Guideline of guidelines: thromboprophylaxis for urological surgery

Abstract

Decisions regarding thromboprophylaxis in urologic surgery involve a trade-off between decreased risk of venous thromboembolism (VTE) and increased risk of bleeding. Both patient-and procedure-specific factors are critical in making an informed decision on the use of thromboprophylaxis. Our systematic review of the literature revealed that existing guidelines in urology are limited. Recommendations from national and international guidelines often conflict and are largely based on indirect as opposed to procedure-specific evidence. These issues have likely contributed to large variation in the use of VTE prophylaxis within and between countries. The majority of existing guidelines typically suggest prolonged thromboprophylaxis for high-risk abdominal or pelvic surgery, without clear clarification of what these procedures are, for up to 4 weeks post-discharge. Existing guidance may result in the undertreatment of procedures with low risk of bleeding and the over-treatment of oncological procedures with low risk of VTE. Guidance for patients who are already anticoagulated are not specific to urological procedures but generally involve evaluating patient and surgical risks when deciding on bridging therapy. The European Association of Urology Guidelines Office has commissioned an ad hoc guideline panel that will present a formal thromboprophylaxis guideline for specific urological procedures and patient risk factors.

Systematic reviews of observational studies of risk of thrombosis and bleeding in urological surgery (ROTBUS): introduction and methodology

“…Each year, millions of patients who undergo urological surgery incur the risk of deep vein thrombosis and pulmonary embolism, together referred to as venous thromboembolism (VTE), and major bleeding. Because pharmacological prophylaxis decreases the risk of VTE, but increases the risk of bleeding, and because knowledge of the magnitude of these risks remains uncertain, both clinical practice and guideline recommendations vary widely [1]. One of the uncertainties is the recommended duration of pharmacological thromboprophylaxis.…”

Venous thromboembolism prophylaxis in urology: A review

“…The AUA has published a best practice statement in 2009 and the European Association of Urology guidelines are currently pending. Multiple other regional and organizational guidelines are available, but are mainly based on recommendations from panel experts . Overall, most recommendations state that low‐risk categories need no prophylaxis or solely mechanical prophylaxis.…”

“…Moderate‐risk categories can either have mechanical or pharmacological prophylaxis. The high‐risk category should have both mechanical and pharmacological prophylaxis, and extended prophylaxis should be considered (Table ) . Adherence to mechanical prophylaxis ranges from 53.5% to 75% in a meta‐analysis .…”

“…Multiple other regional and organizational guidelines are available, but are mainly based on recommendations from panel experts. 39 Overall, most recommendations state that low-risk categories need no prophylaxis or solely mechanical prophylaxis. Moderate-risk categories can either have mechanical or pharmacological prophylaxis.…”

“…The high-risk category should have both mechanical and pharmacological prophylaxis, and extended prophylaxis should be considered (Table 1). 14,20,30,39 Adherence to mechanical prophylaxis ranges from 53.5% to 75% in a metaanalysis. 40 However, compliance with pharmacological prophylaxis even in high-risk patients is relatively poor.…”