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JU INSIGHT: Intraoperative Blood Transfusion and Risk of Venous Thromboembolism After Radical Cystectomy
By: Amanda Myers, MD, Mayo Clinic, Jacksonville, Florida; Igor Frank, MD, Mayo Clinic, Rochester, Minnesota; Paras H. Shah, MD, Mayo Clinic, Rochester, Minnesota; Robert F. Tarrell, MS, Mayo Clinic, Rochester, Minnesota; Bryce Baird, MD, Mayo Clinic, Jacksonville, Florida; Chandler Dora, MD, Mayo Clinic, Jacksonville, Florida; R. Jeffrey Karnes, MD, Mayo Clinic, Rochester, Minnesota; R. Houston Thompson, MD, Mayo Clinic, Rochester, Minnesota; Matthew K. Tollefson, MD, Mayo Clinic, Rochester, Minnesota; Stephen A. Boorjian, MD, Mayo Clinic, Rochester, Minnesota; Timothy D. Lyon, MD, Mayo Clinic, Jacksonville, Florida, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota | Posted on: 17 Mar 2023
Myers A, Frank I, Shah PH, et al. Intraoperative blood transfusion is associated with increased risk of venous thromboembolism after radical cystectomy. J Urol. 2023;209(3)525-531.
Study Need and Importance
Venous thromboembolism (VTE) is a significant cause of morbidity and potential mortality after radical cystectomy, as well as the most expensive index complication. There is growing evidence that blood transfusions may increase the risk of postoperative venous thromboembolism; however, several important confounders—including tumor stage and receipt of neoadjuvant chemotherapy—have not been accounted for due to the inherent limitations of the data sets used previously. Therefore, our objective was to assess whether perioperative blood transfusion is associated with VTE following radical cystectomy after adjusting for disease-related characteristics.
What We Found
We identified 3,755 patients treated with radical cystectomy at Mayo Clinic, of whom 162 (4.3%) experienced a VTE within 90 days of surgery. Blood transfusion was studied as a 3-tiered variable: no transfusion, postoperative transfusion alone, or intraoperative with or without postoperative transfusion. Intraoperative with or without postoperative blood transfusion was associated with a significantly increased risk of VTE (adjusted OR 1.73, 95% CI 1.17-2.56, P = .002) after multivariable adjustment. Moreover, each unit of blood transfused intraoperatively was associated with 7% higher odds of VTE (adjusted OR 1.07, 95% CI 1.01-1.13, P = .03).
Limitations
This study is limited by its retrospective nature and potential for measurement bias as evaluation for VTE was based on clinical judgment. Additionally, although year of surgery was adjusted for, changes to institutional VTE prophylaxis over the study period may have influenced outcomes.
Interpretation for Patient Care
Efforts should be made to limit intraoperative transfusion through preoperative diagnosis and treatment of anemia, optimization of anticoagulant status, tranexamic acid infusion, and/or a robotic surgical approach when feasible. Surgeons should furthermore have a low index of suspicion to obtain diagnostic imaging and educate patients on the importance of VTE prophylaxis after intraoperative transfusion (see Figure).
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