Bowel Preparation Versus No Preparation Before Ileal Urinary Diversion

Advances in Bowel Preparation and Antimicrobial Prophylaxis for Open and Laparoscopic Urologic Surgery

Surgical site infections (SSIs) represent a major source of postoperative complications adversely impacting morbidity and mortality indices in surgical care. The discovery of antibiotics in the mid-20th century, and their ensuing use for preoperative antimicrobial bowel preparation and prophylaxis, drastically reduced the occurrence of SSIs providing a major tool to surgeons of various specialties, including urology. Because, the appropriate use of these antimicrobials is critical for their continued safety and efficacy, an understanding of the recommendations guiding their application is essential for all surgeons. Here, we comprehensively review these recommendations with a focus on open and laparoscopic urologic surgeries.

Assessment of mechanical bowel preparation prior to nephrectomy in the minimally invasive surgery era: insights from a national database analysis in the United States

Purpose

This study was performed to evaluate the association between mechanical bowel preparation (MBP) and perioperative outcomes following nephrectomy in the minimally invasive surgery (MIS) era.

Methods

All partial and radical nephrectomies between 2019 and 2021 from the National Surgical Quality Improvement Program database were evaluated. Thirty-day perioperative outcomes were compared between groups where MBP was performed vs. not, in both the MIS and open surgery (OS) cohorts. A propensity score matching technique was utilized within MIS cases to control for covariates. The chi-square and t tests were used to determine significance.

Results

A total of 11,869 cases met the inclusion criteria and were included in the analysis. Of these, 8,204 (69.1%; comprising 65.3% robotic and 34.7% laparoscopic) underwent MIS, while 3,655 (30.9%) underwent OS. The rate of MBP was higher in the MIS group (16.0% vs. 10.0%, p < 0.001). Within the MIS group, MBP was associated with reduced rates of postoperative ileus (0.9% vs. 1.9%, p = 0.02), while other complications were comparable. Propensity score matching showed no association between MBP and postoperative ileus. However, a lower rate of 30-day readmission in the MBP group became statistically significant (4.4% vs. 6.4%, p = 0.01). Conversely, patients in the MBP group also demonstrated higher rates of pneumonia (1.29% vs. 0.46%, p = 0.002) and pulmonary embolism (0.6% vs. 0%, p < 0.001) after matching.

Conclusion

MBP practice prior to nephrectomy is infrequent in both OS and MIS cases, with minor differences in perioperative outcomes for patients undergoing MIS. Routine MBP should continue to be excluded from the standard of care for nephrectomy in the MIS era.

Implementation of the enhanced recovery after surgery protocol for radical cystectomy patients: A single centre experience

PURPOSE

The enhanced recovery after surgery (ERAS) protocol for radical cystectomy aims to facilitate postoperative recovery and hasten a return to normal daily activities. This study aims to report on the perioperative outcomes of implementation of an ERAS protocol at a single Australian institution.

MATERIALS AND METHODS

We identified 73 patients with pT1-T4 bladder cancer who underwent open radical cystectomy at Western Health, Victoria between June 2016 and August 2021. A retrospective analysis of a prospectively maintained database was performed. Perioperative outcomes included length of hospital stay, nasogastric tube requirement and duration of postoperative ileus.

RESULTS

The median age was 74 years (interquartile range [IQR] 66-78) for the ERAS group and 70 years (IQR 65-78) for the pre-ERAS group patients. All patients in each group underwent ileal conduit formation. The median length of hospital stay was 7.0 days (IQR 7.0-9.3) for the ERAS group and 12.0 days (IQR 8.0-16.0) for the pre-ERAS group (p=0.003). Within the ERAS group, 25.0% had a postoperative ileus, and 25.0% had a nasogastric tube inserted, compared with 64.9% (p=0.001) and 45.9% (p=0.063) respectively within pre-ERAS group. The median bowel function recovery time, defined as duration from surgery to first bowel action, was 5.0 days (IQR 4.0-7.0) in the ERAS group and 7.5 days (IQR 5.0-8.5) in the pre-ERAS group (p=0.016).

