Incidence and Predictors of Venous Thromboembolism Following Major Urologic Cancer Surgery: Toward Risk-Stratified, Personalized Prophylaxis Strategies

<b>Background/Objectives</b>: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), remains a significant postoperative complication following major urologic cancer surgeries. Despite widespread use of thromboprophylaxis, the real-world effectiveness of these strategies remains uncertain. <b>Methods</b>: We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, including procedure-targeted data for radical cystectomy, radical prostatectomy, and radical nephrectomy from 2019 to 2022. Patients aged 18-90 years with complete data were included. Descriptive statistics and multivariate logistic regression analyses were performed to identify predictors of DVT and evaluate the impact of thromboprophylaxis strategies. <b>Results</b>: A total of 65,105 patients were analyzed: 28,805 prostatectomies, 28,414 cystectomies, and 7886 nephrectomies. The 30-day incidence of DVT and PE was 1.1% and 0.8%, respectively. Multivariate analysis identified prolonged hospital stay (>4 days), operative time (>180 min), and age > 75 years as independent predictors of DVT. Subgroup analyses confirmed these findings for cystectomy and prostatectomy but not for nephrectomy. Thromboprophylaxis was administered in 97.8% of patients; however, its use was not significantly associated with reduced DVT incidence, except for pharmacologic prophylaxis in cystectomy patients (OR 0.04, <i>p</i> = 0.03). <b>Conclusions</b>: Despite high adherence to thromboprophylaxis protocols, DVT remains a clinically relevant complication after urologic cancer surgery. Our findings highlight the importance of procedural factors in DVT risk and question the universal effectiveness of current prophylaxis strategies. These findings underscore the need for personalized, risk-stratified thromboprophylaxis protocols tailored to patient and procedural factors.