Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, ON, Canada.
Eur Urol. 2018 Feb;73(2):242-251. doi: 10.1016/j.eururo.2017.03.008. Epub 2017 Mar 23.
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).
To provide estimates of the baseline risk of symptomatic VTE and bleeding requiring reoperation in urological cancer surgery.
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.
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%.
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.
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.
药物性血栓预防需要权衡静脉血栓栓塞症（VTE）风险降低与出血风险增加之间的关系，这一权衡取决于预防治疗前（基线风险）VTE 和出血的风险。
提供泌尿外科癌症手术后有症状 VTE 和需要再次手术的出血的基线风险估计值。
我们确定了报告泌尿外科手术后有症状 VTE 或出血的当代观察性研究。我们使用了风险最低的研究，并考虑了血栓预防和随访时间，以在术后 4 周内得出基线风险的最佳估计值。我们使用 GRADE 方法评估证据质量。
我们纳入了 71 项报告 14 种泌尿外科癌症手术的研究。前列腺切除术和膀胱癌切除术的证据质量通常为中度，其他手术的证据质量为低或极低。血栓预防的持续时间高度可变。膀胱癌切除术的 VTE 风险较高（风险组间为 2.6%-11.6%），而出血风险较低（0.3%）。前列腺切除术的 VTE 风险因手术方式而异，从无盆腔淋巴结清扫术（PLND）的机器人前列腺切除术的 0.2%-0.9%到广泛 PLND 的开放性前列腺切除术的 3.9%-15.7%。出血风险为 0.1%-1.0%。肾手术的 VTE 风险在低危患者中为 0.7%-2.9%，高危患者中为 2.6%-11.6%；出血风险为 0.1%-2.0%。
某些手术（例如开放性和机器人膀胱癌切除术）需要延长血栓预防，但其他手术（例如低危患者的无 PLND 机器人前列腺切除术）则不需要。对于“接近危险”的手术，决策将取决于 VTE 和出血方面的价值观和偏好。
临床医生经常给接受泌尿外科癌症手术的患者使用血液稀释剂以预防血栓形成。不幸的是，血液稀释剂也会增加出血风险。本研究提供了关于血栓形成和出血风险的信息，这对于决定是否使用血液稀释剂至关重要。
