1
|
Mannava S, Vogler A, Markel T. Pathophysiology and Management of Postoperative Ileus in Adults and Neonates: A Review. J Surg Res 2024; 297:9-17. [PMID: 38428262 DOI: 10.1016/j.jss.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 01/05/2024] [Accepted: 02/05/2024] [Indexed: 03/03/2024]
Abstract
Postoperative ileus (POI) is caused by enteric neural dysfunction and inflammatory response to the stress of surgery as well as the effect of anesthetics and opioid pain medications. POI results in prolonged hospital stays, increased medical costs, and diminished enteral nutrition, rendering it a problem worth tackling. Many cellular pathways are implicated in this disease process, creating numerous opportunities for targeted management strategies. There is a gap in the literature in studies exploring neonatal POI pathophysiology and treatment options. It is well known that neonatal immune and enteric nervous systems are immature, and this results in gut physiology which is distinct from adults. Neonates undergoing abdominal surgery face similar surgical stressors and exposure to medications that cause POI in adults. In this review, we aim to summarize the existing adult and neonatal literature on POI pathophysiology and management and explore applications in the neonatal population.
Collapse
Affiliation(s)
- Sindhu Mannava
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Attie Vogler
- Department of Pediatric Inpatient Physical Therapy, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Troy Markel
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
2
|
Ahmadi H, Daneshmand S. Association between use of ERAS protocols and complications after radical cystectomy. World J Urol 2022; 40:1311-1316. [PMID: 35568722 DOI: 10.1007/s00345-022-04023-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/21/2022] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Implementation of enhanced recovery protocols in cystectomy patients has significantly changed the perioperative course of this major operation. This paper summarizes evidence based interventions to enhance the postoperative course of radical cystectomy. METHODS A comprehensive search of PubMed and Embase databases was performed and also the results of our institutional enhanced recovery protocol were discussed. RESULTS One of the major advantages of such changes is the reduced rate of postoperative gastrointestinal (GI) complications especially postoperative ileus which could be contributed to several components of these protocols. However, Alvimopan is the only component which its use is supported by level I evidence. Although there are some evidence suggesting the decreased rate of urinary tract infection with the use of prophylactic antibiotics and wound complications by the use of negative wound pressure devices, their clear benefit is yet to be shown. Although robotic approach has proven advantages in intraoperative blood loss and postoperative blood transfusion rate, surgical team's experience and dedicated infrastructure seem to be more influential in optimized outcome than just the surgical approach. CONCLUSION current evidence suggests that such protocols have not only reached the goal of maintaining complication rate while decreasing length of hospital stay, but it might have caused a decrease in the rate of low-grade complications, especially GI complications.
Collapse
Affiliation(s)
- Hamed Ahmadi
- USC/Norris Comprehensive Cancer Center, USC Institute of Urology, 1441 Eastlake Ave, Suite 7416, Los Angeles, CA, 90089, USA.,Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - Siamak Daneshmand
- USC/Norris Comprehensive Cancer Center, USC Institute of Urology, 1441 Eastlake Ave, Suite 7416, Los Angeles, CA, 90089, USA.
| |
Collapse
|
3
|
Maibom SL, Joensen UN, Poulsen AM, Kehlet H, Brasso K, Røder MA. Short-term morbidity and mortality following radical cystectomy: a systematic review. BMJ Open 2021; 11:e043266. [PMID: 33853799 PMCID: PMC8054090 DOI: 10.1136/bmjopen-2020-043266] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To study short-term (<90 days) morbidity and mortality following radical cystectomy (RC) for bladder cancer and identify modifiable risk factors associated with these. DESIGN Systematic review. METHODS The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE were searched for relevant papers on 11 June 2019 and rerun on 27 May 2020. Studies reporting complications, reoperations, length of stay and mortality within 90 days were included. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine and the quality of evidence was assessed using the Newcastle-Ottawa Scale. RESULTS The search retrieved 1957 articles. Sixty-six articles were included. The quality of evidence was poor to good. Most studies were retrospective, and no randomised clinical trials were identified. Of included studies a median of 6 Martin criteria for reporting complications after surgery were fulfilled. The Clavien-Dindo classification for grading complications was most frequently used. The weighted overall complication rate after RC was 34.9% (range 28.8-68.8) for in-house complications, 39.0% (range 27.3-80.0) for 30-day complications and 58.5% (range 36.1-80.5) for 90-day complications. The most common types of complications reported were gastrointestinal (29.0%) and infectious (26.4%). The weighted mortality rate was 2.4% (range 0.9-4.7) for in-house mortality, 2.1% (0.0-3.7) for 30-day mortality and 4.7% (range 0.0-7.0) for 90-day mortality. Age and comorbidity were identified as the best predictors for complications following RC. CONCLUSION Short-term morbidity and mortality are high following RC. Reporting of complications is heterogeneous and the quality of evidence is generally low. There is a continuous need for randomised studies to address any intervention that can reduce morbidity and mortality following RC. PROSPERO REGISTRATION NUMBER 104937.
