Current perioperative management of radical cystectomy with intestinal urinary reconstruction for muscle-invasive bladder cancer and reduction of the incidence of postoperative ileus

Orthotopic bladder substitution (neobladder): part I: indications, patient selection, preoperative education, and counseling

Bladder substitution following radical cystectomy for urothelial cancer (transitional cell carcinoma) has become increasingly common and in many centers has evolved to become the standard method of urinary diversion. In determining the best type of urinary diversion for a specific patient, consideration must be given to both the morbidity associated with surgery and the potential positive impact on the patient's quality of life. Decision-making and perioperative care is ideally multidisciplinary, involving physicians and nurse specialists in urology, continence, and ostomy therapy. Physiotherapists may also be involved for pelvic floor muscle retraining. This article highlights preoperative considerations for patients undergoing radical cystectomy with a focus on issues specific to orthotopic bladder substitution as the method of urinary diversion. The second article in this 2-part series will outline postoperative strategies to manage these patients.

Risk of in-hospital complications after radical cystectomy for urinary bladder carcinoma: population-based follow-up study of 7608 patients

Objective

Patients and Methods

Results

Conclusions

Preoperative risk factors related to bladder cancer rehabilitation: a registry study

INTRODUCTION

Patients diagnosed with (muscle-) invasive bladder cancer (IBC) are more likely to harbour comorbidities due to their advanced age at diagnosis. Under-nutrition is a predictor for postoperative morbidity and mortality in cancer patients, but under-reported in urology. Understanding the IBC patient profile before major surgery could facilitate and optimise outcome of the surgical patient.

BACKGROUND/OBJECTIVES

To identify preoperative risk factors for early rehabilitation before radical cystectomy (RC).

SUBJECTS/METHODS

A historical registry-based study of 76 patients referred for RC at Aarhus University Hospital, Denmark (DK) in 2009. Early rehabilitation was defined by length of stay (LOS) postoperatively with a cutoff ≥11 days. High comorbidity was expressed by the charlson comorbidity index score (CCI) ≥3. LOS was calculated by linking the unique Civil Registration Number with the National Patient Registry. Preoperative nutritional risk was identified using the screening tool, nutritional risk score 2002 (NRS) of the European Society of Clinical Nutrition and Metabolism. Multivariate analysis was used to identify risk factors for early rehabilitation.

RESULTS

The proportion of patients at preoperative nutritional risk was 26% (95% confidence interval (CI): (95% CI: 17; 37) and 43% of patients held a high CCI (95% CI: 33; 55). Prolonged LOS was independently associated with female gender (P=0.02) and age ≥70 years (P=0.04). NRS and CCI were not associated with LOS.

CONCLUSIONS

Attention should be focused on women and elderly patients undergoing RC to optimise early rehabilitation and reduce LOS. It is still unknown whether preoperative nutritional risk and comorbidity are obstacles in early rehabilitation of RC patients.

Definition, incidence, risk factors, and prevention of paralytic ileus following radical cystectomy: a systematic review

CONTEXT

Postoperative paralytic ileus (POI) has profound clinical consequences because it represents a substantial burden on both patients and health care resources.

OBJECTIVE

To determine the knowledge base regarding POI in the radical cystectomy (RC) population with an emphasis on preventive measures and risk factors.

EVIDENCE ACQUISITION

A systematic literature search of Medline (1966 to February 2011) and a study review were conducted. Eligible studies explicitly reported the incidence of POI and/or at least two quantitative measures of gastrointestinal recovery.

EVIDENCE SYNTHESIS

The search identified 727 relevant articles; 77 met eligibility criteria, comprising 13 793 patients. Of these, 21 used explicit definitions of POI, and they varied widely. Across studies, the incidence of POI ranged from 1.58% to 23.5%. Possible risk factors for POI included increasing age and body mass index. Seventeen studies reported effects of an intervention on POI: 3 randomized controlled studies, 11 observational cohort studies with concurrent comparison, and 3 observational cohort studies with nonconcurrent comparison. Gum chewing was associated with shortened times to flatus (2.4 vs 2.9 d; p<0.0001) and bowel movement (BM) (3.2 vs 3.9 d; p<0.001) in one observational cohort study (n=102); omission of a postoperative nasogastric tube (NGT) was associated with shorter time to flatus (4.21 vs 5.33 d; p=0.0001) and shorter length of stay (14.4 vs 19.1 d; p=0.001) in one observational cohort study (n=430); and the routine use of bowel preparation was associated with an increased incidence of POI (5% vs 19%) in another series (n=86). Additionally, readaptation of the dorsolateral peritoneal layer was shown to shorten times to flatus (p=0.016) and times to BM (p=0.011) in one randomized controlled study (n=200).