CONCLUSIONS

Implementation of an ERAS protocol is associated with a reduction in hospital length of stay, postoperative ileus and bowel function recovery time.

Robotic Intracorporeal Ileal Conduit Urinary Diversion Technique

The gold standard surgical treatment for muscle invasive bladder cancer is radical cystectomy and urinary diversion. This procedure has historically been performed as an open surgery. With the advances of robotic surgery, robotic cystectomy and urinary diversion has gained popularity with the ability to perform intracorporeal urinary diversions in addition to extirpative surgery. Herein, we detail our technique for intracorporeal ileal conduit.

A comparison between limited bowel preparation and comprehensive bowel preparation in radical cystectomy with ileal urinary diversion: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Our aim is to evaluate the value of limited bowel preparation (LBP) in radical cystectomy (RC) with ileal urinary diversion (IUD).

METHODS

A systematic literature search was conducted on electronic database up to February 2020. All data were analyzed using RevMan5 (version 5.3). A subgroup analysis comparing the efficacy of CBP and no bowel preparation (NBP) was also performed.

RESULTS

Six randomized controlled trials (RCTs) including 743 patients were finally enrolled for statistical analysis. According to the meta-analysis, there was no significant difference between LBP group and comprehensive bowel preparation (CBP) group, concerning operative time (p = 0.79), length of stay (p = 0.46), the time to first toleration of clear liquids (p = 0.95), and overall complications (p = 0.29). However, the time to first bowel activity (SMD: - 0.77, 95% CI - 1.47 to - 0.07, p = 0.03), risk of fever (RR: 0.53, 95% CI 0.33-0.85, p = 0.008), time to first flatus (SMD: - 1.06, 95% CI - 2.02 to - 0.10, p = 0.03), and risk of wound healing disorders (RR: 0.65, 95% CI 0.44-0.95, p = 0.03) were significantly lower in LBP group compared with CBP group. Subgroup analysis showed a significant lower risk of wound healing disorders in favor of NBP (RR: 0.50, 95% CI 0.29-0.87, p = 0.01).

CONCLUSIONS

Current evidence indicated that LBP protocols might accelerate recovery of gastrointestinal function, promote wound healing, and reduce the risk of fever without increasing complications in patients undergoing RC with IUD. Besides, bowel preparation also did not hinder wound healing. Further, well-designed RCTs conducted by experienced surgeons are warranted before making the final clinical guidelines.

Enhanced recovery protocol versus standard protocol for patients undergoing radical cystectomy: results of a prospective randomized study

Background

To assess patients undergoing radical cystectomy using enhanced recovery protocol and standard protocol in terms of intraoperative and postoperative outcomes and complications.

Results

All operative and postoperative complications were recorded. In group B, time to normal bowel activity ranged from 1 to 4 days, and the mean was 1.8 days (± 1.02), while it ranged from 1 to 5 days, and the mean was 3.17 days (± 1.14) in group A which was statistically significant (p value < 0.001). The length of hospital stay in group B ranged from 6 to 50 days, the mean was 13.16 days (± 7.83), while it ranged from 8 to 35 days, and the mean was 14.71 days (± 5.78) in group A which was statistically significant (p value = 0.033). Postoperative mortality was similar in both groups.

Conclusion

In patients undergoing radical cystectomy, enhanced recovery protocol is considered as a safe procedure and not associated with any increase in intraoperative and postoperative complications compared to standard protocol. The length of hospital stay and time to return to full diet are reduced.