Collapse
Affiliation(s)
- Sophia Liff Maibom
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Ulla Nordström Joensen
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Alicia Martin Poulsen
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
- Section for Surgical Pathophysiology, The Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Klaus Brasso
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Martin Andreas Røder
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
4
|
Radical Cystectomy. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
5
|
Feng D, Li X, Liu S, Han P, Wei W. 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. Int Urol Nephrol 2020; 52:2005-2014. [PMID: 32974866 DOI: 10.1007/s11255-020-02516-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 05/19/2020] [Indexed: 02/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Dechao Feng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, 610041, People's Republic of China
| | - Xue Li
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Shengzhuo Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, 610041, People's Republic of China
| | - Ping Han
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, 610041, People's Republic of China
| | - Wuran Wei
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, 610041, People's Republic of China.
| |
Collapse
|
6
|
Ertas IE, Ince O, Emirdar V, Gultekin E, Biler A, Kurt S. Influence of preoperative enema application on the return of gastrointestinal function in elective Cesarean sections: a randomized controlled trial. J Matern Fetal Neonatal Med 2019; 34:1822-1826. [PMID: 31397204 DOI: 10.1080/14767058.2019.1651264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AIM There is an extensive literature on the mechanical bowel preparation by an enema in colorectal, abdominal, and gynecologic surgeries that provide evidence against the use of enema. There are, however, few studies investigating the effect of enema prior to elective Cesarean sections. The aim of this study is to investigate whether preoperative enema facilitates the return of gastrointestinal activity in pregnant women undergoing elective Cesarean section. MATERIALS AND METHODS The surgeon-blinded prospective randomized controlled study included 225 elective Cesarean patients between the ages of 18 and 44. The patients were randomized into two groups: those who had enema preoperatively (n = 114) and those who did not (n = 111). The outcome measures were first bowel sound time and first flatus time, the length of hospital stay, the rate of mid ileus symptoms, and additional analgesic and antiemetic need. RESULTS In the non-enema group, the time of the first bowel sound, flatus time, length of hospital stay, the rates of additional analgesic need, additional antiemetic need, and mild ileus symptoms were respectively 10.5 ± 5.8 hours, 16.0 ± 7.6 hours, 1.9 ± 0.3 days, 8.1%, 7.2%, and 2.7%. For the enema group, the same parameters were respectively 11.6 ± 4.7 hours, 17.5 ± 6.5 hours, 1.8 ± 0.3 days, 7%, 6.1% ,and 1.8%. For all parameters, the difference between the groups was not statistically significant (p values were respectively .09, .12, .8, .79, .68, and .26). CONCLUSIONS The study suggests that preoperative enema in elective cesarean sections does not prevent postoperative gastrointestinal complications and does not shorten the recovery of bowel movements or length of hospital stay.
Collapse
Affiliation(s)
- Ibrahim Egemen Ertas
- Department of Gynecology and Obstetrics, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Onur Ince
- Department of Gynecology and Obstetrics, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Volkan Emirdar
- Department of Gynecology and Obstetrics, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Emre Gultekin
- Department of Gynecology and Obstetrics, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Alper Biler
- Department of Gynecology and Obstetrics, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Sefa Kurt
- Department of Gynecology and Obstetrics, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| |
Collapse
|
7
|
Contemporary Preoperative and Intraoperative Management of the Radical Cystectomy Patient. Urol Clin North Am 2018; 45:169-181. [DOI: 10.1016/j.ucl.2017.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
8
|
|
9
|
|
10
|
Djaladat H, Daneshmand S. Gastrointestinal Complications in Patients Who Undergo Radical Cystectomy with Enhanced Recovery Protocol. Curr Urol Rep 2016. [PMID: 27125653 DOI: 10.1007/s11934.016-0607-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Gastrointestinal (GI) complications are among the most common complications following radical cystectomy and urinary diversion. The most common is postoperative ileus, although its precise pathophysiology is not completely understood. Enhanced recovery after surgery (ERAS) protocols include evidence-based steps to optimize postoperative recovery and shorten hospital stay, mainly through expedited GI function recovery. They include avoiding bowel preparation and postoperative nasogastric tube, early feeding, non-narcotic pain management, and the use of cholinergic and mu-receptor opioid antagonists. We reviewed the literature in regard to GI complications using enhanced recovery protocols and share our institutional experience with over 300 patients.
