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Incidence of Deep Venous Thrombosis and Lymphoceles After Robotic Assisted Laparoscopic Radical Prostatectomy and Concomitant Pelvic Lymphadenectomy. Does Pharmacological Prophylaxis Matter?
Jessica Kreshover, M.D., Satya Allaparthi, MRCS,MD, Thomas Hoang, MD, Nadeem N. Dhanani, MD, MPH, Ingolf A. Tuerk, MD,PhD.
Caritas St Elizabeth Hospital, Boston, MA, USA.

BACKGROUND:
Venous thrombo embolism is a major concern in cancer patients undergoing pelvic surgery. As,such patients undergoing robotic-assisted laparoscopic radical prostatectomy (RARP) might be at particular risk for deep venous thrombosis (DVT) . Multiple guidelines including that of AUA best practice statement exist for prevention of venous thrombo embolism in patients undergoing RARP. A major concern arises when RARP and concomitant pelvic lymphadenectomy (PLAD) was perfomed. Our aim was to determine the incidence of symptomatic lymphoceles and DVT's as well as the role of pharmacological prophylaxis in patients who underwent RARP vs. RARP + PLAD.
METHODS:
After institutional review board approval a retrospective chart review was conducted. We reviewed charts of all patients who had undergone RARP and RARP + PLAD performed by single surgeon (IT) at our institution in between November 2008 and January 2010 .All patients in our cohort received low molecular weight heparin (LMWH) as prophylaxis and had lower extremity sequential compression devices during surgery. Perioperative data included blood loss, operative time, intraoperative bleeding, and length of hospital stay. Symptomatic DVT and PE within 90 d of surgery were regarded as venous thrombo embolism (VTE), diagnosed mostly by Doppler ultrasound or contrast venography and PE by lung ventilation/perfusion scan or chest computed tomography or both.
RESULTS:
Of the 351 patients, 171 had RARP and 184 had RARP+PLAD. The mean ± SD of age (yrs) and prostate weight (gms) in both groups were 58.83±7.304 vs. 60.043±7.91 (p=0.134) and 49.775±15.9 vs. 48.629±17.26 (p=0.526) respectively. However, a statistically significant difference was noted in PSA (ng/ml) and BMI (kg/m²) 4.85±2.3 vs.9.6± 12.404 (p=0.001) ; 27.74± 3.95 and 30.09± 12.5 (p=0.01) between two groups. As, expected there were statistically significant differences in operative time (minutes) 123.75± 21.135 vs.138.1±39.834 (p= 0.001), between two groups as an additional procedure of PLAD was done. There was no difference in length of stay (days) 1.22 ± 1.2,1.032 ± 0.18 (p=0.39) and EBL (ml) 199.9±127 vs.184.3±160.7 (p=0.321) in both groups. In RARP and RARP+PLAD groups we observed 2 (1.2%) lymphoceles , one (0.5%) VTE and 11(6%) lymphoceles and one (0.5%) VTE respectively. We used Pearson chi-square with p value < 0.05 to evaluate the association between lymphoceles and BMI (p=0.998), operating time (p=0.963) and number of nodes removed (p=0.998). Patients with DVT had significantly greater BMI , operating time and number of nodes removed than those who underwent RARP+PLAD and did not develop DVT.
CONCLUSIONS:
Perioperative LMWH administration was associated with a subjective perception of increased intraoperative bleeding, although the mean blood loss was not statistically significant between the groups. Indeed, when patients undergo a concomitant pelvic lymphadenectomy, the likelihood of lymphocele formation seems to increase. There is data to suggest that lymphocele formation may increase the risk of VTE events in the perioperative period but in our study we noticed very few DVTs . This fact should be considered when deciding on routine use of pharmacological VTE prophylaxis in this set of patients .However, LMWH administration appears to be safe for high-risk patients undergoing RALP+PALD .


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