Does Postoperative Rehabilitation for Radical Cystectomy Call for Enhanced Recovery after Surgery? A Systematic Review and Meta-analysis

The aim of this review was to systematically compare the outcomes of enhanced recovery after surgery (ERAS) with standard care (SC) after radical cystectomy. We performed a systematic search of PubMed, Ovid, Web of Science, and the Cochrane Library to identify studies published until September 2017 which involved a comparison of ERAS and SC. A meta-analysis was performed to assess the outcomes of ERAS versus SC. Sixteen studies including 8 prospective and 8 retrospective trials met the eligibility criteria. A total of 2100 participants were assigned to ERAS (1258 cases) or SC (842 cases). The time to first flatus passage {WMD=-0.95 days, 95% CI (-1.50,-0.41), P=0.0006}, time until return to a regular diet {WMD=-2.15 days, 95% CI (-2.86,-1.45), P<0.00001} and the length of hospital stay {WMD=-3.75 days, 95% CI (-5.13,-2.36), P<0.00001} were significantly shorter, and the incidence of postoperative complications {OR=0.60, 95% CI (0.44, 0.83), P=0.002}, especially postoperative paralytic ileus {OR=0.43, 95% CI (0.30, 0.62), P<0.00001} and cardiovascular complications {OR=0.28, 95% CI (0.09, 0.90), P=0.03} was significantly lower in the ERAS group than those in the SC group. This meta-analysis demonstrated that ERAS was associated with a shorter time to first flatus passage, return of bowel function, and the length of hospital stay than SC in patients undergoing radical cystectomy, as well as a lower rate of postoperative complications, especially paralytic ileus and cardiovascular complications.

Enhanced Recovery After Surgery Protocols in Major Urologic Surgery

The purpose of the review

The analysis of the components of enhanced recovery after surgery (ERAS) protocols in urologic surgery.

Recent findings

ERAS protocols has been studied for over 20 years in different surgical procedures, mostly in colorectal surgery. The concept of improving patient care and reducing postoperative complications was also applied to major urologic surgery and especially procedure of radical cystectomy. This procedure is technically challenging, due to a major surgical resection and high postoperative complication rate that may reach 65%. Several clinical pathways were introduced to improve perioperative course and reduce the length of hospital stay. These protocols differ from ERAS modalities in other surgeries. The reasons for this are longer operative time, increased risk of perioperative transfusion and infection, and urinary diversion achieved using transposed intestinal segments. Previous studies in this area analyzed the need for mechanical bowel preparation, postoperative nasogastric tube decompression, as well as the duration of urinary drainage. Furthermore, the attention has also been drawn to perioperative fluid optimization, pain management, and bowel function.

Summary

Notwithstanding partial resemblance between the pathways in major urologic surgery and other pelvic surgeries, there are still scarce guidelines for ERAS protocols in urology, which is why further studies should assess the importance of preoperative medical optimization, implementation of thoracic epidural anesthesia and analgesia, and perioperative nutritional management.

Postoperative management of radical cystectomy. Review of the evidence on the prevention and treatment of urological complications

INTRODUCTION AND OBJECTIVES

This review article focuses on the prevention and management of the most common postoperative urological complications of radical cystectomy. We reviewed the current literature and conducted an analysis of frequency, prevention and treatment of complications.

ACQUISITION OF EVIDENCE

We conducted a search on Medline to identify original articles, literature reviews and editorials focusing on the urological complications of radical cystectomy during the first 90 days after surgery. We identified those series that included more than 100 patients.

SYNTHESIS OF THE EVIDENCE

The literature regarding the prevention and treatment of complications after cystectomy is in general retrospective and nonstandardised. The level of evidence is generally low, and it is difficult to make evidence-based recommendations.

CONCLUSIONS

Progress has been made in recent years in reducing mortality and preventing the complications of cystectomy. The most common complications are gastrointestinal, for which significant efforts have been made to implement ERAS and Fast Track protocols. The complications that can most significantly change patients' quality of life are urinary stoma.

Visceral and gastrointestinal complications in robotic urologic surgery

INTRODUCTION

with the widespread use of minimally invasive techniques, robot-assisted urologic surgery has become widely adopted. Despite their infrequency, visceral and gastrointestinal complications could be life-threatening.

OBJECTIVES

To identify the main gastrointestinal injuries that occur in a robot-assisted urologic surgery. To know the overall incidence and how is their management.

