Canadian Urological Association guideline on perioperative thromboprophylaxis and management of anticoagulation

Abstract

Surgery exposes patients to a risk of venous thromboembolism (VTE) and bleeding. VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE), which represent serious and sometimes fatal consequences of surgery. Therefore, optimizing treatment plans to reduce VTE risk while also minimizing bleeding risk is important to patients and the healthcare system. The goal of this Canadian Urological Association (CUA) guideline is to provide a structured approach to the prevention of perioperative thromboembolic events that may be applied in Canada. In this guideline, two forms of perioperative VTE prophylaxis are considered. The first is prophylaxis used for primary prevention VTE for patients undergoing surgery. The second is management of an anticoagulant or antiplatelet agent used for treatment or as a form of secondary prevention during the perioperative period. The CUA thromboprophylaxis guideline panel feels that it is important for urologists to be engaged in the discussion and management in each of these situations. The panel recognizes that in many clinical contexts, other specialists, including internists, cardiologists, neurologists, and hematologists, may also be involved in this aspect of patient care. The guidance provided in this document is intended to help urologists engage with their patients and colleagues in a collaborative context. The guidance provided in this document is intended to reflect best practice for the usual case for a specific surgery and patient population. This guideline is not intended for unusual conditions or circumstances, which are typically rare, and should be addressed involving appropriate specialists on a case-by-case basis. Decisions regarding thromboprophylaxis involve a tradeoff, in which the intended purpose is to decrease the risk of VTE while recognizing that thromboprophylaxis also increases the risk of bleeding. A systematic review and meta-analysis of randomized placebo-controlled trials performed for the American College of Chest Physicians VTE guideline reported that VTE prophylaxis decreases the relative risk of VTE by 50% and increases the relative risk of bleeding by 50%.1 In cases where the risk of VTE is high and the bleeding risk is low, VTE prophylaxis is usually warranted because the net benefit is favourable. When the risk of VTE is low and the bleeding risk is high, VTE prophylaxis may be harmful and is usually not warranted. In many cases, the tradeoff between VTE prevention and bleeding risk may be close and the “most favourable” approach to VTE prophylaxis is less clear. In these situations, individual patient values and preferences must be considered to determine the best management plan (Fig. 1). Open in a separate window Fig. 1 Graphical depiction of evaluating the tradeoffs of venous thromboembolism (VTE) and bleeding.