REVIEW URRENT C OPINION
Enhanced recovery pathway following radical cystectomy Hooman Djaladat and Siamak Daneshmand
Purpose of review To evaluate perioperative enhanced recovery protocols for patients undergoing radical cystectomy and urinary diversion and describe our unique protocol. Recent findings Radical cystectomy is a morbid procedure with rather long hospital stay and complication rates. The main reason for lengthy hospital stay is bowel complication including paralytic ileus. Different perioperative care plans have been recommended to decrease hospital stay and complication rate. Most of this recovery plans focus on enhancing gastrointestinal function recovery, pain management and early mobility. Summary Enhanced recovery after surgery protocol includes pre, intra and postoperative evidence-based modifications for improving perioperative care of cystectomy patients. Significant shortening of hospital stay without increasing early complication or readmission rate could be achieved safely in most of the patients. Keywords enhanced recovery, postoperative pathway, protocol, radical cystectomy
INTRODUCTION Enhanced recovery after surgery (ERAS) protocols are evidence-based multimodal care pathways that aim to provide optimal perioperative care for patients undergoing complex surgeries. The goal of these protocols is to minimize perioperative stress and promote acute recovery, demonstrated by significant reduction in hospital stay with no adverse effects on complication or readmission rates. Enhanced recovery protocols (ERPs) were first introduced in patients undergoing colectomy and include a considerable number of pre, intra and postoperative changes in management compared with standard protocols, including reduced preoperative fasting to early postoperative feeding [1]. Results demonstrated reduced postoperative complications and faster recovery [2]. There are scant data on ERPs in complex urology surgeries. Radical cystectomy and urinary diversion remain one of the most complex and morbid procedures in urology with high complication rates and hospital stay [3]. There has been a significant lag in the adoption of such protocols in urologic surgery that is most likely multifactorial and may include the belief that urinary diversion is a more complex operation
than colorectal surgeries with subsequent higher gastrointestinal complications, persistence of surgical dogma, or the fact that implementation of such protocols requires considerable effort. The main reasons for prolonged hospital stay following cystectomy remain gastrointestinal complications, mostly paralytic ileus [3]. Improvement in surgical technique, anesthesia and perioperative care has resulted in reduced morbidity and length of stay (LOS) after cystectomy. Previous investigators have described standardized perioperative care for patients undergoing radical cystectomy, with a reduction in mean hospital stay [4]. Herein, we discuss the current literature on the topic and describe our ERP for patients undergoing radical cystectomy and urinary diversion using our institutional evidence-based model. Norris Comprehensive Cancer Center, USC Institute of Urology, Institute of Urology, Los Angeles, California, USA Correspondence to Siamak Daneshmand, MD, Department of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90089, USA. Tel: +1 323 865 3700; fax: +1 323 865 0120; e-mail: [email protected] Curr Opin Urol 2014, 24:135–139 DOI:10.1097/MOU.0000000000000027
0963-0643 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-urology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Minimally invasive urologic oncology
KEY POINTS ERP for patients with radical cystectomy includes pre, intra and postoperative modifications to standard care. The highlights of protocol are carbohydrate loading, no bowel prep, no postop NG tube, focus on non-narcotic pain management, peripheral m receptor opioid antagonist, use of neostigmine and early feeding. The protocol is feasible and well tolerated and is associated with significant shortening of hospital stay without increasing complication or readmission rates.