Collapse
Affiliation(s)
- Hooman Djaladat
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, 90089, Los Angeles, CA, USA
| | - Siamak Daneshmand
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, 90089, Los Angeles, CA, USA.
| |
Collapse
|
11
|
Gastrointestinal Complications in Patients Who Undergo Radical Cystectomy with Enhanced Recovery Protocol. Curr Urol Rep 2016; 17:50. [DOI: 10.1007/s11934-016-0607-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
12
|
Pariser JJ, Anderson BB, Pearce SM, Han Z, Rodriguez JA, Landon E, Pisano JC, Smith ND, Steinberg GD. The effect of broader, directed antimicrobial prophylaxis including fungal coverage on perioperative infectious complications after radical cystectomy. Urol Oncol 2015; 34:121.e9-14. [PMID: 26572724 DOI: 10.1016/j.urolonc.2015.10.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/28/2015] [Accepted: 10/09/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Radical cystectomy (RC) with urinary diversion has a significant risk of infection. In an effort to decrease the rate of infectious complications, we instituted a broader, culture-based preoperative antimicrobial regimen, including fungal coverage, and studied its effect on infectious complications after RC. MATERIALS AND METHODS In May 2013, antimicrobial prophylaxis for RC was changed at our institution after review of previous positive cultures. Ampicillin-sulbactam 3g, gentamicin 4mg/kg, and fluconazole 400mg replaced cefoxitin. Patients undergoing RC from May 2011 to May 2014 were included. Before and after implementation of the new regimen, 30-day infectious complications (positive blood culture, urinary tract infection, wound infection, abscess, and pneumonia) and adverse events (Clostridium difficile, readmission, and mortality) were compared. Multivariate logistic regression was used to identify independent risk factors for infection while controlling for covariates. RESULTS In total, 386 patients were studied (258 before the change and 128 after). The overall infection rate decreased with the new regimen (41% vs. 30%, P = 0.043) with improvements in wound (14% vs. 6%, P = 0.025) and fungal (10% vs. 3%, P = 0.021) infections. Median length of stay decreased from 8 (interquartile range [IQR]: 7-12) to 7 (IQR: 7-10) days (P = 0.008). On multivariate analysis, the new regimen decreased the risk of infections (odds ratio [OR] = 0.58, 95% CI [0.35-0.99], P = 0.044) whereas body mass index, operating room time, smoking, and total parenteral nutrition increased the risk (all P< 0.05). CONCLUSIONS Risk factors for infection after RC include body mass index, operating room time, smoking, and total parenteral nutrition use. Changing from cefoxitin to broader, culture-directed antimicrobial prophylaxis, based on institutional data to include antifungal coverage, decreased postoperative infections.
Collapse
Affiliation(s)
- Joseph J Pariser
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL.
| | - Blake B Anderson
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Shane M Pearce
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Zhe Han
- Department of Pharmaceutical Services, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Joseph A Rodriguez
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Emily Landon
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Jennifer C Pisano
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Norm D Smith
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Gary D Steinberg
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL
| |
Collapse
|
13
|
Matulewicz RS, Brennan J, Pruthi RS, Kundu SD, Gonzalez CM, Meeks JJ. Radical Cystectomy Perioperative Care Redesign. Urology 2015; 86:1076-86. [PMID: 26383615 DOI: 10.1016/j.urology.2015.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 08/19/2015] [Accepted: 09/01/2015] [Indexed: 01/27/2023]
Abstract
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.
Collapse
Affiliation(s)
- Richard S Matulewicz
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL.
