Venous thromboembolism following radical cystectomy: significant predictors, comparison of different anticoagulants and timing of events.

PURPOSE: We determined the rate, timing and predictors of venous thromboembolism after open radical cystectomy for urothelial bladder cancer. We also compared the use of warfarin (1971 to 2008) and unfractionated heparin (2008 to 2012) as prophylaxis. MATERIALS AND METHODS: We retrospectively reviewed the records of 2,316 patients who underwent open radical cystectomy and extended pelvic lymph node dissection for urothelial bladder cancer with intent to cure at our institution between 1971 and 2012. The rate and timing of symptomatic venous thromboembolism that developed within 3 months of surgery was calculated in the cohort. Multivariate stepwise logistic regression was used to find significant predictors of symptomatic venous thromboembolism and compare the warfarin based and heparin based prophylaxis protocols. RESULTS: A total of 109 symptomatic venous thromboembolism cases developed for a rate of 4.7%, including 2.1% for deep vein thrombosis and 2.6% for pulmonary embolism. Of these cases 57.8% developed after discharge home at a median of 20 days postoperatively (range 2 to 91). Four significant predictors of venous thromboembolism were identified, including body mass index (p = 0.0015), surgical margins (p = 0.025), diversion type (p = 0.023) and hospitalization duration (p <0.0001). Use of prophylactic heparin vs warfarin was not a significant predictor (p = 0.31). CONCLUSIONS: Venous thromboembolism remains a significant complication of open radical cystectomy. Using an in-house, heparin based anticoagulation protocol consistent with current AUA (American Urological Association) guidelines has not decreased the rate of venous thromboembolism compared to historical warfarin use. On closer evaluation most venous thromboembolism cases in our population occurred after discharge home. Future studies are needed to establish the benefits of extended duration venous thromboembolism prophylaxis regimens that cover the critical post-hospitalization period.