ENHANCED RECOVERY AFTER SURGERY PROTOCOLS Improvements in surgical technique, anesthesia and perioperative care has recently resulted in reduced morbidity and LOS after cystectomy although the mean hospital stay at most centers remains high at 10–11 days [5 ]. Pruthi et al. [4] pioneered a perioperative care plan on 40 patients undergoing cystectomy for bladder cancer with decreased mean hospital stay of 5.1 days. Arumainayagam et al. [3] reported their experience with ERP in patients with bladder cancer who underwent cystectomy in the UK. The three most important components of their protocol were no bowel preparation, early enteral feeding and mobilization. Median LOS following cystectomy was 13 (11–17) days in cases with ERP vs. 17 (15–23) days in controls (P < 0.001). The significant difference between US and UK healthcare system model should be taken into account when interpreting these numbers. In 2010, Pruthi et al. [6] updated their initial experience using their perioperative care plan on 100 patients with focus on early nasogastric (NG) tube removal, earlier feeding and use of prokinetic agents. They demonstrated the beneficial effect of non-narcotic analgesic pain management and gum chewing with no detrimental effect of not having an NG tube after the surgery. They still used bowel preparation prior to surgery with advancement to regular diet by postop day (POD) 4. They reported on mean time to bowel movement of 2.9 days and mean LOS of 5 days. The Vanderbilt group has also described their experience with a collaborative care pathway in a group of 304 patients undergoing radical cystectomy and urinary diversion resulting in discharge on POD 6–8 in 74% of patients. The pathway included mechanical bowel preparation, full liquid diet after bowel function return and home health support after discharge. Delayed discharge is independently correlated with postoperative ileus (most common), minor or major complication and blood &
136
www.co-urology.com
transfusion [7]. Maffezzini et al. [8] also reported on a multimodal care plan to enhance recovery in 71 patients undergoing radical cystectomy. The pathway included preoperative bowel preparation, epidural catheter, jejunostomy cannula and early NG tube removal. Median time to return of bowel function was 2 days and median LOS was 15 days. Mechanical bowel preparation has been traditionally recommended for patients undergoing bowel resection but can cause dehydration and electrolyte imbalances. A meta-analysis performed to investigate the effect of bowel preparation in reducing the incidence of postoperative complications in patients undergoing elective colorectal procedures showed no differences in rate of mortality, reoperation, peritonitis and wound infection [9]. Preoperative carbohydrate loading has been shown to play an important role in decreasing hospital stay and recovery after colonic surgery in a randomized controlled trial [10] Nasogastric decompression has traditionally been used following cystectomy to decompress the stomach, prevent emesis and aspiration and protect the bowel anastomosis. Donat et al. [11] described an overnight-only NG tube with use of metoclopramide demonstrating the benefits of early return of bowel function and reduced pulmonary complications. These benefits have been confirmed by numerous other studies [5 ,9,12–15], yet the use of NG tubes following cystectomy and diversion remains high. Prokinetics like metoclopramide have been shown to significantly reduce rate of postoperative nausea and vomiting with an early tolerance of solid foods [12]. Postoperative ileus stands out as one of the most common causes of increased LOS after cystectomy [8,16]. Opening the peritoneum, bowel manipulation, resection and anastomosis and hypovolemia or hyper-volemia may all contribute to peristalsis impairment [8,15]. Opioid receptors are distributed throughout the gastrointestinal tract, indicating that endogenous and exogenous opiates can modulate gastrointestinal motor and secretory functions. Most opiates that have m receptor activity inhibit gastric motility and delay emptying as well [17]. Alvimopan, a m-opioid receptor antagonist has been shown in multiple randomized trials to accelerate gastrointestinal activity after bowel resection. In patients undergoing radical cystectomy, it has been shown to significantly decrease time to bowel activity and hospital stay [18]. A recent phase IV study involving use of Alvimopan to decrease LOS is currently in press. Accurate fluid delivery perioperatively can prevent both dehydration and hypervolemia, reduce surgical complications and shorten LOS [19]. Ketorolac, a non-narcotic analgesic, has been shown not only to reduce narcotic demand, &
Volume 24 Number 2 March 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Enhanced recovery after cystectomy Djaladat and Daneshmand
but also hasten the return of bowel myoelectrical activity after laparotomy [5 ,20]. Postoperative gum chewing has been shown to stimulate oral-gastric reflexes and bowel motility in both colorectal and cystectomy literature [5 ,21,22]. Neostigmine, an acetyl cholinesterase inhibitor, has also been shown to be associated with decreased time to flatus and bowel movement following bowel resection [23 ]. &
&
&
ENHANCED RECOVERY AFTER SURGERY PROTOCOL AT UNIVERSITY OF SOUTHERN CALIFORNIA This includes pre, intra and postcystectomy care modifications.
PREOPERATIVE Given the evidence against the use of bowel preparation, and the potential for increasing complications, we have omitted all bowel preparation prior to surgery unless there is a preoperative plan for using the colon for continent cutaneous diversion. A high-protein high-carbohydrate liquid drink is recommended for a few days prior to surgery, without any other special diet recommendation. The preoperative visit and an educational class help detect any psychosocial barriers that might interfere with early recovery and discharge. This also improves patient compliance with ERAS and provides a better understanding of postoperative milestone requirements prior to discharge. Alvimopan, a m-opioid receptor antagonist, is given in the preoperative holding area 30–60 min prior to the operation. No epidural analgesia is used in order to minimize the use of narcotics.