| | - Jeffrey Brennan
- Department of Anesthesia, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Raj S Pruthi
- Department of Urology, UNC School of Medicine, Chapel Hill, NC
| | - Shilajit D Kundu
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Chris M Gonzalez
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Joshua J Meeks
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
14
|
Daneshmand S, Lerner SP. Radical cystectomy. Bladder Cancer 2015. [DOI: 10.1002/9781118674826.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
15
|
Chi AC, McGuire BB, Nadler RB. Modern Guidelines for Bowel Preparation and Antimicrobial Prophylaxis for Open and Laparoscopic Urologic Surgery. Urol Clin North Am 2015; 42:429-40. [PMID: 26475940 DOI: 10.1016/j.ucl.2015.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Amanda C Chi
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Barry B McGuire
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Robert B Nadler
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| |
Collapse
|
16
|
Arnold A, Aitchison LP, Abbott J. Preoperative Mechanical Bowel Preparation for Abdominal, Laparoscopic, and Vaginal Surgery: A Systematic Review. J Minim Invasive Gynecol 2015; 22:737-52. [DOI: 10.1016/j.jmig.2015.04.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/02/2015] [Accepted: 04/02/2015] [Indexed: 12/14/2022]
|
17
|
Manger JP, Nelson M, Blanchard S, Helo S, Conaway M, Krupski TL. Alvimopan: A cost-effective tool to decrease cystectomy length of stay. Cent European J Urol 2014; 67:335-41. [PMID: 25667750 PMCID: PMC4310883 DOI: 10.5173/ceju.2014.04.art4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/15/2014] [Accepted: 08/28/2014] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We sought to evaluate the cost effectiveness of perioperative use of alvimopan in cystectomy and urinary diversion. A recent randomized controlled trial demonstrated the efficacy of alvimopan in reducing postoperative ileus and length of stay in cystectomy; however, a major limitation was the exclusion of epidural analgesia. MATERIALS AND METHODS Eighty-six cystectomy and urinary diversion procedures performed by seven surgeons were analyzed between January 2008 and April 2012. The first 50 patients did not receive alvimopan perioperatively, while the subsequent 36 received a single dose of 12 mg preoperatively and then 12 mg every 12 hours for 15 doses or until discharge. RESULTS The groups were equal with respect to age, gender, indication, surgeon, and type of diversion. Patients who received alvimopan experienced a shorter length of stay (LOS) versus those in who did not receive alvimopan (10.5 vs. 8.6 days, p = 0.005, 95% CI 0.6-3.3). Readmission for ileus was low in both alvimopan and control groups (0% and 4.4%, respectively). Costs were significantly lower in the alvimopan group than the control groups (2012 USD 32,443 vs. 40,604 p <0.001). This difference stood up to multivariate analysis with a $7,062 difference in hospital stay. CONCLUSIONS Use of alvimopan in the routine perioperative care of our cystectomy and urinary diversion patients has decreased LOS by 1.9 days. Additionally, institution of routine perioperative alvimopan has reduced costs by $7,062 per admission (20% reduction). This demonstrates a real world application of alvimopan at a moderate volume center.
Collapse
Affiliation(s)
| | - Marc Nelson
- University of Virginia, Department of Urology, Charlottesville, USA
| | | | - Sevann Helo
- Albany Medical Center, Division of Urology, Albany, USA
| | - Mark Conaway
- University of Virginia, Division of Biostatistics and Epidemiology, Charlottesville, USA
| | | |
Collapse
|
18
|
|
19
|
Smith J, Meng ZW, Lockyer R, Dudderidge T, McGrath J, Hayes M, Birch B. Evolution of the Southampton Enhanced Recovery Programme for radical cystectomy and the aggregation of marginal gains. BJU Int 2014; 114:375-83. [PMID: 24467630 DOI: 10.1111/bju.12644] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To describe and assess the evolution of an enhanced recovery programme (ERP) for open radical cystectomy. PATIENTS AND METHODS We introduced a mentored ERP for radical cystectomy in January 2011. The programme underwent service evaluation and multiple changes in August 2012 that we define as marginal gains. We present a retrospective review of 133 consecutive patients undergoing open radical cystectomy, grouped according to the three stages of the ERP from October 2008 to April 2013: (1) non-ERP group (October 2008 to December 2010): n = 69; (2) ERP-1 group (January 2011 to July 2012): n = 37; and (3) ERP-2 group (August 2012 to April 2013): n = 27. Primary outcomes were length of hospital stay (LOS), readmission, morbidity at 90 days using the Clavien classification system and mortality. Secondary outcomes were time to flatus, ileus rates, re-operation rates and oncological outcomes. RESULTS There were no differences in patient demographics among any of the groups for: age, gender, BMI, American Society of Anesthesiologists score and the use of neoadjuvant chemotherapy. There were no differences in readmission, morbidity and mortality rates. The overall 90-day mortality was six patients (4.5%). There were significant differences in ileus rates between the non-ERP, the ERP-1 and the ERP-2 groups: 44.9% (31 patients), 29.7% (11 patients) and 14.8% (four patients), respectively (P = 0.017). There was a significant difference in the presence of pathological lymphadenopathy in the ERP-2 group: non-ERP group, 10.1%; ERP-1 group, 16.2%; and ERP-2 group, 44.4%; P = 0.002. There was also a difference in the mean (sd) lymph node yield in ERP-2: non-ERP group, 8.4 (5.4) nodes; ERP-1, 8.2 (6.4) nodes; and ERP-2, 16.7 (5.4) nodes (P < 0.001). The median (range) LOS was 14 (7-91) days, 10 (6-55) days and 7 (3-99) days in the non-ERP, ERP-1 and ERP-2 groups, respectively (P < 0.001). CONCLUSIONS Auditing an already successful ERP and implementing a number of marginal gains has led to a significant decrease in the median LOS for radical cystectomy. The LOS for open radical cystectomy at University Hospital Southampton has halved. In the second phase of our ERP, our median LOS is 7 days.
