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

Major abdominal surgery, and also radical cystectomy, is followed by a delayed return of bowel function attributable to postoperative ileus (POI), which, in addition, stands out as one of the most frequent complications that causes increased length of stay (LOS). Some variability exists in the definition of POI since time to return of peristalsis and time to first passage of flatus, which are commonly referred to as indicators of bowel activity, have their own weaknesses, observer dependent and time dependent, among other variables. A number of causes have been recognized to induce or maintain the condition of ileus. Some among them are part of the perioperative period. The practices of mechanical bowel preparation (MBP) and of fasting before surgery have been challenged and can be safely abandoned. The perception of pain is an acknowledged promoter of POI; therefore, providing complete pain control constitutes the rationale in favor of administering anesthesia and analgesia combined, both in the form of concurrent general and epidural anesthesia (i.e., at the thoracic level, T9, T11), and represents the mainstay of intraoperative measures. Hypovolemia is also associated with an increased risk of POI. The use of nasogastric tubing (NGT) has been associated with increased pulmonary complications; moreover, bowel resection can be performed safely without postoperative NGT. Early postoperative provision of artificial nutrients has shown beneficial effects, both in the form of total parenteral and enteral nutrition (PEN, EN). We devised a perioperative care regimen, adopting a multimodality approach aimed at minimizing the effects of the above listed factors to ascertain if they could contribute to preventing or reducing POI and the complications associated with radical cystectomy and intestinal urinary diversion. In addition, we investigated the impact of early artificial nutrition, combining PEN and EN via a jejunal nutrition cannula. Time to return of bowel movements, time to reinstitution of a regular diet, presence and duration of POI, and incidence and nature of complications constituted the study end points. Of 143 consecutive patients, 107 who underwent radical cystectomy with intestinal urinary reconstruction were able to be evaluated for results and complications. The male to female ratio was 86:21, the mean age was 74 years, and more than two-third belonged to the American Society of Anesthesiologists categories II and III. Pathologic stages of disease were bladder confined in 48 patients, locally advanced in 33, and extravesical in 26. Urinary diversion with intestine consisted in the configuration of heterotopic reservoirs in 39 patients, orthotopic substitution in 38, and uretero-ileo-cutaneostomy in 30. Bowel movements returned after a median time of 2 days (range, 1-6), and the median time to reinstitution of a regular diet was 4 days (range, 3-9). POI beyond postoperative day 4 was observed in 17.7% of the patients. Overall, a total of 28 patients (26.1%) experienced complications, specifically, medical complications in 19 patients and surgical complications leading to relaparotomy in 11. The mortality rate was 3.7%. No effects were observed on postoperative protein depletion, despite the provision of early artificial nutrition. Our results suggest that a short median time of return of both peristalsis and flatus, and to regular diet resumption with a low incidence of POI, can be obtained in the majority of patients with a perioperative regimen aimed at reducing the effect of some of the causes associated with induction or maintenance of POI. Further studies of multimodality perioperative care plans, similar to that used in the present study, are required.

Multimodal perioperative plan for radical cystectomy and intestinal urinary diversion. I. Effect on recovery of intestinal function and occurrence of complications.

