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Article of the Month: Guideline of Guidelines – Thromboprophylaxis for Urological Surgery

Every Month the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Kari Tikkinen, discussing his paper.

If you only have time to read one article this week, it should be this one.

Guideline of guidelines: thromboprophylaxis for urological surgery

Philippe D. Violette*, Rufus Cartwright†‡, Matthias Briel§, Kari A.O. Tikkinen¶ and Gordon H. Guyatt**,

 

*Division of Urology, Department of Surgery, Woodstock Hospital, Woodstock, ON, Canada, † Department of Epidemiology and Biostatistics, Imperial College London, London, UK, Department of Urogynaecology, St. MaryHospital, London, UK, §Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland, Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, **Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada, and ††Department of Medicine, McMaster University, Hamilton, ON, Canada

 

 

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 under-treatment 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.

AOTM Key Points

 

Editorial: Optimal Thromboprophylaxis Remains a Challenge

The ‘Guideline of guidelines: thromboprophylaxis for urological surgery’, published in this month’s issue of BJUI by Violette et al. [1], addresses a critical issue in urological practice and offers a comprehensive overview of available guidelines. Many urological surgeries, especially cancer surgeries, present a significant risk of thromboembolism, as well as bleeding. Therefore, urological surgeons should be well educated in the matter in order to be able to offer optimal prophylaxis to patients. Reading through the current recommendations and guidelines, one realises the wide variety of possible ways to risk stratify a patient, but also the large differences in opinions on how and when to offer prophylaxis. Consequently, even members within the same national society treat their patients in completely different ways.

The ideal recommendation will have to be individualised, taking thromboembolic and bleeding risk into account for each individual patient and specific surgery type. This stratification of patients not only presents a challenge in clinical practice but also for the design of meaningful clinical trials. As many medical questions regarding thromboprophylaxis remain unanswered, the currently available recommendations are based on our pathophysiological understanding and remain eminence-based, rather than evidence-based.

For many years, the ‘Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines’ [2] were viewed as the most respected guidelines in surgery. They include recommendations for a wide variety of surgical procedures, including urological surgeries. With an ageing population, our patients will more often be on anticoagulant treatment before surgery. While most guidelines still recommend stopping the anticoagulant treatment and bridging with heparin, new evidence from randomised controlled trials [3, 4] indicate that bridging by heparin significantly increases the risk for major bleeding without reducing the thromboembolic risk in most patients. Despite a recent appeal by internists and cardiologists [5], revised guidelines from the American College of Chest Physicians to replace the partially outdated recommendations have yet to be published. As mentioned by Violette et al. [1] in their current review, bridging should probably only be offered to a limited number of patients with a very high risk of thromboembolic complications.

The European Association of Urology has recognised the problem and presented the prospect of providing a guideline on thromboprophylaxis for urological procedures later this year. Looking at the landscape of available high-quality publications it will still be highly challenging to provide clear recommendations for urological surgeries. The key to a comprehensive application will be the clinical practicality. With this review, the authors have set the stage to a critical review of the recommendations from a urological point of view.

 

Daniel Eberli
University and University Hospital of Zurich, Zurich, Switzerland

 

References

 

1 Violette PD, Cartwright R, Briel M, Tikkinen KAO, Guyatt GHGuideline of guidelines: thromboprophylaxis for urological surgery. BJU Int 2016; 118: 35158

 

 

 

4 Douketis JD, Spyropoulos AC, Kaatz S et al. Perioperative bridging anticoagulation in patients with atrial brillation. N Engl J Med 2015; 373: 82333

 

 

6 Devereaux PJ, Mrkobrada M, Sessler DI et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014; 370: 1494503

 

Video: Guideline of Guidelines – Thromboprophylaxis for Urological Surgery

Guideline of guidelines: thromboprophylaxis for urological surgery

Philippe D. Violette*, Rufus Cartwright†‡, Matthias Briel§, Kari A.O. Tikkinen¶ and Gordon H. Guyatt**,

 

*Division of Urology, Department of Surgery, Woodstock Hospital, Woodstock, ON, Canada, † Department of Epidemiology and Biostatistics, Imperial College London, London, UK, Department of Urogynaecology, St. MaryHospital, London, UK, §Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland, Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, **Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada, and ††Department of Medicine, McMaster University, Hamilton, ON, Canada
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 under-treatment 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.

 

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