Collapse
Affiliation(s)
- Julian Smith
- Department of Urology, University Hospital Southampton, Southampton, UK
| | | | | | | | | | | | | |
Collapse
|
20
|
Deng S, Dong Q, Wang J, Zhang P. The role of mechanical bowel preparation before ileal urinary diversion: a systematic review and meta-analysis. Urol Int 2014; 92:339-48. [PMID: 24642687 DOI: 10.1159/000354326] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 07/11/2013] [Indexed: 02/05/2023]
Abstract
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.
Collapse
Affiliation(s)
- Shi Deng
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | | | | | | |
Collapse
|
21
|
Cerruto MA, De Marco V, D'Elia C, Bizzotto L, De Marchi D, Cavalleri S, Novella G, Menestrina N, Artibani W. Fast Track Surgery to Reduce Short-Term Complications following Radical Cystectomy and Intestinal Urinary Diversion with Vescica Ileale Padovana Neobladder: Proposal for a Tailored Enhanced Recovery Protocol and Preliminary Report from a Pilot Study. Urol Int 2014; 92:41-9. [DOI: 10.1159/000351312] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 04/12/2013] [Indexed: 11/19/2022]
|
22
|
Terrone C. Re: the impact of mechanical bowel preparation on postoperative complications for patients undergoing cystectomy and urinary diversion. Eur Urol 2013; 65:252-3. [PMID: 24289858 DOI: 10.1016/j.eururo.2013.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Carlo Terrone
- Division of Urology, ASO Maggiore della Carità University Hospital, University of Eastern Piedmont, Novara, Italy.
| |
Collapse
|
23
|
Kelly ME, McGuire BB, Nason GJ, Lennon GM, Mulvin DW, Galvin DJ, Quinlan DM. Peri-operative management in urinary diversion surgery: A time for change? Surgeon 2013; 13:127-31. [PMID: 24135285 DOI: 10.1016/j.surge.2013.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/15/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- M E Kelly
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - B B McGuire
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - G J Nason
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - G M Lennon
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D W Mulvin
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D J Galvin
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D M Quinlan
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| |
Collapse
|
24
|
Sasaki J, Matsumoto S, Kan H, Yamada T, Koizumi M, Mizuguchi Y, Uchida E. Objective assessment of postoperative gastrointestinal motility in elective colonic resection using a radiopaque marker provides an evidence for the abandonment of preoperative mechanical bowel preparation. J NIPPON MED SCH 2013; 79:259-66. [PMID: 22976604 DOI: 10.1272/jnms.79.259] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND It has been suggested that mechanical bowel preparation (MBP) has no benefit in terms of anastomotic healing, infection rate, or improvement in the postoperative course in patients undergoing elective colorectal surgery, and that it should be abandoned. However, the effect of MBP on postoperative gastrointestinal motility has been assessed subjectively. In this randomized trial, we objectively assessed the effect of MBP on postoperative gastrointestinal motility and mobility in elective colonic resection. METHOD In total, 79 patients scheduled to undergo elective colonic resection for cancer were randomized to MBP or no-MBP groups prior to surgery. All patients ingested radiopaque markers before surgery to evaluate postoperative gastrointestinal motility, objectively evaluated by the transition of the markers at postoperative days (PODs) 1, 3, 5 and 7. The groups were then further subdivided into open and laparoscopic-assisted colectomy (LAC) groups and evaluated in terms of gastrointestinal motility and postoperative mobility. RESULTS There was no significant difference between the no-MBP and MBP groups in terms of perioperative and postoperative course. In the LAC subgroup, there was no significant difference between the no-MBP and MBP groups in terms of marker transition. However, in the open subgroup, there was a significant difference between the groups in terms of the residual ratio of markers in the small intestine at POD 3 (no-MBP 35.3% vs. MBP 69.2%; p=0.041), excretion rate of markers at POD 5 (no-MBP 49.7% vs. MBP 8.8%; p=0.005), and residual ratio in the small intestine at POD 7 (no-MBP 3.1% vs. MBP 28.8%; p=0.028). Additionally, the excretion rate in the no-MBP group was significantly higher than in the MBP group at POD 7 (74.1% vs. 33.8%; p=0.007). CONCLUSIONS Our data provide additional evidence to support the abandonment of MBP in elective open colonic surgery.
