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

Abstract

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