ACQUISITION OF THE EVIDENCE

Search in PubMed of articles related to visceral and gastrointestinal complications in robot-assisted urology surgery, written in English or Spanish. Relevant publications as well literature reviews and chapters from books were reviewed.

SYNTHESIS OF THE EVIDENCE

Along with vascular injuries, visceral and gastrointestinal lesions are among most dangerous complications. A complete preoperative study to individualize each patient characteristics and the correct use of imaging could help us to avoid complications in the first place. To know all the risky steps in the different robotic urologic procedures will let us anticipate the damage. Knowledge of main and most dangerous injuries in the different abdominal and pelvic organs is fully recommended. Early diagnosis and evaluation of lesions will let us an acute management during surgery. Recognition delay could change a repairable injury into a life-threatening situation.

CONCLUSIONS

Despite the undeniable benefits of robotic approach, there are minor and major gastrointestinal injuries that all urologic surgeons must know. Those related with trocar placement are especially important. Immediate diagnosis and management is mandatory.

Enhanced Recovery After Surgery for Radical Cystectomy

Even with advances in perioperative medical care, anesthetic management, and surgical techniques, radical cystectomy (RC) continues to be associated with a high morbidity rate as well as a prolonged length of hospital stay. In recent years, there has been great interest in identifying multimodal and interdisciplinary strategies that help accelerate postoperative convalescence by reducing variation in perioperative care of patients undergoing complex surgeries. Enhanced recovery after surgery (ERAS) attempts to evaluate and incorporate scientific evidence for modifying as many of the factors contributing to the morbidity of RC as possible, and optimize how patients are cared for before and after surgery. In this chapter, we review the preoperative, intraoperative and postoperative elements of using an ERAS protocol for RC.

Bladder Cancer Recovery Pathways: A Systematic Review

BACKGROUND

Enhanced recovery pathways, also known as fast-track protocols, have been adopted since the early 2000s by various surgical specialties with the goal of improving patient outcomes and reducing the cost burden of major surgery on the health care system.

OBJECTIVE

To review the scientific literature on the origin of enhanced recovery pathways, track the contemporary utilization of such practices for patients undergoing radical cystectomy, and analyze the available data regarding their effect on morbidity, mortality, and treatment cost.

METHODS

A literature search of multiple electronic databases was undertaken. Manuscripts including patients undergoing radical cystectomy were chosen based on predefined criteria with an emphasis on randomized controlled trials and cohort studies. Strength of evidence for each study that met inclusion criteria was assessed based on the risk of bias, consistency, directness, and precision.

RESULTS

Database searches resulted in 1,236 potentially relevant articles. A total of 485 articles were selected for full-text dual review and 106 studies in 52 publications met the inclusion criteria.

CONCLUSION

The utilization of enhanced recovery pathways with the goal of improving overall patient morbidity and mortality is well supported in the literature, however standardization of implementation and adherence across institutions is lacking, and their direct efficacy on reducing preventable treatment related expenditures is unconfirmed.

How to lower postoperative complications after radical cystectomy - a review

Introduction

Lowering morbidity and mortality after RC is subject of considerable interest. Lately, many evidence-based data on improvements in operative technique, anesthetic management, and patient care have been published.

In this article, we present a review of literature on how to lower postoperative complications after RC.

Material and methods

The Medline, and Web of Science databases were searched without a time limit on February 2016 using the terms ‘cystectomy’ in conjunction with ‘radical’, ‘bladder cancer’, ‘complications’ or ‘management’. Boolean operators (NOT, AND, OR) were also used in succession to narrow and broaden the search. The search was limited to the English, Polish and Spanish literature.

Results

Many complications may be avoided by appropriate patient selection and meticulous introduction of care protocols.

Conclusions

RC as treatment free of complications, even in the hands of an experienced urologist, does not exist. A large number of complications are acceptable in the name of good long-term results. Optimum results are possible with proper surgical technique, good patients and urinary diversion selection and proper patient management in the pre-, peri, and postoperative period.

