Preoperative Immunonutrition Significantly Reduced Surgical Site Infection After Urinary Diversion for Invasive Bladder Cancer: A Retrospective Cohort Study

BACKGROUND

Radical cystectomy and ileal conduit have a high incidence of surgical site infection. In this study, we evaluated the effects of preoperative immunonutrition on its incidence following these procedures.

MATERIALS AND METHODS

We retrospectively enrolled 86 patients who underwent radical cystectomy and ileal conduit at our hospital between 2014 October and 2021 July. They were sequentially divided into the Immunonutrition group (n = 43) and Control group (n = 43). Patients in the Immunonutrition group drank 4 packs of IMPACT (Nestle, Japan) per day for 5 days before surgery. IMPACT contains arginine and eicosapentaenoic acid. We compared levels of plasma arginine and eicosapentaenoic acid before and after surgery and the rate of surgical site infection between the groups. Factors related to surgical site infection were analyzed using univariate and multivariable logistic regression analysis.

RESULTS

No statistically significant differences were observed in patient characteristics between the groups except for surgical operative method (P < .001) and transfusion (P = .009). Levels of plasma arginine and eicosapentaenoic acid were significantly increased the day before surgery in the immunonutrition group (P < .001). However, the levels of plasma arginine on the day after surgery did not vary significantly between the groups. The incidence of surgical site infection was significantly lower in the immunonutrition group (P = .014). Multivariate analyses showed a significant association of surgical site infection with immunonutrition (OR = 0.14, CI 0.03-0.72, P = .019) and with ASA classification (OR = 4.76, CI 1.23-18.40, P = .024).

CONCLUSIONS

Preoperative immunonutrition significantly reduced the incidence of surgical site infection following radical cystectomy and ileal conduit.

Enhanced Recovery After Robot-assisted Radical Cystectomy: EAU Robotic Urology Section Scientific Working Group Consensus View

CONTEXT

Radical cystectomy (RC) is associated with frequent morbidity and prolonged length of stay (LOS) irrespective of surgical approach. Increasing evidence from colorectal surgery indicates that minimally invasive surgery and enhanced recovery programmes (ERPs) can reduce surgical morbidity and LOS. ERPs are now recognised as an important component of surgical management for RC. However, there is comparatively little evidence for ERPs after robot-assisted radical cystectomy (RARC). Due to the multimodal nature of ERPs, they are not easily validated through randomised controlled trials.

OBJECTIVE

To provide a European Association of Urology (EAU) Robotic Urology Section (ERUS) policy on ERPs to guide standardised perioperative management of RARC patients.

EVIDENCE ACQUISITION

The guidance was formulated in four phases: (1) systematic literature review of evidence for ERPs in robotic, laparoscopic, and open RC; (2) an online questionnaire survey formulated and sent to ERUS Scientific Working Group members; (3) achievement of consensus from an expert panel using the Delphi process; and (4) a standardised reporting template to audit compliance and outcome designed and approved by the committee.

EVIDENCE SYNTHESIS

Consensus was reached in multiple areas of an ERP for RARC. The key principles include patient education, optimisation of nutrition, RARC approach, standardised anaesthetic, analgesic, and antiemetic regimens, and early mobilisation.

CONCLUSIONS

This consensus represents the views of an expert panel established to advise ERUS on ERPs for RARC. The ERUS Scientific Working Group recognises the role of ERPs and endorses them as standardised perioperative care for patients undergoing RARC. ERPs in robotic surgery will continue to evolve with technological and pharmaceutical advances and increasing understanding of the role of surgery-specific ERPs.

PATIENT SUMMARY

There is currently a lack of high-level evidence exploring the benefits of enhanced recovery programmes (ERPs) in patients undergoing robot-assisted radical cystectomy (RARC). We reported a consensus view on a standardised ERP specific to patients undergoing RARC. It was formulated by experts from high-volume RARC hospitals in Europe, combining current evidence for ERPs with experts' knowledge of perioperative care for robotic surgery.

Enhanced recovery protocols (ERP) in robotic cystectomy surgery. Review of current status and trends

Open radical cystectomy with pelvic lymphadenectomy and urinary diversion is associated with a high complication rate. Robotic-assisted laparoscopic radical cystectomy is increasingly performed in many urologic surgical departments in an effort to reduce surgical stress and decrease perioperative morbidity. Robotic cystectomy survival studies demonstrate similar oncologic outcomes compared to the open procedure. Enhanced recovery protocols (ERP) after major surgery are multimodal perioperative interventions to reduce surgical stress, complications, and patient convalescence. Evidence for different ERP interventions are currently mainly from colorectal surgery and recently adapted to major urologic operations including cystectomy. Guidelines for perioperative care after open radical cystectomy for bladder cancer were recently published, but these recommendations may differ when considering a robotic approach. Therefore, we look at the current evidence for ERP in both open and robotic radical cystectomy and the potential for improving ERPs in robotic cystectomy by utilizing a totally intracorporeal robotic cystectomy approach. We also present the Karolinska ERP currently utilized in totally intracorporeal robotic cystectomy.

Preoperative immunonutrition in liver resection-a propensity score matched case-control analysis

BACKGROUND/OBJECTIVES

The value of preoperative nutritional support in liver resection remains questionable. The aim of the present study was to compare the incidence of postoperative complications after liver resection between those patients that received preoperative immunonutrition versus those patients without preoperative nutritional support.

SUBJECTS/METHODS

Patients undergoing elective liver resection between 9 November 2007 and 14 May 2013 were considered for the study: 84 with preoperative immunonutrition (Oral-Impact, Nestle, 3 × 237 ml per day for seven days at home) and 63 control patients without preoperative nutritional support. To reduce selection bias, propensity score matching was performed. Primary endpoint was the overall complication rate. Secondary endpoints were infectious and major complications.

RESULTS

Ninety-eight patients could be matched (49 in each group). Seventy-seven patients (78.6%) had a minor and 21 patients (21.4%) a major liver resection. The two groups were balanced for age, gender distribution, American Society of Anesthesiology score ⩾3, NRS 2002 score, weight loss>10%, cirrhosis, steathosis, preoperative chemotherapy, pathology, major liver resection and extrahepatic procedures. No significant differences were observed in the overall complication rate (53.0% versus 51.0%), infectious complications (38.7% versus 28.5%) and major complications (12.2% versus 10.2%) for the immunonutrition and control group, respectively.

CONCLUSIONS

The present study did not permit to demonstrate an impact of preoperative immunonutrition with Oral-Impact on postoperative complications after minor liver resection.