What are the European Association of Urology (EAU) guidelines for Venous Thromboembolism (VTE) prophylaxis after Radical Prostatectomy (RP)?

EAU Guidelines for VTE Prophylaxis After Radical Prostatectomy

Risk Stratification is Essential

The EAU guidelines recommend a patient- and procedure-specific approach to VTE prophylaxis after radical prostatectomy, stratifying patients into low, moderate, or high-risk categories based on both patient factors and surgical characteristics. 1, 2, 3

Patient Risk Factors (4 Key Factors):

• Age >75 years 3
• BMI >35 3
• VTE in a first-degree relative 3
• Personal history of VTE 3

Patients are categorized as:

• Low risk: No risk factors (VTE incidence 0.4-0.8%) 3
• Moderate risk: 1-2 risk factors 3
• High risk: 3-4 risk factors (VTE incidence 1.5-15.7%) 3

Procedure Risk Factors:

• Surgical approach: Open retropubic prostatectomy carries higher VTE risk than laparoscopic/robotic approaches (0.5% baseline for minimally invasive) 2, 3
• Extended pelvic lymph node dissection: Significantly increases VTE risk 2, 3
• Operative time >180 minutes: Independent risk factor 2

Mechanical Prophylaxis

Well-fitted graduated compression stockings should be used as part of mechanical prophylaxis for all patients. 1 Intermittent pneumatic compression devices can be combined with pharmacological prophylaxis in highest-risk patients. 4

Pharmacological Prophylaxis Recommendations

Moderate-to-High Risk Patients (Caprini Score ≥3):

LMWH is the preferred agent, with enoxaparin 40 mg subcutaneously once daily starting 6-8 hours postoperatively. 2, 5

• Standard duration: Minimum 7-10 days for all patients receiving pharmacological prophylaxis 2
• Extended duration (4 weeks): Recommended for high-risk patients with additional features including:
  • Extended pelvic lymph node dissection 2
  • Obesity 2
  • Prior VTE history 2
  • Restricted mobility 2

Low-Risk Patients:

Mechanical prophylaxis alone is appropriate; pharmacological prophylaxis should not be used when net benefit is negligible or possibly harmful. 3

Critical Safety Considerations

Contraindications to LMWH:

• Active major bleeding 1
• Thrombocytopenia with positive antiplatelet antibodies 1
• History of heparin-induced thrombocytopenia 1

Dose Adjustments:

• Renal impairment (CrCl <30 mL/min): Reduce enoxaparin to 30 mg once daily 1, 2
• Neuraxial anesthesia: Avoid LMWH 12 hours before epidural/spinal catheter manipulation; may administer 2 hours after catheter removal 1

Key Distinctions from Radical Cystectomy

A critical pitfall is over-extrapolating radical cystectomy data to radical prostatectomy. 1 Radical cystectomy has a substantially higher VTE risk (2.6-11.6%) compared to radical prostatectomy without extended lymph node dissection, which is why extended prophylaxis is standard for cystectomy but selective for prostatectomy. 1

Evidence Quality Note

The EAU approach builds on American College of Chest Physicians methodology and generates absolute estimates of baseline VTE and bleeding risk for specific procedures, with a simplified risk stratification system (low, intermediate 2x risk, high 4x risk). 6 The major bleeding risk after radical prostatectomy ranges from 0.4-1.4%, which must be weighed against VTE risk for each patient. 3