Gastrointestinal recovery Alvimopan is continued postoperatively. Neostigmine is also administered to facilitate the regaining of gastrointestinal tract motility. Both neostigmine and alvimopan are discontinued once the patient has a bowel movement. A magnesium-based lactulose or bisacodyl (suppository) is started on POD 1 and continued daily until bowel movement. Prophylaxis for stress ulcer (proton pump inhibitor and H2 receptor blocker) and nausea and vomiting (ondansetron and/or metoclopramide) is administered regularly. Patients are encouraged to ambulate starting POD 1. Sips of liquids (including highcarbohydrate high-protein fluids) are started early on the day of surgery if tolerated. On POD 1, a clear liquid diet is started and gradually increased. Regular diet is started on POD 2 if the patient has no nausea, vomiting or abdominal distention regardless of gas passage or bowel movement. More recently, we are evaluating starting regular diet (tailored for postoperative surgical patients) on POD 1. If the patient is not tolerating oral food by POD 6 and there is no bowel activity, parenteral nutrition is considered.
Pain management Unless contraindicated, i.v. ketorolac tromethamine and acetaminophen acetate are the mainstay of early postoperative pain management. Paraincisional subfascial catheters with constant local anesthetic (0.2% Ropivacaine) release are also used for local pain control. Rapid-onset opioid is reserved for breakthrough pain. Oral painkillers are started on POD 1, and most patients transition to oral analgesics by POD 3.
INTRAOPERATIVE
Discharge and postop care
In general, cystectomy, extended pelvic lymph node dissection and urinary diversion are performed through an infraumbilical incision. Blood loss and surgical time are kept to a minimum. Intraoperative fluid intake is maintained by warm ringer lactate solution and albumin bolus, if needed. Fluid intake is minimized while the ureters are clipped. Intravenous (i.v.) acetaminophen acetate is started intraoperatively and narcotic use is kept to a minimum. The patient is then transferred to the ward unless there is any indication for admission to ICU.
Discharge orders are written when patient meets the following criteria: adequate pain control with oral medications, adequate mobility and catheter/stoma care, normal laboratory results, adequate oral intake (1 l/day), having bowel movement. In addition, prophylactic antibiotic is started and continued for 3 weeks or until catheter/stent removal. Starting from patient 25, alkalinization (with oral sodium bicarbonate) was also added to the protocol if discharge bicarbonate was low (
Enhanced recovery pathway following radical cystectomy Hooman Djaladat and Siamak Daneshmand
Purpose of review To evaluate perioperative enhanced recovery protocols for patients undergoing radical cystectomy and urinary diversion and describe our unique protocol. Recent findings Radical cystectomy is a morbid procedure with rather long hospital stay and complication rates. The main reason for lengthy hospital stay is bowel complication including paralytic ileus. Different perioperative care plans have been recommended to decrease hospital stay and complication rate. Most of this recovery plans focus on enhancing gastrointestinal function recovery, pain management and early mobility. Summary Enhanced recovery after surgery protocol includes pre, intra and postoperative evidence-based modifications for improving perioperative care of cystectomy patients. Significant shortening of hospital stay without increasing early complication or readmission rate could be achieved safely in most of the patients. Keywords enhanced recovery, postoperative pathway, protocol, radical cystectomy
INTRODUCTION Enhanced recovery after surgery (ERAS) protocols are evidence-based multimodal care pathways that aim to provide optimal perioperative care for patients undergoing complex surgeries. The goal of these protocols is to minimize perioperative stress and promote acute recovery, demonstrated by significant reduction in hospital stay with no adverse effects on complication or readmission rates. Enhanced recovery protocols (ERPs) were first introduced in patients undergoing colectomy and include a considerable number of pre, intra and postoperative changes in management compared with standard protocols, including reduced preoperative fasting to early postoperative feeding [1]. Results demonstrated reduced postoperative complications and faster recovery [2]. There are scant data on ERPs in complex urology surgeries. Radical cystectomy and urinary diversion remain one of the most complex and morbid procedures in urology with high complication rates and hospital stay [3]. There has been a significant lag in the adoption of such protocols in urologic surgery that is most likely multifactorial and may include the belief that urinary diversion is a more complex operation
than colorectal surgeries with subsequent higher gastrointestinal complications, persistence of surgical dogma, or the fact that implementation of such protocols requires considerable effort. The main reasons for prolonged hospital stay following cystectomy remain gastrointestinal complications, mostly paralytic ileus [3]. Improvement in surgical technique, anesthesia and perioperative care has resulted in reduced morbidity and length of stay (LOS) after cystectomy. Previous investigators have described standardized perioperative care for patients undergoing radical cystectomy, with a reduction in mean hospital stay [4]. Herein, we discuss the current literature on the topic and describe our ERP for patients undergoing radical cystectomy and urinary diversion using our institutional evidence-based model. Norris Comprehensive Cancer Center, USC Institute of Urology, Institute of Urology, Los Angeles, California, USA Correspondence to Siamak Daneshmand, MD, Department of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90089, USA. Tel: +1 323 865 3700; fax: +1 323 865 0120; e-mail: [email protected] Curr Opin Urol 2014, 24:135–139 DOI:10.1097/MOU.0000000000000027
0963-0643 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-urology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Minimally invasive urologic oncology
KEY POINTS ERP for patients with radical cystectomy includes pre, intra and postoperative modifications to standard care. The highlights of protocol are carbohydrate loading, no bowel prep, no postop NG tube, focus on non-narcotic pain management, peripheral m receptor opioid antagonist, use of neostigmine and early feeding. The protocol is feasible and well tolerated and is associated with significant shortening of hospital stay without increasing complication or readmission rates.
