CUA: VTE Prophylaxis (2019)

See Original Guideline

Background

• Decisions regarding thromboprophylaxis involve a trade-off, in which the intended purpose is to decrease the risk of VTE while recognizing that thromboprophylaxis also increases the risk of bleeding
• To judge the net benefit of VTE prophylaxis, one must know the surgery-specific baseline risk of VTE and major bleeding. For a given procedure the baseline risk of VTE may be further increased by patient factors.
• The incidence of VTE is highest and roughly linear in the first four weeks after surgery and reduces substantially thereafter; the incidence of major bleeding is highest on the day of surgery and decreases rapidly over the next 5 days
• The panel adapted or endorsed recently published EAU guidelines on the same topic

Recommendations for use of VTE prophylaxis in urological surgery

• See Table from Original Guideline for summary of CUA recommendations for postoperative VTE prophylaxis
• The following recommendations apply to the use of LMWH as a prophylactic agent, starting the morning after surgery and CONTINUING FOR 28 DAYS as compared to not giving any pharmacological prophylaxis.
• Risk factors for VTE (4):
  1. Age > 75 (2x risk)
  2. BMI ≥35(2x risk)
  3. VTE in 1st degree relative (parents, full siblings, or children) (2x risk)
  4. Personal history of VTE (4x risk)
• Risk stratification
  • Low-risk: no risk factors
  • Moderate-risk: any 1 risk factor (other than personal history of VTE (high-risk))
  • High-risk: ≥2 risk factors or personal history of VTE
• Summary of patients recommended to receive VTE prophylaxis (guidelines specify “recommend” over “suggest”)
  • Oncologic surgery
    • All patients and procedures: suggest use of mechanical prophylaxis
    • Summary of pharmacologic prophylaxis recommendations:
      • Radical cystectomy: all patients
      • Radical prostatectomy
        • Open
          • All patients except low-risk undergoing RP without extended lymph node dissection
        • Laparoscopic/Robotic
          • High-risk with extended lymph node dissection
      • Nephrectomy
        • Laparoscopic/robotic
          • High-risk with partial nephrectomy
  • Non-oncologic surgery
    • None; though high-risk patients undergoing donor nephrectomy, nephrectomy for benign disease, or renal transplant are suggested to receive pharmacological and mechanical prophylaxis

• Detailed recommended for VTE prophylaxis
  • Oncologic surgery
    • Bladder (radical cystectomy (open or robotic))
      • All patients: recommend pharmacological prophylaxis
    • Prostate (radical prostatectomy)
      • Stratified based on approach (open vs. lap/robotic) and extent of lymph node dissection
        • No lymph node dissection
        • Standard dissection (node of Cloquet, along external iliac vein to the bifurcation of the internal and external iliac, and obturator fossa)
        • Extended dissection (standard dissection and dissection above bifurcations of iliac vessels or including presacral, precaval, or preaortic nodes)
      • Open radical prostatectomy
        • Without extended lymph node dissection:
          • Low-risk: suggest pharmacological prophylaxis
          • Moderate or high-risk: recommend pharmacological prophylaxis
        • With extended lymph node dissection:
          • All patients: recommend pharmacological prophylaxis
      • Robotic or laparoscopic radical prostatectomy
        • Without lymph node dissection:
          • Low-risk: recommend against use of pharmacological prophylaxis
          • Moderate or high-risk: suggest against use of pharmacological prophylaxis
        • With standard lymph node dissection
          • Low-risk: recommend against use of pharmacological prophylaxis
          • Moderate-risk: suggest against use of pharmacological prophylaxis
          • High-risk: suggest use of pharmacological prophylaxis
        • With extended lymph node dissection
          • Low-risk: suggest against use of pharmacological prophylaxis
          • Moderate-risk: suggest use of pharmacological prophylaxis
          • High-risk: recommend use of pharmacological prophylaxis
    • Kidney
      • Open (RN, PN, nephroureterectomy)
        • All patients: suggest use of pharmacological prophylaxis
      • Laparoscopic renal surgery for cancer
        • Radical nephrectomy or laparoscopic nephroureterectomy
          • Low or moderate-risk: suggest against use of pharmacological prophylaxis
          • High-risk: suggest use of pharmacological prophylaxis
        • Partial nephrectomy
          • Low or moderate-risk: suggest against use of pharmacological prophylaxis
          • High-risk: recommend use of pharmacological prophylaxis
        • Robotic renal surgery
          • Partial nephrectomy
            • Low-risk: suggest against use of pharmacological prophylaxis
            • Moderate-risk: suggest use of pharmacological prophylaxis
            • High-risk: recommend use of pharmacological prophylaxis
    • RPLND (primary or post-chemotherapy)
      • All patients: suggest pharmacological prophylaxis
  • Non-oncological surgery
    • Ambulatory day surgery, TURP, continence, or prolapse surgery
      • All patients: recommend against pharmacological prophylaxis and suggest against use of mechanical prophylaxis
    • TURP, continence or prolapse surgery
      • All patients: suggest against use of pharmacological use and suggest against use of mechanical prophylaxis
    • Donor nephrectomy, nephrectomy for benign disease, renal transplant
      • Low or moderate-risk: suggest against use of pharmacological prophylaxis and suggest against
      • High-risk: suggest use of pharmacological and mechanical prophylaxis

Recommendations for bridging of anticoagulation and antiplatelet agents

• See Table (no direct link available) from Original Guideline on summary of CUA recommendations for peri-procedure management of anticoagulants and antiplatelet agents
• Patients are considered to be at very high risk of thrombosis if any 1 of the following are present:
  1. Drug-eluting stent placement within 6 months
  2. Bare metal stent placement within 6 weeks
  3. Transient ischemic attack (TIA) stroke within 30 days
  4. New incidence of VTE within 1 month
  5. Severe thrombophilia (such as antithrombin deficiency, antiphospholipid antibody, or other as identified by appropriate specialist)
  6. Cage-ball mechanical heart valves
• In patients receiving an antiplatelet agent (e.g. aspirin, clopidogrel, ticagrelor) who do not have a very high risk of thrombosis (see above) the panel recommends stopping antiplatelet agents 7 days prior to surgery without bridging and restarting antiplatelet therapy 4 days post-surgery as compared to a longer period off therapy
• In patients receiving an anticoagulant agent (see example below) who do not have very high risk of thrombosis, the panel recommends stopping prior to surgery without bridging therapy and restarting 4 days post-surgery as compared to a longer period off therapy. The recommended duration off anticoagulation prior to surgery varies by therapy as follows:
  • Direct oral anti-coagulant (DOAC) (dabigatran, apixaban, edoxaban, rivaroxaban) 3 days prior;
    • Note: Renal function may affect DOAC clearance and prolong anticoagulant activity. For patients with impaired renal function, DOAC may need to be stopped longer than 3 days prior to surgery.
  • Warfarin 5 days prior
  • LMWH (therapeutic dosing) 12 hours (if twice daily dosing) or 24 hours (if once daily dosing) prior
  • Fondaparinux 24 hours prior
• Patients at very high risk of thrombosis in whom surgery can be delayed until the period of very high risk is completed should have surgery delayed until the period of very high risk is over
• For patients at very high risk of thrombosis in whom surgery cannot be delayed, our panel recommends multidisciplinary discussion and an individualized treatment plan