Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Brigham and Women's Hospital, Boston, MA, USA.
Eur Urol Focus. 2020 Jan 15;6(1):74-80. doi: 10.1016/j.euf.2018.08.025. Epub 2018 Sep 15.
Novel venous thromboembolism (VTE) prophylaxis programs, including postdischarge pharmacologic prophylaxis, have been associated with decreased VTE rates. Such practices have not been widely adopted in managing radical cystectomy (RC) patients.
To evaluate the effect of a perioperative VTE prophylaxis program on VTE rates after RC.
DESIGN, SETTING, AND PARTICIPANTS: Single-institution, nonrandomized, pre- and post-intervention analysis of 319 patients undergoing RC at Brigham and Women's Hospital between July 2011 and April 2017. Patient and outcome data were prospectively collected as part of the American College of Surgeons National Surgical Quality Improvement Program.
Before June 2015, patients only received postoperative pharmacologic and mechanical VTE prophylaxis in the inpatient setting. Starting June 2015, a perioperative VTE prophylaxis program was implemented as part of an enhanced recovery after surgery (ERAS) protocol, including a 28-d course of postdischarge enoxaparin.
Primary outcome was 30-d postoperative VTE rate. Secondary outcomes were perioperative bleeding rates, 30-d complication, readmission, and mortality rates, and length of stay. Univariate analysis was performed comparing outcomes between pre- and post-intervention cohorts.
Of the 319 patients who underwent RC, 210 (66%) were in the pre- and 109 (34%) in the post-intervention cohort. VTE rate was significantly lower in the post-intervention cohort (n=1, 0.9% vs n=13, 6.2%; p=0.04). Rates of perioperative bleeding (35% vs 33%; p=0.80) and 30-d readmissions related to bleeding (1% vs 3.7%; p=0.19) did not differ significantly. Single-institution data limits generalizability, and patient compliance with postdischarge enoxaparin was unknown.
Implementation of a perioperative VTE prophylaxis program as part of an ERAS protocol that includes extended postdischarge pharmacologic prophylaxis was associated with decreased rate of VTE events after RC. Perioperative bleeding and readmissions related to bleeding did not increase with this intervention.
This study evaluated whether clotting complication rates after radical cystectomy (RC) for bladder cancer can be reduced by implementing a new postoperative care pathway. This pathway reduced rates of clotting complications without increasing bleeding rates and should be considered for all patients undergoing RC.
新型静脉血栓栓塞症（VTE）预防方案，包括出院后药物预防，已与 VTE 发生率降低相关。这些做法在管理根治性膀胱切除术（RC）患者中尚未得到广泛应用。
评估围手术期 VTE 预防方案对 RC 后 VTE 发生率的影响。
设计、地点和参与者：对 2011 年 7 月至 2017 年 4 月期间在布莱根妇女医院接受 RC 的 319 例患者进行了单机构、非随机、干预前后分析。患者和结局数据作为美国外科医师学院国家外科质量改进计划的一部分进行了前瞻性收集。
在 2015 年 6 月之前，患者仅在住院期间接受术后药物和机械性 VTE 预防。自 2015 年 6 月起，作为术后恢复增强（ERAS）方案的一部分，实施了围手术期 VTE 预防方案，包括 28 天的出院后依诺肝素疗程。
术后 30 天的 VTE 发生率。次要结局指标为围手术期出血率、30 天并发症、再入院和死亡率以及住院时间。采用单变量分析比较干预前后队列的结局。
在接受 RC 的 319 例患者中，210 例（66%）为干预前队列，109 例（34%）为干预后队列。干预后队列的 VTE 发生率显著降低（n=1，0.9%vs n=13，6.2%；p=0.04）。围手术期出血率（35%vs 33%；p=0.80）和与出血相关的 30 天再入院率（1%vs 3.7%；p=0.19）无显著差异。单机构数据限制了其普遍性，并且无法确定患者对出院后依诺肝素的依从性。
作为 ERAS 方案的一部分实施围手术期 VTE 预防方案，包括延长出院后药物预防，与 RC 后 VTE 事件发生率降低相关。该干预措施并未增加与出血相关的围手术期出血和再入院率。
本研究评估了为膀胱癌患者实施新的术后护理途径是否可以降低 RC 后凝血并发症的发生率。该途径降低了血栓并发症的发生率，而没有增加出血率，应考虑用于所有接受 RC 的患者。
