:1. Participants with more than one risk factor for DVT were 16/82 (20%).

Conclusions

Prevalence of DVT among major post-abdominal surgery patients was low (5%). Cancer was the most common associated factor apart from surgery.

The need for a post-operative thromboembolic event registry? A five-year retrospective tertiary institution study of venothromboembolic events within 30 days of major urological surgery

Background:

Recent evidence has suggested that the use of extended (≤ 28 ± seven days) post-operative low-molecular-weight heparin (LMWH) therapy following major abdominal/pelvic surgery can significantly reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). However, there is still significant discordance as to optimal LMWH duration among general and urological surgeons. There is marked variation over prescribing practices within urological surgery, and prospective studies have not reached a consensus. We aimed to determine if there was a significant prevalence of symptomatic thromboembolic events post-major urological surgery.

Materials and methods:

A five-year retrospective audit of major urological cases undertaken in our institution sought to examine the number of vascular complications encountered within 30 ± seven days of surgery by patients on standard thromboprophylactic therapy.

Results:

A total of 439 major surgical cases were carried out, of which 79% were oncological. Ninety-three per cent of patients had at least one cardiovascular disease risk factor. There was one post-operative clinically evident DVT (0.22%) and no PEs in this cohort.

Conclusion:

Our results suggest that symptomatic thromboembolic events post-major urological surgery may be infrequent. However, there is the need for a comprehensive multi-centre prospective study to examine for thromboembolic events post-discharge. As such, we must recommend careful patient selection in determining who would benefit from extended thromboprophylaxis.

Impact of screening versus symptomatic measurement of deep vein thrombosis in a national quality improvement registry

BACKGROUND

Deep vein thrombosis (DVT) is a quality measure recorded by initiatives such as the National Surgical Quality Improvement Program (NSQIP). However, because surveillance-detected DVT rates may be higher than symptomatic DVT rates, we examined how differences in the method of DVT detection may affect the use of this quality measure.

METHODS

Using the NSQIP database (2007-2009), we compared DVT rates of vascular (amputation, open aortic procedures, and lower extremity bypass) and nonvascular (prostatectomy, gastric bypass [GBP], and hip arthroplasty) operations. Using a predefined literature search strategy, we compared the incidence of DVT in NSQIP to the incidence of DVT reported in published literature, diagnosed by symptomatic status or by surveillance studies.

RESULTS

Within NSQIP, the overall incidence of postoperative DVT was 0.7%. This varied from 0.3% after GBP to 1.8% after open aortic surgery. Across all procedures except amputation, the incidence of DVT in NSQIP was similar to the incidence of DVT reported in our literature survey of "symptomatic" DVTs. The relative rate (RR) of literature-derived symptomatic DVTs to NSQIP ranged from 0.7 for aortic cases (95% confidence interval [CI], 0.3-1.7) to 1.4 (95% CI, .7-3.1) for GBP. Overall, surveillance studies had 11.6 higher RR of DVT compared to NSQIP (95% CI, 10.5-13), ranging from 2.6 for GBP (95% CI, 1.4-5) to 14 .5 for hip arthroplasty (95% CI, 10.5-20).

CONCLUSIONS

The incidence of DVT reported in NSQIP is similar to the reported incidence of symptomatic DVT for many high-risk procedures but is much lower than rates of DVT reported in surveillance studies. Clear delineation of symptomatic vs surveillance detection of DVT would improve the usefulness of this measurement in quality improvement registries.

What do prostate cancer patients die of?

BACKGROUND

A recent rise in the incidence of prostate cancer and a more favorable outcome have increased the proportions of other causes of death in affected men. Extending the survival of prostate cancer patients thus requires knowledge of all causes of death.

METHODS

Data on the population, cancers, and causes of death were gathered from the nationwide Swedish Family-Cancer Database. A Cox regression model, comparing prostate cancer patients with all other men, was applied. Hazard ratios (HR) were calculated both for the underlying cause and for dying with a specific cause listed among multiple causes of death.

FINDINGS

Among 686,500 observed deaths, 62,500 were prostate cancer patients. For underlying causes other than prostate cancer, the highest cause-specific HRs were found for external causes (HR, 1.24; 95% confidence interval [CI], 1.16-1.31), diseases of the pulmonary circulation (HR, 1.22; 95% CI, 1.09-1.37), and heart failure (HR, 1.18; 95% CI, 1.11-1.24). For specific multiple causes, the highest HRs were found for anemia (HR, 2.28; 95% CI, 2.14-2.42), diseases of the pulmonary circulation (HR, 1.61; 95% CI, 1.55-1.68), and urinary system disease (HR, 1.90; 95% CI, 1.84-1.96).

INTERPRETATIONS

Prostate cancer patients have a higher risk for dying from various causes other than prostate cancer, including external causes and heart failure. Mechanisms have been proposed linking these elevated risks to both cancer and treatment. More attention should be paid to comorbidities in men with prostate cancer. The present study fulfills a gap in the knowledge of death causes in prostate cancer patients.