Collapse
Affiliation(s)
- Junpei Sasaki
- Surgery for Organ Function and Biological Regulation, Graduated Medicine, Nippon Medical School, Tokyo, Japan.
| | | | | | | | | | | | | |
Collapse
|
25
|
Zaid HB, Kaffenberger SD, Chang SS. 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. Curr Urol Rep 2013; 14:78-83. [PMID: 23397271 DOI: 10.1007/s11934-012-0300-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
Collapse
Affiliation(s)
- Harras B Zaid
- Department of Urologic Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN 37232-2765, USA.
| | | | | |
Collapse
|
26
|
Sugihara T, Yasunaga H, Horiguchi H, Fujimura T, Nishimatsu H, Ohe K, Matsuda S, Fushimi K, Kattan MW, Homma Y. Does mechanical bowel preparation improve quality of laparoscopic nephrectomy? Propensity score-matched analysis in Japanese series. Urology 2013; 81:74-9. [PMID: 23273073 DOI: 10.1016/j.urology.2012.09.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 09/22/2012] [Accepted: 09/28/2012] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Toru Sugihara
- Department of Urology, Shintoshi Hospital, Iwata, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Koo V, Brace H, Shahzad A, Lynn N. The challenges of implementing Enhanced Recovery Programme in urology. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2013. [DOI: 10.1111/ijun.12006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
28
|
Ramirez JA, McIntosh AG, Strehlow R, Lawrence VA, Parekh DJ, Svatek RS. Definition, incidence, risk factors, and prevention of paralytic ileus following radical cystectomy: a systematic review. Eur Urol 2012; 64:588-97. [PMID: 23245816 DOI: 10.1016/j.eururo.2012.11.051] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 11/27/2012] [Indexed: 01/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Jorge A Ramirez
- Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA
| | | | | | | | | | | |
Collapse
|
29
|
Hashad MME, Atta M, Elabbady A, Elfiky S, Khattab A, Kotb A. Safety of no bowel preparation before ileal urinary diversion. BJU Int 2012; 110:E1109-13. [PMID: 23167296 DOI: 10.1111/j.1464-410x.2012.11415.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED 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.
Collapse
|
30
|
Does using comprehensive preoperative bowel preparation offer any advantage for urinary diversion using ileum? A meta-analysis. Int Urol Nephrol 2012; 45:25-31. [DOI: 10.1007/s11255-012-0319-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 10/16/2012] [Indexed: 02/01/2023]
|
31
|
Saar M, Ohlmann CH, Siemer S, Lehmann J, Becker F, Stöckle M, Kamradt J. Fast-track rehabilitation after robot-assisted laparoscopic cystectomy accelerates postoperative recovery. BJU Int 2012; 112:E99-106. [DOI: 10.1111/j.1464-410x.2012.11473.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Matthias Saar
- Department of Urology and Paediatric Urology; University of Saarland; Homburg/Saar; Neunkirchen; Germany
| | - Carsten-Henning Ohlmann
- Department of Urology and Paediatric Urology; University of Saarland; Homburg/Saar; Neunkirchen; Germany
| | - Stefan Siemer
- Department of Urology and Paediatric Urology; University of Saarland; Homburg/Saar; Neunkirchen; Germany
| | - Jan Lehmann
- Urology Practice Prüner Gang; Kiel; Neunkirchen; Germany
| | | | - Michael Stöckle
- Department of Urology and Paediatric Urology; University of Saarland; Homburg/Saar; Neunkirchen; Germany
| | - Jörn Kamradt
- Department of Urology and Paediatric Urology; University of Saarland; Homburg/Saar; Neunkirchen; Germany
| |
Collapse
|
32
|
Large MC, Kiriluk KJ, DeCastro GJ, Patel AR, Prasad S, Jayram G, Weber SG, Steinberg GD. The impact of mechanical bowel preparation on postoperative complications for patients undergoing cystectomy and urinary diversion. J Urol 2012; 188:1801-5. [PMID: 22999697 DOI: 10.1016/j.juro.2012.07.039] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Indexed: 12/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- Michael C Large
- Section of Urology, University of Chicago Medical Center, Chicago, Illinois, USA.
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J 2011; 5:342-8. [PMID: 22031616 DOI: 10.5489/cuaj.11002] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.
Collapse
Affiliation(s)
- Megan Melnyk
- Department of Urological Sciences, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, Vancouver, BC
| | | | | | | |
Collapse
|
34
|
Raynor MC, Lavien G, Nielsen M, Wallen EM, Pruthi RS. Elimination of preoperative mechanical bowel preparation in patients undergoing cystectomy and urinary diversion. Urol Oncol 2011; 31:32-5. [PMID: 21719323 DOI: 10.1016/j.urolonc.2010.11.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 11/05/2010] [Accepted: 11/08/2010] [Indexed: 11/18/2022]
Abstract
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.
Collapse
Affiliation(s)
- Mathew C Raynor
- Division of Urologic Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | | | | | | | | |
Collapse
|
35
|
Aslan G, Baltaci S, Akdogan B, Kuyumcuoğlu U, Kaplan M, Cal C, Adsan O, Turkolmez K, Ugurlu O, Ekici S, Faydaci G, Mammadov E, Turkeri L, Ozen H, Beduk Y. A prospective randomized multicenter study of Turkish Society of Urooncology comparing two different mechanical bowel preparation methods for radical cystectomy. Urol Oncol 2011; 31:664-70. [PMID: 21546277 DOI: 10.1016/j.urolonc.2011.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 03/18/2011] [Accepted: 03/19/2011] [Indexed: 11/19/2022]
Abstract
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.
