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UPJ INSIGHT Extended Anticoagulation after Radical Cystectomy Using Direct Acting Oral Anticoagulants: A Single-Institutional Experience
By: Kassem S. Faraj, MD; Adri Durant, MD; David Mauler, MD; Mouneeb Choudry, MD; Rohan Singh, BS; Yu-Hui Chang, PhD; Mark D. Tyson, MD, MPH | Posted on: 01 Oct 2022
Faraj KS, Durant A, Mauler D, et al. Extended anticoagulation after radical cystectomy using direct acting oral anticoagulants: a single-institutional experience. Urol Pract. 2022;9(5)451-458
Study Need and Importance
Extended prophylactic anticoagulation therapy with enoxaparin effectively reduces the incidence of venous thromboembolism (VTE) after radical cystectomy (RC). Medication costs or aversion to injectable prophylaxis likely contributes to low adherence rates in major abdominopelvic surgeries such as RC. To improve compliance, we modified our extended anticoagulation options to direct oral anticoagulants (DOAs; eg apixaban 2.5 mg twice daily or rivaroxaban 10 mg daily). This study assesses our experience with extended VTE prophylaxis using DOAs.
What We Found
Of 657 patients, 101 patients received extended VTE prophylaxis, and 46 (45.5%) patients received a DOA agent. At 90 days of followup, 40 patients (7.2%) who did not receive extended prophylaxis on discharge developed a VTE compared to 2 patients (3.6%) in the enoxaparin group and 0 patients in the DOA group (p=0.11). Seven patients (1.3%) who did not receive extended anticoagulation developed gastrointestinal bleeding compared to 0 patients in the enoxaparin group and 1 (2.2%) in the DOA group (p=0.60). On multivariable analysis, both enoxaparin and DOA were associated with similar reductions in the risk of developing VTE compared to controls (enoxaparin OR 0.33, p=0.09, and DOA OR 0.19, p=0.15).
Limitations
Major limitations of this study include its retrospective design and small sample size, which likely contributed to the lack of statistical significance despite large effect sizes. Additionally, multiple surgeons were involved throughout the study period, and some surgeon-specific practices and protocols may not have been accounted for in the adjusted analysis.
Interpretation for Patient Care
Preliminary evidence from this study suggests that DOAs are comparable to enoxaparin in preventing VTE after RC without substantial risk of gastrointestinal bleeding. However, more data are required to confirm these nascent observations.