CONCLUSIONS

The incidence/definition of POI after RC is highly variable. An improved reporting strategy is needed to identify true incidence and risk factors, and to guide future research for both potential preventive and therapeutic interventions.

Safety of no bowel preparation before ileal urinary diversion

Study Type - Harm (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Recent studies show no advantage of bowel preparation before ileal urinary diversion and that avoidance of bowel preparation led to early restoration of intestinal function and shorter hospital stay. However, this was not tested in a prospective comparison. The current study is a prospective comparison to test for the safety of omitting bowel preparation before ileal urinary diversion. This study also examines simultaneous effects of bowel preparation on the ileal flora and mucosa.

OBJECTIVE

• To evaluate the safety of no bowel preparation before ileal reconstructive procedures of the lower urinary tract, in comparison to standard 3-day bowel preparation. The present study also examines the effects of bowel preparation on small bowel wall and bacterial flora.

PATIENTS AND METHODS

• This study enrolled 40 patients scheduled for radical cystectomy and ileal urinary diversion, presenting to the department of urology, Alexandria University, Alexandria, Egypt during the period from January 2009 to September 2010. • Patients were prospectively randomized into two groups: Group (I) had standard 3-day bowel preparation. Group (II) had only over-night fasting before surgery. • Intra-operatively, one ml of ileal fluid was collected for bacteriological studies and an ileal wall biopsy was taken for histopathological examination. • Postoperative complications were reported for all patients using modified Clavien system.

RESULTS

• Both groups showed insignificant difference regarding the frequency and Clavien grade of postoperative complications (P = 0.30). • Under aerobic and anaerobic conditions, 5 cases in group (I) had bacterial overgrowth of E. coli (>105) versus none in group (II) (P = 0.04). Eight patients in group (I) had sterile ileal fluid cultures versus 18 patients (90%) in group (II). No correlation could be made between would infections and the organisms isolated in ileal fluid cultures. • Histopathological examination of ileal biopsies revealed mucosal edema and submucosal congestion in 9 cases in group (I) versus 2 cases in group (II) (P = 0.0310).

CONCLUSIONS

• Omitting bowel preparation before ileal urinary diversion is safe, with no added complications. • Non-preparation of the small bowel is not associated with bacterial overgrowth.

Parenteral nutrition does not improve postoperative recovery from radical cystectomy: results of a prospective randomised trial

BACKGROUND

After radical cystectomy, patients are in a catabolic state because of postoperative stress response, extensive wound healing, and ileus.

OBJECTIVE

To evaluate whether recovery can be improved with total parenteral nutrition (TPN) in patients following extended pelvic lymph node dissection (ePLND), cystectomy, and urinary diversion (UD).

DESIGN, SETTING, AND PARTICIPANTS

We conducted a prospective, randomised, single-centre study of 157 consecutive cystectomy patients.

INTERVENTION

Seventy-four patients (group A) received TPN during the first 5 postoperative days, with additional oral intake ad libitum. Eighty-three patients (group B) received oral nutrition alone.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was the occurrence of postoperative complications. Secondary outcomes were time to recovery of bowel function, biochemical nutritional (serum albumin, serum prealbumin, serum total protein) and inflammatory (C-reactive protein) parameters, length of hospital stay, and costs attributed to the TPN. The Pearson χ(2) test was used for dichotomous variables; the Wilcoxon rank sum test was used for continuous variables.

RESULTS AND LIMITATIONS

Postoperative complications occurred in 51 patients (69%) in group A and in 41 patients (49%) in group B (p=0.013), a difference resulting from group A having more infectious complications than group B (32% vs 11%; p=0.001). Serum prealbumin and serum total protein were significantly lower in group B on postoperative day 7 but not on postoperative day 12. Time to gastrointestinal recovery and length of hospital stay did not differ between the two groups. The costs for TPN were €614 per patient. A potential limitation is the use of a glucose-based parenteral nutrition without lipids.

CONCLUSIONS

Postoperative TPN is associated with a higher incidence of complications, mainly infections, and higher costs following ePLND, cystectomy, and UD versus oral nutrition alone.

