Aim: To compare the outcome of two perioperative protocols with respect to postoperative management of cystectomy patients. Patients and Methods: Between June 2007 and November 2008, 85 consecutive patients with bladder cancer were treated with cystectomy and urinary diversion. Patients were operated in two hospitals by four urologic surgeons. In protocol A, patients were enterally fed via a postpyloric tube while the nasogastric tube (NGT) was removed directly after cystectomy and selective decontamination of the digestive tract was given until normal oral intake. In protocol B, postcystectomy management consisted of total parenteral nutrition by a central venous line and NGT removal after 24 h. Hospital stay and complications were compared between the two hospitals. Results: More than half of all patients (52%) developed one or more complications within 30 days after surgery, 37% in protocol A and 71% in protocol B (p = 0.002). Higher ASA score and protocol type were the only factors significantly associated with early complications in both uni- and multivariate analyses. Length of stay was significantly shorter with protocol A as compared to protocol B, 13 days versus 19 days (p = 0.006). Conclusions: Cystectomy and urinary diversion is a procedure with considerable risk of complications. Enteral nutrition might be advantageous as compared to parenteral nutrition, showing fewer complications and shorter hospital stay. A high ASA score is associated with more early complications. Selective bowel decontamination may have an additional role in preventing infectious complications after cystectomy.

Keywords:
Bladder cancer, Cystectomy, Complications, Nutrition, Hospital stay
1.
Konety BR, Allareddy V, Herr H: Complications after radical cystectomy: analysis of population-based data. Urology 2006;68:58–64.
2.
Froehner M, Brausi MA, Herr HW, Muto G, Studer UE: Complications following radical cystectomy for bladder cancer in the elderly. Eur Urol 2009;56:443–454.
3.
Shabsigh A, Korets R, Vora KC, Brooks CM, Cronin AM, Savage C, Raj G, Bochner BH, Dalbagni G, Herr HW, Donat SM: Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009;55:164–174.
4.
Maurer T, Maurer J, Retz M, Paul R, Zantl N, Gschwend JE, Treiber U: Influence of body mass index on operability, morbidity and disease outcome following radical cystectomy. Urol Int 2009;82:432–439.
5.
Fairey A, Chetner M, Metcalfe J, Moore R, Todd G, Rourke K, Voaklander D, Estey E: Associations among age, comorbidity and clinical outcomes after radical cystectomy: results from the Alberta Urology Institute radical cystectomy database. J Urol 2008;180:128–134.
6.
Quek ML, Stein JP, Daneshmand S, Miranda G, Thangathurai D, Roffey P, Skinner EC, Lieskovsky G, Skinner DG: A critical analysis of perioperative mortality from radical cystectomy. J Urol 2006;175:886–889.
7.
Novara G, De Marco, V, Aragona M, Boscolo-Berto R, Cavalleri S, Artibani W, Ficarra V: Complications and mortality after radical cystectomy for bladder transitional cell cancer. J Urol 2009;182:914–921.
8.
McCabe JE, Jibawi A, Javle PM: Radical cystectomy: defining the threshold for a surgeon to achieve optimum outcomes. Postgrad Med J 2007;83:556–560.
9.
Allareddy V, Allareddy V, Konety BR: Specificity of procedure volume and in-hospital mortality association. Ann Surg 2007;246:135–139.
10.
Hollenbeck BK, Daignault S, Dunn RL, Gilbert S, Weizer AZ, Miller DC: Getting under the hood of the volume-outcome relationship for radical cystectomy. J Urol 2007;177:2095–2099.
11.
Nelson R, Tse B, Edwards S: Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg 2005;92:673–680.
12.
Maffezzini M, Gerbi G, Campodonico F, Parodi D: Multimodal perioperative plan for radical cystectomy and intestinal urinary diversion. I. Effect on recovery of intestinal function and occurrence of complications. Urology 2007;69:1107–1111.
13.
