Faculty of Medical Sciences, UCL Medical School, University College London, London, UK.
Department of Urology, Lister Hospital, Stevenage, UK.
BJU Int. 2019 Dec;124(6):935-944. doi: 10.1111/bju.14906. Epub 2019 Oct 10.
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.
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.
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.
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.
静脉血栓栓塞症（VTE）包括肺栓塞（PE）和深静脉血栓形成（DVT），仍然是大泌尿科癌症手术后公认的并发症。几项国际指南建议使用低分子肝素（LMWH）进行延长血栓预防（ETP），其中分娩期延长至出院后期间，大部分 VTE 发生在此期间。在本文献综述中，我们调查了 ETP 是否应适用于所有接受大泌尿科癌症手术的患者，以及可能影响临床医生决策的特定手术数据。
我们对六个数据库（PubMed、Cochrane、EMBASE、Cumulative Index to Nursing and Allied Health Literature（CINAHL）、PsycINFO 和 British Nursing Index（BNI））进行了搜索，从开始到 2019 年 6 月，以寻找接受大泌尿科恶性肿瘤手术后接受 VTE 预防的成年患者的研究。
分析了 18 项研究。开放式和机器人根治性膀胱切除术（RC）的 VTE 风险最高（2.6-11.6%），ETP 可显著降低 VTE 风险，但对 PE 或死亡率无显著差异。开放式根治性前列腺切除术（RP）（0.8-15.7%）的 VTE 风险与 RC 相当，但机器人 RP（0.2-0.9%）、开放式部分/根治性肾切除术（1.0-4.4%）和机器人部分/根治性肾切除术（0.7-3.9%）的风险较低。尚未表明 ETP 可特异性降低 RP 或肾切除术的 VTE 风险。
使用 ETP 的决定是在 VTE 发生率、出血风险和围手术期发病率/死亡率等变量之间的微妙平衡。应根据每个特定手术类型评估这种平衡。虽然 ETP 对开放式 RP 以及开放式和机器人 RC 仍然具有净效益，但对于微创 RP 以及根治性和部分肾切除术，平衡更为接近。由于缺乏针对 ETP 使用的特定手术证据，对国家指南的依从性仍然很差。因此，我们主张进行更多的研究，直接比较 ETP 与标准预防措施，对于特定的手术类型，以便将来让临床医生做出更明智的决策。