ENHANCED RECOVERY AFTER SURGERY PROTOCOLS Improvements in surgical technique, anesthesia and perioperative care has recently resulted in reduced morbidity and LOS after cystectomy although the mean hospital stay at most centers remains high at 10–11 days [5 ]. Pruthi et al. [4] pioneered a perioperative care plan on 40 patients undergoing cystectomy for bladder cancer with decreased mean hospital stay of 5.1 days. Arumainayagam et al. [3] reported their experience with ERP in patients with bladder cancer who underwent cystectomy in the UK. The three most important components of their protocol were no bowel preparation, early enteral feeding and mobilization. Median LOS following cystectomy was 13 (11–17) days in cases with ERP vs. 17 (15–23) days in controls (P < 0.001). The significant difference between US and UK healthcare system model should be taken into account when interpreting these numbers. In 2010, Pruthi et al. [6] updated their initial experience using their perioperative care plan on 100 patients with focus on early nasogastric (NG) tube removal, earlier feeding and use of prokinetic agents. They demonstrated the beneficial effect of non-narcotic analgesic pain management and gum chewing with no detrimental effect of not having an NG tube after the surgery. They still used bowel preparation prior to surgery with advancement to regular diet by postop day (POD) 4. They reported on mean time to bowel movement of 2.9 days and mean LOS of 5 days. The Vanderbilt group has also described their experience with a collaborative care pathway in a group of 304 patients undergoing radical cystectomy and urinary diversion resulting in discharge on POD 6–8 in 74% of patients. The pathway included mechanical bowel preparation, full liquid diet after bowel function return and home health support after discharge. Delayed discharge is independently correlated with postoperative ileus (most common), minor or major complication and blood &
136
www.co-urology.com
transfusion [7]. Maffezzini et al. [8] also reported on a multimodal care plan to enhance recovery in 71 patients undergoing radical cystectomy. The pathway included preoperative bowel preparation, epidural catheter, jejunostomy cannula and early NG tube removal. Median time to return of bowel function was 2 days and median LOS was 15 days. Mechanical bowel preparation has been traditionally recommended for patients undergoing bowel resection but can cause dehydration and electrolyte imbalances. A meta-analysis performed to investigate the effect of bowel preparation in reducing the incidence of postoperative complications in patients undergoing elective colorectal procedures showed no differences in rate of mortality, reoperation, peritonitis and wound infection [9]. Preoperative carbohydrate loading has been shown to play an important role in decreasing hospital stay and recovery after colonic surgery in a randomized controlled trial [10] Nasogastric decompression has traditionally been used following cystectomy to decompress the stomach, prevent emesis and aspiration and protect the bowel anastomosis. Donat et al. [11] described an overnight-only NG tube with use of metoclopramide demonstrating the benefits of early return of bowel function and reduced pulmonary complications. These benefits have been confirmed by numerous other studies [5 ,9,12–15], yet the use of NG tubes following cystectomy and diversion remains high. Prokinetics like metoclopramide have been shown to significantly reduce rate of postoperative nausea and vomiting with an early tolerance of solid foods [12]. Postoperative ileus stands out as one of the most common causes of increased LOS after cystectomy [8,16]. Opening the peritoneum, bowel manipulation, resection and anastomosis and hypovolemia or hyper-volemia may all contribute to peristalsis impairment [8,15]. Opioid receptors are distributed throughout the gastrointestinal tract, indicating that endogenous and exogenous opiates can modulate gastrointestinal motor and secretory functions. Most opiates that have m receptor activity inhibit gastric motility and delay emptying as well [17]. Alvimopan, a m-opioid receptor antagonist has been shown in multiple randomized trials to accelerate gastrointestinal activity after bowel resection. In patients undergoing radical cystectomy, it has been shown to significantly decrease time to bowel activity and hospital stay [18]. A recent phase IV study involving use of Alvimopan to decrease LOS is currently in press. Accurate fluid delivery perioperatively can prevent both dehydration and hypervolemia, reduce surgical complications and shorten LOS [19]. Ketorolac, a non-narcotic analgesic, has been shown not only to reduce narcotic demand, &