Current Strategies to Enhance Recovery following Radical Cystectomy: Single Centre Initial Experience

A radical cystectomy (RC) with pelvic lymph node dissection is the gold standard treatment for muscle-invasive bladder carcinoma. The morbidity associated with RC is clearly lower than that in the previous decades; it still continues to remain higher than 30% in the early postoperative period associated with and remains the most effective method for local control. We present current strategies being developed to further enhance recovery in patients undergoing RC and stratifying these into pre, intra, and post operative. We present our current strategies to enhance revcovery in patients undergoing RC which includes a combination of a through preoperative assessment with cardiopulmonary exercise (CPX), preoperative carbohydrate loading drinks, and intraoperative fluid monitoring with the trans-oesophageal Doppler probe (TODP) that may enhance recovery following radical cystectomy. We conclude that using these strategies may not only help in reducing peri/post operative morbidity and the duration of inpatient stay but may also help in enhancing the patient's long-term recovery.

Early removal of nasogastric tube is beneficial for patients undergoing radical cystectomy with urinary diversion

PURPOSE

Examine the beneficial effect of early nasogastric tube (NGT) removal in patients undergoing radical cystectomy with urinary diversion.

PATIENTS AND METHODS

43 consecutive patients underwent radical cystectomy with urinary diversion and were randomized into 2 groups. In the intervention group (n = 22), the NGT was removed 12 hours after the operation. Comparatively, in the control group (n = 21), the NGT remained in place until the appearance of the first flatus. The appearance of ileus, patient ambulation, time to regular diet, and hospital discharge of the two patient groups were assessed. Patient discomfort due to the NGT was also recorded.

RESULTS

The 2 groups showed statistical homogeneity of their baseline characteristics. Two patients (9.09%) from the intervention and 3 patients (14.3%) from the control group developed postoperative ileus and were treated conservatively. No significant differences in intraoperative, postoperative, bowel outcomes or other complications were found between the two groups. All patients preferred the NGT to be removed first in comparison to their other co-existing drains.

CONCLUSIONS

This is the first randomized, prospective study, to our knowledge, to assess early NGT removal after radical cystectomy. We advocate early removal, independently of the selected type of urinary diversion, since it is not correlated with ileus and is advantageous in terms of patient comfort and earlier ambulation.

Perioperative morbidity of radical cystectomy: A review

A systematic review of the literature on perioperative morbidity (POM) was done using Medline software with a combination of keywords like mortality, morbidity, and complications. In addition, we review the analysis of our hospital data of 261 Radical cystectomies (RCs) performed in an 11-year period and our latest clinical pathway for RC. Age range in our series was 50 to 81 years with 240 males and 21 females. RCs were performed by intraperitoneal method in 172 patients and by our extraperitoneal (EP) method in 89 patients. Urinary diversion was ileal conduit in 159 patients and neobladder in 102 patients. Blood loss ranged between 500 and 1500 ccs. Postoperative mortality occurred in eight patients (3%). Among the other early post-op complications, major urinary leak was seen in nine and minor in 11, requiring PCN in five patients and reoperation in four patients. Bowel leak or obstruction was seen in six and four patients, respectively, requiring reoperation in six patients. EP RC in our series showed some benefit in reduction of POM. The mortality of RC has declined but the POM still ranges from 11 to 68%, as reported in 23 series (1999-2008) comprising of 14 076 patients. Various risk factors leading to POM and some corrective measures are discussed in detail. However, most of these series are retrospective and lack standard complication reporting, which limits the comparison of outcomes. Various modifications in open surgical technique and laparoscopic and Robotic approaches are aimed at reduction in mortality and POM of RC.

A prospective randomized multicenter study of Turkish Society of Urooncology comparing two different mechanical bowel preparation methods for radical cystectomy

OBJECTIVE

To investigate the outcomes and complication rates of urinary diversion using mechanical bowel preparation (BP) with 3 day conventional and limited BP method through a standard perioperative care plan.

MATERIALS AND METHODS

This study was designed as a prospective randomized multicenter trial. All patients were randomized to 2 groups. Patients in standard 3-day BP protocol received diet restriction, oral antibiotics to bowel flora, oral laxatives, and saline enemas over a 3-day period, whereas limited the BP arm received liberal use of liquid diet, sodium phosphate laxative, and self administered enema the day before surgery. All patients received same perioperative treatment protocol. The endpoints for the assessment of outcome were anastomotic leakage, wound infection, wound dehiscence, intraperitoneal abscess, peritonitis, sepsis, ileus, reoperation, and mortality. Bowel function recovery, including time to first bowel movement, time to first oral intake, time to regular oral intake, and length of hospital stay were also assessed.

RESULTS

Fifty-six patients in 3-day BP and 56 in limited BP arm were evaluable for the study end points. Postoperatively, 1 patient in limited BP and 2 patients in 3-day BP arm died. There was no statistical difference in any of the variables assessed throughout the study, however, a favorable return of bowel function and time to discharge as well as lower complication rate were observed in limited BP group.

