INTRODUCTION OF A TAILORED ENHANCED RECOVERY PROTOCOL TO REDUCE SHORT-TERM COMPLICATIONS FOLLOWING RADICAL CYSTECTOMY AND INTESTINAL URINARY DIVERSION WITH VESCICA ILEALE PADOVANA (VIP) NEOBLADDER

INTRODUCTION AND AIM OF THE STUDY Different fast track programs for patients undergoing radical cystectomy (RC) can be found in the current literature. The aim of this article was to develop a new enhanced recovery protocol (ERP) throughout an exhaustive literature search, and to plan a pilot study to test the ERP on a small cohort of patients undergoing RC and intestinal urinary diversion for bladder cancer with the vescica ileale Padovana (VIP) neobladder. MATERIALS AND METHODS The ERP was designed after a structured literature review carried out from 1966 to December 2010 using MEDLINE via PubMed. The MEDLINE was performed including and combining the following terms, including both ‘‘MeSH’’ (Medical Subject Heading) and ‘‘free text’’ protocols: “fast track”, “cystectomy” and “enhanced recovery”. In order to test the ERP a pilot observational prospective cohort study was planned, involving all patients consecutively undergoing RC and VIP neobladder from December 2010 to June 2011 at our Urologic Unit. RESULTS The literature search rendered a total of 712 articles related to fast-track surgery, 10655 to enhanced recovery, and 8805 to cystectomy. Combining the search strings we retrieved only 2 cohort studies, and a German review article, used to develop our VIP-neobladder tailored ERP, showed in Table 1. Nine consecutive patients met inclusion criteria and participated in the pilot study. No patients died due to surgical complications. Overall 2 of 9 patients experienced complications (22.2%), none requiring surgical intervention. According to Clavien grading, complications were both grade 2. INTERPRETATION OF RESULTS We applied our enhanced recovery program to radical cystectomy and intestinal urinary diversion with vescica ileale Padovana (VIP) neobladder, assessing the results in terms of feasibility and effectiveness, but our pilot study is underpowered and unsuitable to identify predictors of any grade complications. The main problem during the application of our protocol has been the strict adherence to it by all the professional figures involved. In order to assess possible preoperative prognostic factors for the success of a ERP and to corroborate our positive preliminary results larger and specific case series and randomised controlled trials are needed. CONCLUSIONS The introduction of our ERP has been proven to be feasible and effective in the management of patients undergoing RC and intestinal urinary diversion with VIP neobladder. The quality of the postoperative course was enhanced by the absence of the nasogastric tube, the control of nausea and vomiting and early postoperative feeding. Postoperative pain relief was managed with well results, making possible an early mobilization. All these findings led to a more rapid recovery of the bowel function without the occurrence of significant complications.Our protocol was well tolerated. Table 1. Perioperative ERP. Pre-operative phase – day before RC - Hospital admission - Normal breakfast - Unrestricted clear fluids, refer to dietician for a <1500 calorie diet - Bowel preparation: enema (240 mL) at 8:00 p.m. - Antithrombotic prophylaxis with molecular weight heparin (LMWH) Pre-operative phase – day of RC - Clear fluids up to 2 h before RC, then nil by mouth - Nutritional drink (Nutricia-preOp. drink) two hours before sugery (400 mL/200 cal) - No anesthetic premedication - Elastic compressive stockings before surgery - Piperacillin/Tazobactam 4g/0.5g as prophylaxis for infection Intra-operative phase - Combined general and epidural anesthesia with an intrathecal catheter left in place to allow continuous infusion of analgesic drugs during the first postoperative days - Active prevention of hypothermia - Optimizing intra-operative intravenous fluid administration - Nasogastric tube (NGT) insertion preoperatively and removal at the end of surgery - Central venous catheter not inserted regularly - Minimizing intraoperative blood loss - Antiemetic prophylaxis with ondansetron 4mg and droperidol 1.25-2.5mg - Infiltration of the surgical wound with local anaesthetic Post-operative phase Day 1 - Female patients, remove vaginal pack - Mobilise and refer to physiotherapist - Respiratory rehabilitation exercises - 1100 calorie diet as toletated - Free clear liquids as tolerated (if not enough intravenous hydratation) - Analgesic therapy if needed (ropivacaine, paracetamol, ketorolac) - Metoclopramide regularly - Continue taking intravenous pantoprazole 40 mg - Continue taking antibiotics and LMWH as prophylaxis - Chewing gum (1 piece of gum every 2 to 4 hours) as tolerated Day 2 - 1500 calories diet as tolerated - Free clear fluids - Continue to mobilise (sitting position and deambulation) - Remove the first drain if draining <50 mL in 24 hours - Remove epidural catheter - Flush 30 mL into neobladder 6-hourly - Continue taking antibiotics as prophylaxis - Orally administration of pantoprazole 20 mg - Analgesia if needed (paracetamol, ketorolac) - Continue LMWH as prophylaxis - Metoclopramide regularly Day 3 - Continue to mobilise and encourage self care - Enema (120 mL twice per day) - Remove the second drain if draining <50 mL in 24 hours - 1650 calorie diet as tolerated - Analgesia if needed (paracetamol, ketorolac) - Metoclopramide regularly - Continue LMWH as prophylaxis - Continue pantoprazole - Flush 30 mL into neobladder 6-hourly Day 4 - Continue to mobilise and encourage self-care - 2000 calorie diet as tolerated - Analgesia if needed (paracetamol, ketorolac) - Continue LMWH as prophylaxis - Metoclopramide if needed - Continue flushing 30 mL into neobladder 6-hourly Day 5 to 7 - Free diet (dietician to eventually assess further nutritional requirements) - Start planning for discharge - Continue to mobilise and encourage self-care - If a patient is not eating or drinking after 5–6 days but with bowel activity, then start nasogastric feeding. If there is no bowel activity then start total parenteral nutrition. - Continue flushing 30 mL into neobladder 6-hourly Day 8 to 9 - Ureteral stents out (no stentogram) - Remove clips - Continue flushing 30 mL into neobladder 6-hourly Day 10 to 14 - Continue as previous - Cystograghy on day 13: if the cystogram finding is normal, remove the urethral catheter; patient to stay at least 24 h after stent removal - Schedule for return to home