Management of Patients Receiving Direct Oral Anticoagulants Scheduled for Radical Prostatectomy: An Update of a Prospective Assessment

BACKGROUND: In the perioperative setting, temporary interruption of direct oral anticoagulants (DOACs) is mandatory. However, the safety of these recommendations is largely based on nonurological surgical experiences.

OBJECTIVE: To verify the safety of these recommendations in patients undergoing radical prostatectomy (RP).

DESIGN, SETTING, AND PARTICIPANTS: A total of 5317 patients underwent RP in our tertiary care centre between December 2017 and February 2020. Of them, 107 consecutive patients had DOACs in standard preoperative medication. DOAC intake was stopped 2-3 d before RP. Postoperatively, patients received weight- and risk-adapted low-molecular-weight heparin (LMWH). DOAC intake was restarted, and administration of LMWH was stopped the 3rd day after surgery. For comparison, we performed 1:2 propensity-score matching (DOAC:non-DOAC), which resulted in 321 consecutive patients.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Perioperative outcomes and 30-d morbidity were compared between both cohorts. The Wilcoxon rank sum test and the Pearson's chi-square test were used.

RESULTS AND LIMITATIONS: The median age of patients with DOACs was 68 yr. Sixty-six patients (61.7%) stopped DOAC intake 48 h and 41 patients (38.3%) 72 h before RP. In comparison with the matching cohort, the median blood loss during RP, median duration of surgery, and median duration of hospitalisation did not differ in a statistically significant fashion. Similarly, there was no significant difference in 30-d morbidity between groups. Importantly, the rate of bleeding and thromboembolic complications did likewise not differ significantly, though it is a nonrandomised and retrospective study.

CONCLUSIONS: Standardised perioperative management of DOACs is important to minimise bleeding and thromboembolic complications. RP can be performed with a low perioperative complication risk if patients are adherent to our presented algorithm.

PATIENT SUMMARY: We looked at peri- and postoperative complications and compared direct oral anticoagulant (DOAC) and non-DOAC patients. We found no significant difference in thromboembolic and bleeding complications between the groups. We conclude that our regime is safe.