Enhanced Recovery after Urological Surgery: A Contemporary Systematic Review of Outcomes, Key Elements, and Research Needs

CONTEXT

Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and reduce recovery times.

OBJECTIVE

To overview the use and key elements of ERAS pathways, and define needs for future clinical trials.

EVIDENCE ACQUISITION

A comprehensive systematic MEDLINE search was performed for English language reports published before May 2015 using the terms "postoperative period," "postoperative care," "enhanced recovery after surgery," "enhanced recovery," "accelerated recovery," "fast track recovery," "recovery program," "recovery pathway", "ERAS," and "urology" or "cystectomy" or "urologic surgery."

EVIDENCE SYNTHESIS

We identified 18 eligible articles. Patient counseling, physical conditioning, avoiding excessive alcohol and smoking, and good nutrition appeared to protect against postoperative complications. Fasting from solid food for only 6h and perioperative liquid-carbohydrate loading up to 2h prior to surgery appeared to be safe and reduced recovery times. Restricted, balanced, and goal-directed fluid replacement is effective when individualized, depending on patient morbidity and surgical procedure. Decreased intraoperative blood loss may be achieved by several measures. Deep vein thrombosis prophylaxis, antibiotic prophylaxis, and thermoregulation were found to help reduce postsurgical complications, as was a multimodal approach to postoperative nausea, vomiting, and analgesia. Chewing gum, prokinetic agents, oral laxatives, and an early resumption to normal diet appear to aid faster return to normal bowel function. Further studies should compare anesthetic protocols, refine analgesia, and evaluate the importance of robot-assisted surgery and the need/timing for drains and catheters.

CONCLUSIONS

ERAS regimens are multidisciplinary, multimodal pathways that optimize postoperative recovery.

PATIENT SUMMARY

This review provides an overview of the use and key elements of Enhanced Recovery after Surgery programs, which are multimodal, multidisciplinary care pathways that aim to optimize postoperative recovery. Additional conclusions include identifying effective procedures within Enhanced Recovery after Surgery programs and defining needs for future clinical trials.

Recommendations for the improvement of bladder cancer quality of care in Canada: A consensus document reviewed and endorsed by Bladder Cancer Canada (BCC), Canadian Urologic Oncology Group (CUOG), and Canadian Urological Association (CUA), December 2015

This initiative was undertaken in response to concerns regarding the variation in management and in outcomes of patients with bladder cancer throughout centres and geographical areas in Canada. Population-based data have also revealed that real-life survival is lower than expected based on data from clinical trials and/or academic centres. To address these perceived shortcomings and attempt to streamline and unify treatment approaches to bladder cancer in Canada, a multidisciplinary panel of expert clinicians was convened last fall for a two-day working group consensus meeting. The panelists included urologic oncologists, medical oncologists, radiation oncologists, patient representatives, a genitourinary pathologist, and an enterostomal therapy nurse. The following recommendations and summaries of supporting evidence represent the results of the presentations, debates, and discussions. Methodology

Demonstrating Value: A Case Study of Enhanced Recovery

An enhanced recovery after surgery strategy will be increasingly adopted in the era of value-based care. The various elements in each enhanced recovery after surgery protocol are likely to add value to the overall patient surgical journey. Although the evidence varies considerably based on type of surgery and patient group, the team-based approach of care should be universally applied to patient care. This article provides an overview of up-to-date techniques and methodology for enhanced recovery, including an overview of value-based care, delivery, and the evidence base supporting enhanced recovery after surgery.

Radical Cystectomy Perioperative Care Redesign

OBJECTIVE

To present an evidence-based review of the perioperative management of the radical cystectomy (RC) patient in the context of a care redesign initiative.

METHODS

A comprehensive review of the key factors associated with perioperative management of the RC patient was completed. PubMed, Medline, and the Cochrane databases were queried via a computerized search. Specific topics were reviewed within the scope of the three major phases of perioperative management: preoperative, intraoperative, and postoperative. Preference was given to evidence from prospective randomized trials, meta-analyses, and systematic reviews.