CONCLUSIONS

Regarding all endpoints, including septic and nonseptic complications, current clinical research offers no evidence to show any advantage of 3-day BP over limited BP.

Modulation of aldosterone release by epidural analgesia impacts brain natriuretic peptide: a link to stress cardiomyopathy? Pilot study

OBJECTIVE

Data pertaining to whether stress-induced aldosterone release is associated with cardiac disorders are lacking. This study was designed to compare whether the modulation of intra-operative aldosterone release by epidural analgesia had an effect on the brain natriuretic peptide (BNP) levels.

DESIGN, PATIENTS, MEASUREMENTS

A study was pilot prospective, open label randomized one. Patients were randomized to one of two anaesthesia protocols: group 1 included 13 patients who received general anaesthesia, and group 2 included 12 patients who received combined general anaesthesia and epidural analgesia. Study protocol was by completed 25 male patients, median age 56 years, without significant comorbidities, who underwent radical cystectomy because of urinary bladder tumour. Serum aldosterone, BNP, cortisol (measured by radioimmunoassay), adrenocorticotropine hormone (ACTH) (by solid-phase ELSA), blood chemistry, complete blood count and vital signs were compared preoperatively, intra-operatively and at postoperative days (POD) 1 and 7.

RESULTS

Hemodynamics was stable in both groups. Group 1 showed threefold serum aldosterone, (P = 0·001) 20-fold ACTH (P = 0·003) and twofold cortisol (P = 0·001) increases intra-operatively, unlike group 2. Both groups had a twofold BNP increase in POD 1 that remained above normal on POD 7 only in group 1 (P = 0·02; P = 0·019 vs group 2).

CONCLUSION

Alleviation of aldosterone release by epidural analgesia modulated the postoperative serum BNP pattern in patients with a low risk for cardiac diseases who underwent noncardiac surgery.

Radical cystectomy and orthotopic bladder substitution using ileum

Over the past decade, continent urinary diversion, especially orthotopic bladder substitutions, has become increasingly popular following radical cystectomy for bladder cancer. The ultimate goal of orthotopic bladder substitution is to offer patients the best quality of life, similar to that of patients with native bladders. To achieve that purpose, surgeons should be familiar with the characteristics of good candidates for neobladders, the possible intraoperative and postoperative problems related to the surgery, and the solutions to these problems. Postoperative surveillance and instructions given to the patients also contribute to successful, functional results. Here, we reviewed the indications, pitfalls, and solutions for orthotopic bladder substitutions and the patients' quality of life after surgery. When performed properly, orthotopic continent diversion offers good quality of life with few long-term complications. Therefore, we believe it is the best option for the majority of patients requiring cystectomy.

Improvement of an Enhanced Recovery Protocol for Radical Cystectomy

Introduction:

Enhanced recovery protocols (ERPs) aim to improve outcome following major abdominal surgery. Our ERP for radical cystectomy focuses on reduced bowel preparation and standardised feeding and analgesic regimens. Although the ERP safely decreased hospital stay, time to return of bowel function has not been affected. The current study aims to assess the addition of chewing gum on return of bowel function as part of an ERP.

Patients and methods:

We examined the addition of chewing gum to our ERP. Data was obtained retrospectively from 112 consecutive patients, 56 before and 56 after implementing chewing gum in to the EPR. The primary outcome measured was return of bowel function signified by first defecation after surgery.

Results:

The demographics of the two groups showed no significant difference in age, gender distribution, American Society of Anesthesiologists grade, or type of urinary diversion. A significant reduction in the time to return of bowel function was observed in patients using chewing gum post-operatively (4 versus 6 days, p < 0.0001). The median inpatient stay was 13 days in both groups; however there was a trend to an earlier discharge in those patients receiving chewing gum.

Conclusion:

The introduction of chewing gum to our ERP is associated with a faster return of bowel function and may lead to a reduced inpatient stay.

Will tissue-engineered urinary bladders change indications for a laparoscopic cystectomy?

Radical open cystectomy is a treatment of choice for muscle invasive urinary bladder cancer. Laparoscopic radical cystectomy (LapRC) is surgically advanced and is an extremely difficult technique but presents many advantages. Urinary diversion (conduit, pouch or neobladder) when performed during laparoscopy necessitates a conversion to open procedure. Urinary diversion using an autologous bowel is associated with longer operative times and complications. The authors have analyzed the LapRC procedure and its 2 main parts--that is, bladder resection and urinary diversion. The emphasis was on the operative time and complications related to the urinary diversion procedure. A urinary diversion created in vitro could make the LapRC totally intracorporeal, and it could be completed within an acceptable time. Tissue engineering techniques used for urinary diversion after cystectomy shorten the operative time and help avoid serious complications related to bowel surgery. LapRC with tissue-engineered urinary diversion could become a management of choice for muscle invasive bladder cancer.

