Urologists prevent DVTs with checklists, AUA policy

February 1, 2010

How closely do urologists follow AUA's policy statement on DVT prevention?

John Pirani, MD, who practices in Gadsen, AL, says that the process for dealing with the potential for DVTs is almost automatic and, in some ways, is determined by hospital policy.

"It's our decision on what comorbidities the patient does have, and to place the patient into each category," he said. "For an outpatient procedure, early ambulation would be level 1. If the patient is low or no risk, nurses can remove the compression hose before the patient goes home. For an overnight stay, if the patient has some other cofactors, they would have hose plus Lovenox. A patient with coronary artery disease or a previous history of DVT would be a level 3 and would require a bit more Lovenox and probably Plavix therapy post-op. But the treatment for each category is set."

A practitioner for 10 years, Dr. Pirani doesn't think AUA's guidance is a bad idea; however, "We already have standards for DVT from the American College of Surgeons. I'd like to see the AUA come up with guidelines on other things."

Hospital standards are automatic

In Middletown, CT, Jeffrey Rabuffo, MD's situation is similar situation. He's aware of the AUA statement, but the hospital sets its own standards.

"We have a pathway in our hospital. It's automatic," Dr. Rabuffo said. "When a patient comes in, there are different choices for DVT prophylaxis. There are stockings, heparin, or aspirin, and I have to check one. We have to do something."

In practice for 36 years, Dr. Rabuffo says that for the procedures he does, compression stockings work best.

"What I do doesn't involve medication. For our TURPs and bladder tumors, where patients' legs are up in the air, stockings just work better. Plus, with no medication involved, there's less chance of error. I don't do procedures like cystectomies; most of those types of procedures go off to the universities, so, in general, we would not use heparin because of that," he said.

The hospitals where Armen Kassabian, MD, practices in the Burbank, CA, area, also have policies, and some of them don't quite jibe with AUA's best practices.

"I work at four hospitals, and some have guidelines that include mandatory Lovenox or heparin subcutaneous injections," he explained. "They won't force you to use pharmacology, but if you don't, they want to know why. You have to provide documentation of why you went against their new established standard of care, such as documenting the bleeding or some other contraindication. It's hard to go against the hospital policies."