Collapse
Affiliation(s)
- Guven Aslan
- Department of Urology, Dokuz Eylul University School of Medicine, Izmir, Turkey.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
|
37
|
Aning J, Neal D, Driver A, McGrath J. ENHANCED RECOVERY: FROM PRINCIPLES TO PRACTICE IN UROLOGY. BJU Int 2010; 105:1199-201. [DOI: 10.1111/j.1464-410x.2010.09249.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
38
|
Xu R, Zhao X, Zhong Z, Zhang L. No advantage is gained by preoperative bowel preparation in radical cystectomy and ileal conduit: a randomized controlled trial of 86 patients. Int Urol Nephrol 2010; 42:947-50. [DOI: 10.1007/s11255-010-9732-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 03/20/2010] [Indexed: 10/19/2022]
|
39
|
Jain S, Simms MS, Mellon JK. Management of the Gastrointestinal Tract at the Time of Cystectomy. Urol Int 2009; 77:1-5. [PMID: 16825806 DOI: 10.1159/000092925] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Radical cystectomy impacts on the gastro-intestinal tract in several ways. Clearly there is the need for bowel mobilisation, resection and anastamosis in order to create a urinary diversion, and the use of bowel preparation or antibiotics are controversial topics. Post-operatively ileus is common and there is debate about the routine use of NG tubes. Early enteral feeding is a modern concept but not yet proven. In the long-term there can be problems such as diarrhoea and B12 deficiency. All of these issues are discussed in this review using the latest available evidence.
Collapse
Affiliation(s)
- S Jain
- Urology Group, Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK.
| | | | | |
Collapse
|
40
|
Bowel preparation before laparoscopic gynaecological surgery in benign conditions using a 1-week low fibre diet: a surgeon blind, randomized and controlled trial. Arch Gynecol Obstet 2009; 280:713-8. [DOI: 10.1007/s00404-009-0986-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Accepted: 02/02/2009] [Indexed: 10/21/2022]
|
41
|
|
42
|
Büchler MW, Seiler CM, Monson JRT, Flamant Y, Thompson-Fawcett MW, Byrne MM, Mortensen ER, Altman JFB, Williamson R. Clinical trial: alvimopan for the management of post-operative ileus after abdominal surgery: results of an international randomized, double-blind, multicentre, placebo-controlled clinical study. Aliment Pharmacol Ther 2008; 28:312-25. [PMID: 19086236 DOI: 10.1111/j.1365-2036.2008.03696.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Post-operative ileus (POI) affects most patients undergoing abdominal surgery. AIM To evaluate the effect of alvimopan, a peripherally acting mu-opioid receptor antagonist, on POI by negating the impact of opioids on gastrointestinal (GI) motility without affecting analgesia in patients outside North America. METHODS Adult subjects undergoing open abdominal surgery (n = 911) randomly received oral alvimopan 6 or 12 mg, or placebo, 2 h before, and twice daily following surgery. Opioids were administered as intravenous patient-controlled analgesia (PCA) or bolus injection. Time to recovery of GI function was assessed principally using composite endpoints in subjects undergoing bowel resection (n = 738). RESULTS A nonsignificant reduction in mean time to tolerate solid food and either first flatus or bowel movement (primary endpoint) was observed for both alvimopan 6 and 12 mg; 8.5 h (95% CI: 0.9, 16.0) and 4.8 h (95% CI: -3.2, 12.8), respectively. However, an exploratory post hoc analysis showed that alvimopan was more effective in the PCA (n = 317) group than in the non-PCA (n = 318) group. Alvimopan was well tolerated and did not reverse analgesia. CONCLUSION Although the significant clinical effect of alvimopan on reducing POI observed in previous trials was not reproduced, this trial suggests potential benefit in bowel resection patients who received PCA.