OBJECTIVES: To discuss a multimodal perioperative plan aimed at reducing postoperative ileus and complications associated with radical cystectomy and urinary reconstruction. METHODS: The protocol consisted of preoperative, intraoperative, and postoperative measures. The clinical parameters assessed were the time to the return of bowel movements, the presence and duration of postoperative ileus, the presence and duration of an intolerance to oral feeding, the interval to re-institution of a regular diet, and complications. The biochemical parameters (serum total protein and albumin levels and lymphocyte counts) were also assessed. A sample of 40 patients treated before the implementation of this protocol was included for comparison. RESULTS: A total of 71 patients, mean age 74 years and American Society of Anesthesiologists status 2 and 3, consecutively underwent radical surgery for bladder cancer and were evaluable for results and complications. Urinary diversion was a heterotopic neobladder in 27 patients (38%), orthotopic in 23 (32.3%), and an ileal conduit in 21 (29.5%). Bowel movements returned after a median of 2 days (range 1 to 6), intolerance to oral feeding was observed in 17 (23.9%) of 71 patients, and the median time to re-institution of a regular diet was 4 days (range 3 to 9). The complication rate was 26.7%, and the mortality rate was 4.2%. No effects were observed on postoperative protein depletion. In the historical group, the median time to diet resumption was 8 days (range 7 to 12). CONCLUSIONS: A short time to the resumption of normal intestinal function and a low incidence of postoperative ileus after cystectomy was observed. However, the incidence of postoperative protein depletion was unaffected. Additional studies should address this subject.

A multimodal perioperative plan for radical cystectomy and urinary intestinal diversion: effects, limits and complications of early artificial nutrition.

PURPOSE: We evaluated the effects of early parenteral and enteral postoperative nutritional support on the restoration of normal bowel function, on the protein depletion that follows cystectomy and on observed complications. MATERIALS AND METHODS: Immediate parenteral nutrition was initiated after surgery. It was progressively shifted to the enteral route through a needle catheter jejunostomy inserted at surgery. RESULTS: A total of 28 patients with a mean age of 74.2 years (range 55 to 82) were enrolled into the study. Disease was pathologically confined to the bladder in 22 patients, locally advanced in 3 and extravesical in 3. Urinary diversions included an ileocolonic pouch in 15 patients and an orthotopic ileal reservoir in 13. Of the 28 patients 15 (53.6%) completed the protocol, whereas 13 (46.4%) did not. Median time to peristalsis and spontaneous passage of flatus was postoperative day 2 (range 2 to 5) and median time to normal diet resumption was postoperative day 4 (range 3 to 8). No significant differences were observed between patients who completed the protocol and those who did not with regard to the restoration of normal bowel function, and total protein, serum albumin and lymphocyte count. Minor complications were observed in 9 patients and major complications developed in 4. CONCLUSIONS: Early postoperative artificial nutrition did not affect the return of bowel function or postoperative protein depletion. Different strategies for more effective nutritional support will be explored in further studies.

Peri-operative management of ablative and reconstructive surgery for invasive bladder cancer in the elderly.

INTRODUCTION AND OBJECTIVES: Radical cystectomy and urinary diversion for muscle invasive bladder cancer is a demanding surgical procedure usually followed by a variable period of inability. It might be even more delicate in the elderly. We describe our protocol of pre, intra, and post operative management aimed at minimising the impact of bladder cancer surgery. MATERIALS AND METHODS: The patients were submitted to reduced pre-operative fasting (6-8 hours), no mechanical bowel preparation, and insertion of an epidural cannula. Intra-operative Intra-operatively the protocol included: combined anesthesia (general+epidural), controlled hypotension, correction of blood losses in excess of 10% of the estimated total blood volume, O2 supplementation and insertion of a je, junal cannula for nutrition. Post-operatively: early removal of naso-gastric tubing (2-6 hours), parenteral and enteral nutrition started ion POD1. RESULTS: The feasibility study was conducted on 18 patients, 14 males and 4 women, median age 70 years (range 55 to 82). Six patients belonged to category ASA II, and 12 to ASA III-IV. The protocol was completed by 10 patients and no completed by 8. The only step of the protocol that was not completed was the enteral nutrition that caused symptoms of bowel distension. Among the patients who completed the protocol the return of peristalsis and of normal bowel function were observed on POD 1, and POD 2, respectively, whereas, the recovery required one day more in the remaining patients. DISCUSSION: The protocol was feasible, and contributed to an accelerated recovery of intestinal function. Compliance to the protocol was independent from age. The study is ongoing for a more precise evaluation of the outcomes of the protocol.