Venous thromboembolism can occur months after radical cystectomy
By Will Boggs MD
NEW YORK (Reuters Health) - Most venous thromboembolism (VTE) events following radical cystectomy occur in the months after hospital discharge, and there are few preventable risk factors, researchers from Canada report.
"Many VTE events were found after discharge from hospital and were quite frequent out to three months (much higher proportion had delayed events during recovery from this complex surgery than I would have thought)," Dr. D. Robert Siemens from Queen's University in Kingston, Ontario, told Reuters Health by email.
The reported incidence of VTE after radical cystectomy ranges from 3% to 24%, and the risk is known to extend beyond discharge from the hospital. More detailed information is lacking, however.
Dr. Siemens's team evaluated the timing and risk factors associated with VTE up to 90 days after surgery using data from the Ontario Cancer Registry linked to treatment and surgical pathology records.
Among nearly 3,900 patients who underwent radical cystectomy, 3.6% had VTE within one month, 4.7% had VTE within two months, and 5.4% had VTE within three months after their surgical admission date.
Overall, 55% of patients with VTE presented after discharge from the hospital, with 21.5% of those presenting in the first week and 17.2% in the second week following discharge, the researchers report in BJU International, online March 7.
Patients who developed VTE within 90 days after surgical admission had 35% higher risk of cancer-specific mortality and 27% higher risk of overall mortality, even after controlling for other factors.
In multivariate analysis, higher surgical volume and increased length of hospital stay were the only significant predictors of VTE. Anticoagulation therapy was not associated with the risk of VTE, but only a minority of patients received anticoagulants.
"This confirmed in our minds that all patients should be considered for extended (one month) prophylactic therapy given this data after this complex and morbid surgery," Dr. Siemens said.
"There are some questions unanswered by our data and that of others and that is the role that perioperative chemotherapy might play in this context," he added. "This is something we are interested in figuring out with future work."
Dr. Dean Bajorin from Memorial Sloan Kettering Cancer Center, New York, told Reuters Health by email, "We, like others, thought that prophylactic anticoagulation may be a consideration. However, this means that the majority of patients would receive anticoagulation unnecessarily. Many of these patients have highly vascular bladder tumors that can actively bleed, precluding the prophylactic use of anticoagulation."
"Therefore," said Dr. Bajorin, who was not involved in the study, "we are in the midst of a large-scale study of almost 1,000 patients to determine whether some patients are more susceptible to VTE based on their germline genetics. If successful, we might be able to genetically type patients in advance, identify those most likely to develop thrombotic events prior to treatment, and consider these high-risk patients for anticoagulation."
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