Procedure-specific Risks of Thrombosis and Bleeding in Urological Cancer Surgery: Systematic Review and Meta-analysis

Kari A O Tikkinen; Samantha Craigie; Arnav Agarwal; Philippe D Violette; Giacomo Novara; Rufus Cartwright; Richard Naspro; Reed A C Siemieniuk; Bassel Ali; Leyla Eryuzlu; Johanna Geraci; Judi Winkup; Daniel Yoo; Michael K Gould; Per Morten Sandset; Gordon H Guyatt

doi:10.1016/j.eururo.2017.03.008

Procedure-specific Risks of Thrombosis and Bleeding in Urological Cancer Surgery: Systematic Review and Meta-analysis

Eur Urol. 2018 Feb;73(2):242-251. doi: 10.1016/j.eururo.2017.03.008. Epub 2017 Mar 23.

Authors

Kari A O Tikkinen¹, Samantha Craigie², Arnav Agarwal³, Philippe D Violette⁴, Giacomo Novara⁵, Rufus Cartwright⁶, Richard Naspro⁷, Reed A C Siemieniuk⁸, Bassel Ali⁹, Leyla Eryuzlu³, Johanna Geraci⁹, Judi Winkup⁹, Daniel Yoo³, Michael K Gould¹⁰, Per Morten Sandset¹¹, Gordon H Guyatt¹²

Affiliations

¹ Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. Electronic address: kari.tikkinen@gmail.com.
² Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, ON, Canada.
³ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; School of Medicine, University of Toronto, Toronto, ON, Canada.
⁴ Department of Surgery, Division of Urology, Woodstock General Hospital, Woodstock, ON, Canada; McMaster Department of Surgery Division of Urology, Hamilton, ON, Canada.
⁵ Department of Surgical, Oncological, and Gastroenterological Sciences, Urology Clinic, University of Padua, Padua, Italy.
⁶ Department of Epidemiology and Biostatistics, Imperial College London, London, UK; Department of Urogynaecology, St Mary's Hospital, London, UK.
⁷ Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy.
⁸ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada.
⁹ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
¹⁰ Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
¹¹ Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Haematology, Oslo University Hospital, Oslo, Norway.
¹² Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.

PMID: 28342641
DOI: 10.1016/j.eururo.2017.03.008

Abstract

Context: Pharmacological thromboprophylaxis involves balancing a lower risk of venous thromboembolism (VTE) against a higher risk of bleeding, a trade-off that critically depends on the risks of VTE and bleeding in the absence of prophylaxis (baseline risk).

Objective: To provide estimates of the baseline risk of symptomatic VTE and bleeding requiring reoperation in urological cancer surgery.

Evidence acquisition: We identified contemporary observational studies reporting symptomatic VTE or bleeding after urological procedures. We used studies with the lowest risk of bias and accounted for use of thromboprophylaxis and length of follow-up to derive best estimates of the baseline risks within 4 wk of surgery. We used the GRADE approach to assess the quality of the evidence.

Evidence synthesis: We included 71 studies reporting on 14 urological cancer procedures. The quality of the evidence was generally moderate for prostatectomy and cystectomy, and low or very low for other procedures. The duration of thromboprophylaxis was highly variable. The risk of VTE in cystectomies was high (2.6-11.6% across risk groups) whereas the risk of bleeding was low (0.3%). The risk of VTE in prostatectomies varied by procedure, from 0.2-0.9% in robotic prostatectomy without pelvic lymph node dissection (PLND) to 3.9-15.7% in open prostatectomy with extended PLND. The risk of bleeding was 0.1-1.0%. The risk of VTE following renal procedures was 0.7-2.9% for low-risk patients and 2.6-11.6% for high-risk patients; the risk of bleeding was 0.1-2.0%.

Conclusions: Extended thromboprophylaxis is warranted in some procedures (eg, open and robotic cystectomy) but not others (eg, robotic prostatectomy without PLND in low-risk patients). For "close call" procedures, decisions will depend on values and preferences with regard to VTE and bleeding.

Patient summary: Clinicians often give blood thinners to patients to prevent blood clots after surgery for urological cancer. Unfortunately, blood thinners also increase bleeding. This study provides information on the risk of clots and bleeding that is crucial in deciding for or against giving blood thinners.

Keywords: Baseline risk; Bleeding; Modeling; Reporting; Risk of bias; Thromboprophylaxis; Urology; Venous thromboembolism.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't
Systematic Review

MeSH terms

Humans
Postoperative Complications / epidemiology*
Postoperative Hemorrhage / epidemiology*
Risk Assessment
Urologic Neoplasms / surgery*
Urologic Surgical Procedures
Venous Thromboembolism / epidemiology*

Grants and funding

Medical Research Council/United Kingdom