RESULTS

Preoperative considerations to improve care in the RC patient should include multi-disciplinary medical optimization, patient education, and formal coordination of care. Efforts to mitigate the risk of malnutrition and reduce postoperative gastrointestinal complications may include carbohydrate loading, protein nutrition supplementation, and avoiding bowel preparation. Intraoperatively, a fluid and opioid sparing protocol may reduce fluid shifts and avoid complications from paralytic ileus. Finally, enhanced recovery protocols including novel medications, early feeding, and multi-modal analgesia approaches are associated with earlier postoperative convalescence.

CONCLUSION

RC is a complex and morbid procedure that may benefit from care redesign. Evidence based quality improvement is integral to this process. We hope that this review will help guide further improvement initiatives for RC.

Modern Guidelines for Bowel Preparation and Antimicrobial Prophylaxis for Open and Laparoscopic Urologic Surgery

Mechanical bowel preparation (MBP) and antibiotics (oral and/or intravenous) have historically been used to decrease infectious complications in surgeries that involve manipulation of bowel or potential risk of injury. The use of MBP has recently been challenged in the colorectal surgery literature, thus inspiring similar critical evaluation of our practices in urology. This review gives a brief overview of the history of mechanical and oral antibiotic bowel preparation, as well as the evolution of the practice trends in colorectal surgery and urology. We also examine contemporary guidelines in skin preparation as well as antimicrobial prophylaxis before surgery.

The role of mechanical bowel preparation before ileal urinary diversion: a systematic review and meta-analysis

BACKGROUND

Although the use of mechanical bowel preparation (MBP) is still widely promoted as the dogma before patients undergo ileal urinary diversion, an increasing number of clinical trials have suggested that there is no benefit. Thus, we performed a meta-analysis to evaluate the efficacy of MBP in ileal urinary diversion surgery.

METHODS

A literature search was performed in electronic databases, including PubMed, Embase, Science Citation Index Expanded as well as the Cochrane Library and the Cochrane Clinical Trials Registry, from 1966 to January 1, 2013. Clinical trials comparing outcomes of MBP versus no MBP for ileal urinary diversion surgery were included in the meta-analysis. Pooled odds ratios with 95% confidence intervals were calculated using the fixed- or random-effects models.

RESULTS

In total, two randomized controlled trials and five cohort studies were included in this meta-analysis. The primary outcomes, such as bowel leak and bowel obstruction, showed no statistical difference between the two groups. Additionally, the overall mortality rate and death rate related to operation also manifested that MBP does not offer an advantage over the no MBP.

CONCLUSION

This meta-analysis suggests that MBP does not reduce the incidence of perioperative complications in urinary diversion compared with no MBP. However, large randomized controlled clinical trials are needed to confirm this finding.

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.

Peri-operative management in urinary diversion surgery: A time for change?

INTRODUCTION

Bowel preparation was established as part of the pre-operative course for patients undergoing ileal conduit formation since the late 1970's. Rationales for its use include reduction in infection and wound complications, technically easier anastomosis and earlier return to bowel function. However, recent reports have challenged this practice. Traditionally antibiotics were also administered for several days prior to surgery with the assumption that bacterial load was reduced. Modification of antibiotic protocols resulted from evidence-based findings. Furthermore, publications emphasizing the benefit of Enhanced Recovery Protocols/Programmes (ERP) have become contemporary.

METHODS

An online multiple-choice questionnaire (via Monkey Survey) was administered to all consultant urologists in Ireland. This national cross-sectional study evaluated the use of bowel preparation and antibiotic prophylaxis prior to urinary diversion. In addition, we also assessed consultant urologists' awareness of ERP and their views on the introduction and implementation of such a national program.

RESULTS

Of the 41 consultant urologists surveyed, 80.4% (n = 33) responded. 63.6% routinely used bowel preparation. Klean Prep was the most commonly used bowel preparation. 80.9% of urologists admit their patient's one-day pre-operatively for bowel preparation, with 87.8% using antibiotic prophylaxis at anesthesia induction, and 18.1% continuing the antibiotics for 24-48 h post-operatively. Although 74% of consultants are aware of ERP, only 66.6% are in favor of their national implementation.

