Guidelines, however, recommend DVT prophylaxis for patients undergoing laparoscopic or robotic radical prostatectomy. These have been established primarily based upon other types of surgeries and associated risks. In the online version of European Urology, Dr. Secin and 14 surgeons from 13 European and American institutions suggest that the guidelines should perhaps be modified.

Investigators reviewed their databases for any diagnosis of DVT of PE established in patients operated upon between 1995 and 2006. The diagnoses of DVT or PE were by local institutional criteria as were prophylaxis and treatment guidelines. A venous thromboembolism (VTE) was considered surgically related if it occurred within 90 days of surgery.

In the cohort of 5951 participants, 27 had a DVT (0.5%), 9 experienced a PE (0.2%), and 5 (16%) of these had both a DVT and PE. The incidence of VTE was 0.5%. Two patients died both due to a PE. Most DVT events occurred in the calf and femoral veins. The median time from radical prostatectomy to DVT was 10 days. Treatment of the 27 DVT patients included anti-coagulation in 25, observation in 1, and 1 unspecified. Five of the 27 DVT patients developed a PE and one had chest surgery to remove atrial clots and survived but the other died. Four men had a PE without evidence of DVT by imaging and one of these died.

Variables associated with VTE were evaluated. All patients used graduated compression stockings or pneumatic compression devices; however, heparin prophylaxis usage was variable with 67% of men getting some form of heparin. Heparin was administered preoperatively in 84% of those who received it. Univariate analysis of pre-operative risk factors found that symptomatic VTE was associated with a history of prior DVT or current tobacco use. Peri-operative risks included patient re-exploration, operating time, and length of hospital stay. Prostate volume <100cc was not associated with VTE but larger prostates were and this was likely related to length of surgery. The incidence of VTE did not differ with laparoscopic vs. robotic assisted approaches or for the inclusion of a pelvic lymphadenectomy.

The authors extrapolated the benefit of using heparin. They state that there is a 20% reduction in relative risk of asymptomatic DVT with heparin prophylaxis in open prostatectomy. Applying the 0.5% risk in this series would mean that the absolute risk reduction from heparin use would be 20% x 0.5%, or 0.1%. They also note that patients who received heparin, beginning preoperatively, had a significantly greater blood loss (300cc) compared to those who received no heparin (200cc). Heparin administration was also associated with longer hospital stay, higher transfusion rates, and higher reoperation rates. They conclude that use of heparin prophylaxis is only warranted in high risk patients (prior VTE, current tobacco use, extended operating time, and those undergoing reoperation). Age over 60 years and obesity, shown to be risk factors in other studies were not significant in this report.

Secin FP, Jiborn T, Bjartell AS, Fournier G, Salomon L, Abbou CC, Haber GP, Gill IS, Crocitto LE, Nelson RA, Cansino Alcaide JR, Martínez-Piñeiro L, Cohen MS, Tuerk I, Schulman C, Gianduzzo T, Eden C, Baumgartner R, Smith JA, Entezari K, van Velthoven R, Janestschek G, Serio AM, Vickers AJ, Touijer K, Guillonneau B

Eur Urol. ePub, June 13, 2007
DOI: 10.1016/j.eururo.2007.05.028

UroToday.com Prostate Cancer Section

Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

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