De Smet AM, Kluytmans JA, Cooper BS, Mascini EM, Benus RF, van der Werf TS, van der Hoeven JG, Pickkers P, Bogaers-Hofman D, van der Meer NJ, Bernards AT, Kuijper EJ, Joore JC, Leverstein-van Hall MA, Bindels AJ, Jansz AR, Wesselink RM, de Jongh BM, Dennesen PJ, van Asselt GJ, te Velde LF, Frenay IH, Kaasjager K, Bosch FH, van Iterson M, Thijsen SF, Kluge GH, Pauw W, de Vries JW, Kaan JA, Arends JP, Aarts LP, Sturm PD, Harinck HI, Voss A, Uijtendaal EV, Blok HE, Thieme Groen ES, Pouw ME, Kalkman CJ, Bonten MJ: Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009;360:20–31.
14.
Roos D, Dijksman LM, Sondermeijer BM, Oudemans-van Straaten HM, T de Wit L, Gerhards MF: Perioperative selective decontamination of the digestive tract in elective colorectal surgery. J Gastrointest Surg 2009;13:1839–1844.
15.
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;17:41–48.
16.
Pruthi RS, Chun J, Richman M: Reducing time to oral diet and hospital discharge in patients undergoing radical cystectomy using a perioperative care plan. Urology 2003;62:661–665.
17.
Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M: The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009;250:187–196.
18.
Nieuwenhuijzen JA, de Vries RR, Bex A, van der Poel HG, Meinhardt W, Antonini N, Horenblas S: Urinary diversions after cystectomy: the association of clinical factors, complications and functional results of four different diversions. Eur Urol 2008;53:834–424.
19.
Lewis SJ, Andersen HK, Thomas S: Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis. J Gastrointest Surg 2009;13:569–575.
20.
Mohler JL, Flanigan RC: The effect of nutritional status and support on morbidity and mortality of bladder cancer patients treated by radical cystectomy. J Urol 1987;137:404–407.
21.
Gabor S, Renner H, Matzi V, Ratzenhofer B, Lindenmann J, Sankin O, Pinter H, Maier A, Smolle J, Smolle-Juttner FM: Early enteral feeding compared with parenteral nutrition after oesophageal or oesophagogastric resection and reconstruction. Br J Nutr 2005;93:509–513.
22.
Kiyama T, Efron DT, Tantry U, Barbul A: Trauma and wound healing: role of the route of nutritional support. Int J Surg Investig 2001;2:483–489.
23.
Soliani P, Dell’Abate P, Del RP, Arcuri MF, Salsi P, Cortellini P, Sianesi M: Early enteral nutrition in patients treated with major surgery of the abdomen and the pelvis (in Italian). Chir Ital 2001;53:619–632.
24.
Chang SS, Baumgartner RG, Wells N, Cookson MS, Smith JA Jr: Causes of increased hospital stay after radical cystectomy in a clinical pathway setting. J Urol 2002;167:208–211.
25.
Cheatham ML, Chapman WC, Key SP, Sawyers JL: A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995;221:469–476.
26.
Donat SM, Slaton JW, Pisters LL, Swanson DA: Early nasogastric tube removal combined with metoclopramide after radical cystectomy and urinary diversion. J Urol 1999;162:1599–1602.
27.
De La Cal MA, Cerda E, Garcia-Hierro P, van Saene HK, Gomez-Santos D, Negro E, Lorente JA: Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract: a randomized, placebo-controlled, double-blind trial. Ann Surg 2005;241:424–430.
28.
Emre S, Sebastian A, Chodoff L, Boccagni P, Meyers B, Sheiner PA, Mor E, Guy SR, Atillasoy E, Schwartz ME, Miller CM: Selective decontamination of the digestive tract helps prevent bacterial infections in the early postoperative period after liver transplant. Mt Sinai J Med 1999;66:310–313.
29.
Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, von Meyenfeldt MF, Fearon KC, Revhaug A, Norderval S, Ljungqvist O, Lobo DN, Dejong CH: Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009;144:961–969.
© 2012 S. Karger AG, Basel
2012
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.