CONCLUSION

The majority of Irish urologists use bowel preparation prior to ileal conduit formation. Substantial recent evidence has emerged showing no difference in infective complications or anastomotic leakage when bowel preparation was not used. National guidelines would be beneficial regarding the use of bowel preparation, antibiotic prophylaxis and ERP for urinary diversion surgery.

Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS(®)) society recommendations

PURPOSE

Enhanced recovery after surgery (ERAS) pathways have significantly reduced complications and length of hospital stay after colorectal procedures. This multimodal concept could probably be partially applied to major urological surgery.

OBJECTIVES

The primary objective was to systematically assess the evidence of ERAS single items and protocols applied to cystectomy patients. The secondary objective was to address a grade of recommendation to each item, based on the evidence and, if lacking, on consensus opinion from our ERAS Society working group.

EVIDENCE ACQUISITION

A systematic literature review was performed on ERAS for cystectomy by searching EMBASE and Medline. Relevant articles were selected and quality-assessed by two independent reviewers using the GRADE approach. If no study specific to cystectomy was available for any of the 22 given items, the authors evaluated whether colorectal guidelines could be extrapolated.

EVIDENCE SYNTHESIS

Overall, 804 articles were retrieved from electronic databases. Fifteen articles were included in the present systematic review and 7 of 22 ERAS items were studied. Bowel preparation did not improve outcomes. Early nasogastric tube removal reduced morbidity, bowel recovery time and length of hospital stay. Doppler-guided fluid administration allowed for reduced morbidity. A quicker bowel recovery was observed with a multimodal prevention of ileus, including gum chewing, prevention of PONV and minimally invasive surgery.

CONCLUSIONS

ERAS has not yet been widely implemented in urology and evidence for individual interventions is limited or unavailable. The experience in other surgical disciplines encourages the development of an ERAS protocol for cystectomy.

Improvements in safety and recovery following cystectomy: reassessing the role of pre-operative bowel preparation and interventions to speed return of post-operative bowel function

For radical cystectomy, historical practice trends have favored the use of preoperative bowel preparations to reduce complications, including surgical site infections, ileus, and anastomotic leaks. However, emerging data has questioned this practice. Postoperative cystectomy care also remains in flux, as new pharmacologic agents that may potentiate earlier return of bowel function are studied. We review the current literature with regards to preoperative and postoperative cystectomy bowel management.

Does mechanical bowel preparation improve quality of laparoscopic nephrectomy? Propensity score-matched analysis in Japanese series

OBJECTIVE

To assess the effect of mechanical bowel preparation (MBP) before laparoscopic nephrectomy in terms of operation time and perioperative complications.

MATERIALS AND METHODS

Patients undergoing laparoscopic nephrectomy for T1-T3 tumors were identified in the Japanese Diagnosis Procedure Combination database from 2008 to 2010. The patients were stratified into a preoperative MBP group (polyethylene glycol electrolyte, magnesium citrate solution, and sodium picosulfate) and a non-MBP group and were matched using one-to-one propensity score matching according to age, sex, Charlson score, T category, hospital volume, and hospital academic status. The operation time, postoperative length of stay, and overall complication rate were assessed by multivariate regression analyses.

RESULTS

Of 2740 patients in 355 hospitals, 1110 pairs were generated. The median operation time, postoperative stay, and overall complication rate (MBP vs non-MBP group) was 278 and 268 minutes (P<.004), 10.3 and 10.0 days (P=.695), and 11.8% and 11.4% (P=.740), respectively. The multivariate regression analyses did not find significant superiority of MBP for the 3 endpoints (all P>.05). A shorter operation time was significantly associated with female sex and early-stage tumor. Older age, greater Charlson score, and lower hospital volume adversely affected the postoperative stay and overall complication rate. Stage T3 tumor was unfavorable for the postoperative stay.

