| RE:
THE USE OF ENOXAPARIN TO PREVENT VENOUS THROMBOEMBOLISM IN PATIENTS UNDERGOING
RADICAL RETROPUBIC PROSTATECTOMY: FEASIBILITY AND UTILITY
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KOGENTA NAKAMURA,
ALI KASRAEIAN, SAIF YACOUB, JOHN PENDLETON, SATOSHI ANAI, CHARLES J. ROSSER
Division
of Urology, University of Florida, Jacksonville, and Department of Urology,
University of Florida, Gainesville, Florida, USA
Int
Braz J Urol, 33: 347-354, 2007
To the Editor:
It
is very interesting to me that the use of an anticoagulant such as heparin
is “standard” prophylaxis after an open radical prostatectomy
(RP) in much of Western Europe but not in the US. I do not know if it
is used in conjunction with a laparoscopic RP but it would seem that there
would be little difference.
There is no argument that venous thromboembolism
(VTE) is the most important nonsurgical complication following major urologic
surgery and this would include RP. The rate of VTE has been steadily declining
over the past two decades thanks to improved techniques during surgery
and thus less blood loss, i.e. less risk of hypotension, a lower operative
time, earlier mobilization, and the use of VTE prophylaxis. Despite these
advances, the incidence of symptomatic VTE ranges between 1 and 5%. Pulmonary
embolus, although quite uncommon, is the most often cited cause of post
RP death (< 1 in 500).
Indeed patients undergoing a RP have known
risk factors for a VTE, such as older age, pelvic surgery, node dissection,
cancer. Thus the consensus for some method to reduce the risk of a VTE.
There are very few recent prospective trials, which compare different
methods for VTE prophylaxis in urologic surgery. The three commonly used
approaches to VTE prophylaxis are graduated compression stockings (GCS),
intermittent pneumatic compression devices (IPCD), and pharmacologic therapy,
i.e. one of the heparin products.
An outstanding review of VTE prophylaxis
was published in 2004 (1). The recommendation for urologic surgery and
specifically major open procedures such as RP was routine prophylaxis
with low dose unfractionated heparin two or three times daily. Acceptable
alternatives include IPCD and /or GCS or low molecular weight heparin.
Thus, we have a choice. No perfect answer.
What do I do? For the past 15 years our
anesthesia team and I have used a protocol which consists of a long acting
spinal supplemented by general anesthesia(2). Patients are positioned
in the supine flexed position with the kidney rest raised. IPCD are placed
when the patient enters the operating room and are maintained during surgery
and until the next morning when the patient is out of bed and ambulating.
Ninety percent of patients are discharged the day after surgery without
additional VTE prophylaxis.
We reported our incidence of VTE in 1,364
consecutive RP in 2005 (3). There were three VTE events (0.21%) in lower
(n = 2) or upper (n = 1) extremities. No patient had a clinical pulmonary
embolus. The only postoperative death was from a myocardial infarction.
Since that publication, there have been no additional clinical VTE.
The use of a spinal anesthetic may be an
important component to our low incidence of VTE. Prospective trials have
convincingly demonstrated that patients receiving a spinal or epidural
anesthetic with or without a concurrent general component have a significantly
reduced chance of a VTE (4). The precise mechanism is not clear but less
stasis in the lower extremities or lower blood loss may be factors. The
long acting spinal actually encourages early ambulation since the patients
have less postoperative pain.
The article by Nakamura et al. asks what
to do when patients do not comply with the IPCD. My suggestion would be
to emphasize to the nurses and the patient the importance of the devise
and in addition use a spinal anesthetic. Our patients remove the devices
the morning after surgery and begin ambulation.
references
1. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et
al: Prevention of venous thromboembolism: the seventh ACCP conference
on antithrombotic and thrombolytic therapy. Chest. 2004; 126: 338S-400S.
2. Sved P, Nieder A, Manoharan M, Gomez P, Meinbach DS, Kim SS, et al:
Evaluation of analgesic requirements and postoperative recovery after
radical retropubic prostatectomy utilizing long acting spinal anesthesia.
Urology. 2005; 65: 509-12.
3. Koya MP, Manoharan M, Kim S, Soloway MS: Venous thromboembolism in
radical prostatectomy: is heparanoid prophylaxis warranted? BJU Int. 2005;
96: 1019-21.
4. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, et
al: Reduction of postoperative mortality and morbidity with epidural or
spinal anesthesia: results from overview of randomised trials. BMJ. 2000;
321: 1493.
Dr.
Mark S. Soloway
Professor & Chair, Department of Urology
Miller School of Medicine, University of Miami
Miami, Florida, USA
E-mail: MSoloway@med.miami.edu
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