Procedure-specific Risks of Thrombosis and Bleeding in Urological Non-cancer Surgery: Systematic Review and Meta-analysis

Pharmacological thromboprophylaxis involves a trade-off between a reduction in venous thromboembolism (VTE) and increased bleeding. No guidance specific for procedure and patient factors exists in urology.

To inform estimates of absolute risk of symptomatic VTE and bleeding requiring reoperation in urological non-cancer surgery.

We searched for contemporary observational studies and estimated the risk of symptomatic VTE or bleeding requiring reoperation in the 4 wk after urological surgery. We used the GRADE approach to assess the quality of the evidence.

The 37 eligible studies reported on 11 urological non-cancer procedures. The duration of prophylaxis varied widely both within and between procedures; for example, the median was 12.3 d (interquartile range [IQR] 3.1-55) for open recipient nephrectomy (kidney transplantation) studies and 1 d (IQR 0-1.3) for percutaneous nephrolithotomy, open prolapse surgery, and reconstructive pelvic surgery studies. Studies of open recipient nephrectomy reported the highest risks of VTE and bleeding (1.8-7.4% depending on patient characteristics and 2.4% for bleeding). The risk of VTE was low for 8/11 procedures (0.2-0.7% for patients with low/medium risk; 0.8-1.4% for high risk) and the risk of bleeding was low for 6/7 procedures (≤0.5%; no bleeding estimates for 4 procedures). The quality of the evidence supporting these estimates was low or very low.

Although inferences are limited owing to low-quality evidence, our results suggest that extended prophylaxis is warranted for some procedures (eg, kidney transplantation procedures in high-risk patients) but not others (transurethral resection of the prostate and reconstructive female pelvic surgery in low-risk patients).

The best evidence suggests that the benefits of blood-thinning drugs to prevent clots after surgery outweigh the risks of bleeding in some procedures (such as kidney transplantation procedures in patients at high risk of clots) but not others (such as prostate surgery in patients at low risk of clots).

European urology. 2017 Mar 08 [Epub ahead of print]

Kari A O Tikkinen, Samantha Craigie, Arnav Agarwal, Reed A C Siemieniuk, Rufus Cartwright, Philippe D Violette, Giacomo Novara, Richard Naspro, Chika Agbassi, Bassel Ali, Maha Imam, Nofisat Ismaila, Denise Kam, Michael K Gould, Per Morten Sandset, Gordon H Guyatt

Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. Electronic address: ., Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, ON, Canada., Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; School of Medicine, University of Toronto, Toronto, ON, Canada., Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada., Department of Epidemiology and Biostatistics, Imperial College London, London, UK; Department of Urogynaecology, St Mary's Hospital, London, UK., Department of Surgery, Division of Urology, Woodstock General Hospital, Woodstock, ON, Canada; McMaster Department of Surgery Division of Urology, Hamilton, ON, Canada., Department of Surgical, Oncological, and Gastroenterological Sciences, Urology Clinic, University of Padua, Padua, Italy., Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy., Department of Oncology, McMaster University, Hamilton, ON, Canada., Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada., Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Faculty of Pharmacy, University of Waterloo, Kitchener, ON, Canada., Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA., Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Haematology, Oslo University Hospital, Oslo, Norway., Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.

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