Volume 24 Number 2 March 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Enhanced recovery after cystectomy Djaladat and Daneshmand
but also hasten the return of bowel myoelectrical activity after laparotomy [5 ,20]. Postoperative gum chewing has been shown to stimulate oral-gastric reflexes and bowel motility in both colorectal and cystectomy literature [5 ,21,22]. Neostigmine, an acetyl cholinesterase inhibitor, has also been shown to be associated with decreased time to flatus and bowel movement following bowel resection [23 ]. &
&
&
ENHANCED RECOVERY AFTER SURGERY PROTOCOL AT UNIVERSITY OF SOUTHERN CALIFORNIA This includes pre, intra and postcystectomy care modifications.
PREOPERATIVE Given the evidence against the use of bowel preparation, and the potential for increasing complications, we have omitted all bowel preparation prior to surgery unless there is a preoperative plan for using the colon for continent cutaneous diversion. A high-protein high-carbohydrate liquid drink is recommended for a few days prior to surgery, without any other special diet recommendation. The preoperative visit and an educational class help detect any psychosocial barriers that might interfere with early recovery and discharge. This also improves patient compliance with ERAS and provides a better understanding of postoperative milestone requirements prior to discharge. Alvimopan, a m-opioid receptor antagonist, is given in the preoperative holding area 30–60 min prior to the operation. No epidural analgesia is used in order to minimize the use of narcotics.
Gastrointestinal recovery Alvimopan is continued postoperatively. Neostigmine is also administered to facilitate the regaining of gastrointestinal tract motility. Both neostigmine and alvimopan are discontinued once the patient has a bowel movement. A magnesium-based lactulose or bisacodyl (suppository) is started on POD 1 and continued daily until bowel movement. Prophylaxis for stress ulcer (proton pump inhibitor and H2 receptor blocker) and nausea and vomiting (ondansetron and/or metoclopramide) is administered regularly. Patients are encouraged to ambulate starting POD 1. Sips of liquids (including highcarbohydrate high-protein fluids) are started early on the day of surgery if tolerated. On POD 1, a clear liquid diet is started and gradually increased. Regular diet is started on POD 2 if the patient has no nausea, vomiting or abdominal distention regardless of gas passage or bowel movement. More recently, we are evaluating starting regular diet (tailored for postoperative surgical patients) on POD 1. If the patient is not tolerating oral food by POD 6 and there is no bowel activity, parenteral nutrition is considered.
Pain management Unless contraindicated, i.v. ketorolac tromethamine and acetaminophen acetate are the mainstay of early postoperative pain management. Paraincisional subfascial catheters with constant local anesthetic (0.2% Ropivacaine) release are also used for local pain control. Rapid-onset opioid is reserved for breakthrough pain. Oral painkillers are started on POD 1, and most patients transition to oral analgesics by POD 3.
INTRAOPERATIVE
Discharge and postop care
In general, cystectomy, extended pelvic lymph node dissection and urinary diversion are performed through an infraumbilical incision. Blood loss and surgical time are kept to a minimum. Intraoperative fluid intake is maintained by warm ringer lactate solution and albumin bolus, if needed. Fluid intake is minimized while the ureters are clipped. Intravenous (i.v.) acetaminophen acetate is started intraoperatively and narcotic use is kept to a minimum. The patient is then transferred to the ward unless there is any indication for admission to ICU.
Discharge orders are written when patient meets the following criteria: adequate pain control with oral medications, adequate mobility and catheter/stoma care, normal laboratory results, adequate oral intake (1 l/day), having bowel movement. In addition, prophylactic antibiotic is started and continued for 3 weeks or until catheter/stent removal. Starting from patient 25, alkalinization (with oral sodium bicarbonate) was also added to the protocol if discharge bicarbonate was low (