Collapse
Affiliation(s)
- M W Büchler
- Department of Surgery, University of Heidelberg, Heidelberg, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Maffezzini M, Campodonico F, Canepa G, Gerbi G, Parodi D. Current perioperative management of radical cystectomy with intestinal urinary reconstruction for muscle-invasive bladder cancer and reduction of the incidence of postoperative ileus. Surg Oncol 2008; 17:41-8. [DOI: 10.1016/j.suronc.2007.09.003] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 09/11/2007] [Indexed: 12/16/2022]
|
44
|
Arumainayagam N, McGrath J, Jefferson KP, Gillatt DA. Introduction of an enhanced recovery protocol for radical cystectomy. BJU Int 2008; 101:698-701. [PMID: 18190646 DOI: 10.1111/j.1464-410x.2007.07319.x] [Citation(s) in RCA: 150] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe and assess an enhanced recovery protocol (ERP) for the peri-operative management of patients undergoing radical cystectomy (RC), which was started at our institution on 1 October 2005, as RC is associated with increased morbidity and longer inpatient stays than other major urological procedures. PATIENTS AND METHODS An ERP was introduced in our institution that focused on reduced bowel preparation, and standardized feeding and analgesic regimens. In all, 112 consecutive patients were compared, i.e. 56 before implementing the ERP and 56 since introducing the ERP. The primary outcome measures were duration of total inpatient stay and interval from surgery to discharge, and the morbidity and mortality. Data were analysed retrospectively from cancer network and hospital records. 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. Re-admission, mortality and morbidity rates showed no statistically significant difference between the groups. The median (interquartile range) duration of hospital stay was 17 (15-23) days in the no-ERP group, and 13 (11-17) days in the ERP group (significantly different, P < 0.001, Wilcoxon rank-sum test). The median duration of recovery after RC was 15 (13-21) days in the no-ERP group and 12 (10-15) days in the ERP group (significantly different, P = 0.001, Wilcoxon rank-sum test). CONCLUSION The introduction of an ERP was associated with significantly reduced hospital stay, with no deleterious effect on morbidity or mortality.
Collapse
|
45
|
Tabibi A, Simforoosh N, Basiri A, Ezzatnejad M, Abdi H, Farrokhi F. Bowel Preparation Versus No Preparation Before Ileal Urinary Diversion. Urology 2007; 70:654-8. [DOI: 10.1016/j.urology.2007.06.1107] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Revised: 04/15/2007] [Accepted: 06/26/2007] [Indexed: 11/28/2022]
|
46
|
Affiliation(s)
- Hae Won Jung
- Department of Urology, College of Medicine, Hallym University, Seoul, Korea
| | - Sung Tae Cho
- Department of Urology, College of Medicine, Hallym University, Seoul, Korea
| | - Young Goo Lee
- Department of Urology, College of Medicine, Hallym University, Seoul, Korea
| |
Collapse
|
47
|
Muzii L, Bellati F, Zullo MA, Manci N, Angioli R, Panici PB. Mechanical bowel preparation before gynecologic laparoscopy: a randomized, single-blind, controlled trial. Fertil Steril 2006; 85:689-93. [PMID: 16500339 DOI: 10.1016/j.fertnstert.2005.08.049] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2005] [Revised: 08/31/2005] [Accepted: 08/31/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the use of mechanical bowel preparation (MBP) before gynecologic laparoscopy, using as the primary endpoint the appropriateness of the surgical field as judged by the surgeon. DESIGN Prospective, randomized, single-blind clinical trial. SETTING Academic department specializing in gynecologic surgery. PATIENT(S) One-hundred sixty-two patients scheduled for laparoscopy. INTERVENTION(S) The evening before laparoscopy, patients were randomized to either MBP with 90 mL of oral sodium phosphate (NaP) or no bowel preparation. MAIN OUTCOME MEASURE(S) Patient discomfort was evaluated with a visual analogue scale. Bowel preparation was evaluated by a surgeon (blind to bowel-preparation status) using a 5-point scale. Surgical difficulty, operating times, and postoperative complications were recorded. RESULT(S) Preoperative discomfort was significantly greater in the MBP group. No significant difference in the evaluation of the surgical field, operative difficulty, operative time, and postoperative complications was present between the two groups. CONCLUSION(S) Bowel preparation with oral NaP does not offer any significant advantage in patients undergoing laparoscopy for benign gynecologic conditions. In addition, MBP significantly increases preoperative discomfort.
Collapse
Affiliation(s)
- Ludovico Muzii
- Department of Obstetrics and Gynecology, Campus Bio Medico, University of Rome, Rome, Italy.
| | | | | | | | | | | |
Collapse
|
48
|
Abstract
Mechanical cleansing of the colon prior to elective colorectal surgery is a dogmatically established belief in surgery. Polyethylene glycol was extensively used in the 1980's and 1990's but has been largely replaced by other laxative solutions such as sodium phosphate which are better tolerated by the patient. Evidence-based data in the surgical literature question the dogma of routine mechanical bowel cleansing (8 randomized controlled studies and 4 meta-analyses). These data show with a good level of evidence that mechanical bowel preparation is unnecessary and perhaps harmful.
Collapse
Affiliation(s)
- K Slim
- Service de Chirurgie Générale et Digestive, CHU de Clermont-Ferrand, Clermont-Ferrand
| | | | | |
Collapse
|