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Perioperative Outcomes of Aspirin Use in Radical Prostatectomy
Matthew D. Ingham, MD, Ross E. Krasnow, MD, Matthew Mossanen, MD, Ye Wang, PhD, Steven L. Chang, MD, MS.
Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
BACKGROUND: Despite clear evidence demonstrating the benefit of perioperative aspirin (ASA) in reducing the risk of cardiac and cerebrovascular complications, ASA is commonly discontinued before surgery due to a concern for surgical bleeding. To date, there exists a paucity of studies assessing the effect of perioperative ASA on surgical outcomes within urology. The majority of those available investigations are limited to high volume centers, which may not be reflective of the general urologic community practice. As a result, we sought to evaluate the impact of perioperative ASA on outcomes for those undergoing radical prostatectomy (RP) across a broad range of practice settings.
METHODS: A retrospective review of patients undergoing RP (ICD9 60.5, 60.62) from 2003 to 2015 was performed on the Premier Hospital Database (Premier Inc, Charlotte NC, USA), a nationally representative hospital discharge dataset. We restricted the study to elective procedures with a diagnosis of prostate cancer (ICD 185), and excluded patients with a possible cardiovascular or cerebrovascular event on the day of surgery. To reduce unmeasured confounders, we limited the cohort to hospitals that - during the course of study - had at least one patient that received perioperative aspirin yielding a total cohort of 157,674 patients. The cohort was dichotomized into two groups: those receiving perioperative ASA (2.8%, n=4400) and those with no perioperative ASA (97.2%, n=153,274). In terms of outcomes, we assessed in-hospital rates of: major bleeding, overall transfusion, day-of-surgery transfusion, prolonged (>2 days) length of stay (LOS), and prolonged (>270 minutes) operative time. We also assessed 90-day rates of: myocardial infarction, cerebrovascular accident, readmission, major complication (Clavien-Dindo ≥3), deep vein thrombosis/pulmonary embolism, and death. The statistical analysis was based on crude and adjusted logistic regression models, which accounted for patient, hospital, and surgical characteristics.
RESULTS: Patients continuing with perioperative ASA tended to be older (51.5% vs 41.8% ≥65 years, p=0.002), less healthy (13.8% vs 5.3% with a Charlson Comorbidity Index score ≥2, p<0.0001), and more likely to receive an open RP (42.3% vs 28.1%, p<0.0001). With respect to in-hospital outcomes, no significant differences were associated with the use of perioperative ASA. For 90-day outcomes, those patients receiving perioperative ASA were more likely to suffer a myocardial infarction (OR 5.88, CI [3.4-10.18], p<0.001), experience a major complication (OR 2.95, CI [1.58-5.5], p<0.001), or be readmitted (OR 1.63, CI [1.18-2.26], p<0.05). Subgroup analysis showed that the disparity in morbidity was limited to patients undergoing minimally invasive RP.
CONCLUSIONS: This contemporary, population-based study demonstrates that perioperative ASA is not associated with increased in-hospital surgical morbidity following RP. Although these findings suggest that patients on perioperative ASA do not have an elevated risk for bleeding, they are associated with higher 90-day morbidity, which is likely attributed to their baseline comorbidities.
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