Age and body mass index are independent risk factors for the development of postoperative paralytic ileus after radical cystectomy

OBJECTIVES

To identify the risk factors that would aid in the identification of patients at the greatest risk of developing postoperative paralytic ileus (POI). POI is a common complication after radical cystectomy and can result in a prolonged hospital stay and delayed recovery.

METHODS

A retrospective cohort study design was used to analyze data from consecutive patients presenting to our institution for radical cystectomy with pelvic nodal dissection. POI was declared if patients were without evidence of bowel function beyond the anticipated discharge goal of 6 days. The association between several clinical features and the occurrence of POI was examined.

RESULTS

Of 283 patients, 43 (15.2%) developed POI. Of the 43 patients, 38 (88.4%) were given total parenteral nutrition for nutritional supplementation. No difference in the incidence of POI was observed between the sexes, previous abdominal operations, estimated blood loss, transfusion requirement, operative time, neoadjuvant chemotherapy, or previous radiotherapy. POI was observed in 11.3% of normal and overweight patients (body mass index [BMI] <30.0 kg/m(2)) compared with 25.6% of obese patients (BMI ≥30.0 kg/m(2); P = .005). On multivariate analysis adjusted for the influence of competing variables, increasing age (hazard ratio 1.09, 95% confidence interval 1.02-1.16, P = .008) and BMI (hazard ratio 1.09, 95% confidence interval 1.03-1.17, P = .007) were significantly associated with the presence of POI.

CONCLUSIONS

Our results showed that increasing age and BMI were significantly associated with the presence of POI in patients undergoing radical cystectomy for bladder cancer.

Fast track program in patients undergoing radical cystectomy: results in 362 consecutive patients

BACKGROUND

This article outlines our current perioperative management of patients undergoing cystectomy and urinary diversion using advancements in perioperative care to allow for early institution of an oral diet and early hospital discharge.

STUDY DESIGN

Three hundred sixty-two consecutive patients underwent radical cystectomy and urinary diversion with curative intent (2001 through 2008). Each underwent a perioperative care plan ("fast track" program). Throughout our experience, evidence-based modifications to this program were instituted. We analyzed the impact of these modifications and report the outcomes with the most recent 100 patients in whom no additional modification has been used.

RESULTS

Mean age of patients is 66.3 years, with 44% of the patients older than age 70 years and 12% older than age 80 years. We found no detrimental effects to immediate removal of the orogastric tube at the end of the procedure, but found a beneficial effect of empiric metoclopramide use, with lower rates of nausea and vomiting. Perioperative antibiotic coverage has been reduced to 24 hours as per American Urological Association guidelines. Gum-chewing has also been shown to be of benefit with regard to a more rapid recovery of bowel function. Use of nonnarcotic analgesics (eg, ketrolac) has also been central in the pathway. Finally, early institution of an oral diet has been an original and central component to our fast track program.

CONCLUSIONS

Successful application of a fast track program has been applied to our patients undergoing radical cystectomy and urinary diversion, with the potential to use evidence-based modifications to reduce morbidity and improve recovery.

[Urinary diversions: which one one is right for which patient?]

Standardized operating techniques and surgeons' experiences have contributed to the development of complex urinary diversion systems over the last two decades. Patients' desires and comorbidity risks, such as kidney or bowel dysfunction, as well as their mental and manual abilities need to be taken into account. Careful preoperative decision making is essential if patients are to accept the chosen urinary diversion system and improve their quality of life. Ileal and ileocecal orthotopic neobladders have proven to be effective and comfortable for long-time use, thus stimulating decisions for orthotopic bladder substitution despite the risk of incontinence episodes, especially during the night. Catheterization of continent reservoirs connected to the umbilicus (e.g., ileocecal reservoirs, Mainz pouch I) are widely accepted as an alternative diversion procedure if the urethra and/or sphincter region have to be removed. The patient's desire to avoid a wet stoma and achieve a cosmetically "unchanged" body image is met by these urinary diversion techniques. The surgeon's experience and the patient's mental and general health status must be considered in order to meet the increased complexity of these specific urinary diversions. Nevertheless, elderly patients often tend to prefer an ileal conduit as the easiest solution for urinary diversion. Therefore, even in experienced urological departments, the percentage of patients with orthotopic or self-catheterizable bladder substitution ranges between 30% and 66%, while the ileal conduit is selected in up to 64% of cases after cystectomy. The future of laparoscopic cystectomy has just begun and will affect future techniques of urinary diversion.