CONCLUSION

Our large-scale propensity score-matched analysis did not demonstrate a benefit for MBP in operation time, postoperative stay, or overall complications. The results suggest that MBP can be safely omitted before laparoscopic nephrectomy for T1-T3 tumors.

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.

The impact of mechanical bowel preparation on postoperative complications for patients undergoing cystectomy and urinary diversion

PURPOSE

The benefit of routine mechanical bowel preparation for patients undergoing radical cystectomy is not well established. We compared postoperative complications in patients who did or did not undergo mechanical bowel preparation before radical cystectomy.

MATERIALS AND METHODS

In 2008 a single surgeon (GDS) performed open radical cystectomy with an ileal conduit or orthotopic neobladder in 105 consecutive patients with preoperative mechanical bowel preparation consisting of 4 l GoLYTELY®. In 2009 radical cystectomy with an ileal conduit or orthotopic neobladder was performed in 75 consecutive patients without mechanical bowel preparation. A comprehensive database provided clinical, pathological and outcome data.

RESULTS

All patients had complete perioperative data available. The 2 groups were similar in age, Charlson comorbidity score, diversion type, receipt of neoadjuvant radiation or chemotherapy, blood loss, hospital stay, time to diet and pathological stage. Postoperative urinary tract infection, wound dehiscence and perioperative death rates were similar in the 2 groups. Clostridium difficile infection developed within 30 days of surgery in 11 of 105 vs 2 of 75 patients with vs without mechanical bowel preparation (p = 0.08). When adjusted for the annual hospital-wide C. difficile rate, the difference remained insignificant (p = 0.21). Clavien grade 3 or greater abdominal and gastrointestinal complications, including fascial dehiscence, abdominal abscess, small bowel obstruction, bowel leak and entero-diversion fistula, developed in 7 of 105 patients with (6.7%) vs 11 of 75 without (14.7%) mechanical bowel preparation (p = 0.08).

CONCLUSIONS

The use of mechanical bowel preparation for patients undergoing radical cystectomy with an ileal conduit or orthotopic neobladder does not seem to impact the rates of perioperative infectious, wound and bowel complications. Larger series with multiple surgeons are necessary to confirm these findings.

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.

Elimination of preoperative mechanical bowel preparation in patients undergoing cystectomy and urinary diversion

INTRODUCTION

The utility of a preoperative mechanical bowel preparation prior to bowel surgery has recently been questioned. The purpose of this study is to compare the perioperative outcomes between patients undergoing cystectomy with urinary diversion with or without preoperative mechanical bowel preparation.

METHODS

Seventy patients underwent radical cystectomy and urinary diversion between May 2008 and August 2009 for bladder cancer. The first cohort of patients (n = 37) underwent cystectomy and diversion during the period May 2008-December 2008 and underwent a preoperative mechanical bowel preparation including a clear liquid diet, magnesium citrate solution, and an enema before surgery. The second cohort of patients underwent surgery during the period of January 2009-August 2009 (n=33). These patients were given a regular diet before surgery and did not undergo a mechanical bowel preparation except for the enema before surgery was performed to decrease rectal/colonic distention. Outcome measures included gastrointestinal and overall complications, and perioperative outcomes including recovery of bowel function.

RESULTS

There were no differences with regard to recovery of bowel function, time to discharge, or overall complication rates between the 2 groups. More specifically, the rate of GI complications was not different in prepped patients vs. nonprepped patients (22% vs. 15%; P = 0.494). There were no occurrences of bowel anastomotic leak, fistula, abscess, peritonitis, or surgical site infection in either group. One perioperative death occurred in the nonprepped group secondary to cardiovascular complications.

CONCLUSIONS

Preoperative mechanical bowel preparation prior to radical cystectomy with urinary diversion does not demonstrate any significant advantage in perioperative outcomes, including gastrointestinal complications. Further studies aimed at measuring patient satisfaction and larger randomized trials will be beneficial in evaluating the role of mechanical bowel preparation prior to urinary diversion.

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.