BERKELEY, CA (UroToday Inc.) - Radical cystectomy and urinary diversion is the standard treatment approach for muscle invasive bladder cancer. The morbidity and mortality of this operation has decreased significantly in the past 25 years. However, surgeons are always more concerned about performing this procedure in elderly patients.

In the December 2004 issue of Surgical Oncology, Dr. Maffezini and associates from the Hospital Galliera in Genova, Italy present a peri-operative care algorithm for 18 elderly patients undergoing cystectomy.

They enrolled 18 patients etween November 2003 and July 2004. Average age was 70 years with a range of 52-82 years. The authors discuss pre-operative assessment of nutritional status, but it appears that this only consisted of assessment for a >15% weight loss and not of caloric intake, albumin measurement, etc. The authors describe a new approach to preoperative fasting by having patients avoid mechanical bowel preparation and starting fasting at midnight before surgery (but current anesthesia recommendations at many hospitals now already permit clear liquids up to 2 hours prior to surgery).

At surgery a thoracic epidural is placed and a jejunal feeding tube inserted. Post-operatively, the nasogastric tube is removed within the first 8 hours, parenteral nutrition is begun at 6 hours and enteral nutrition is started on post-operative day 1. Eight of 18 patients had enteral feedings discontinued, and one required surgical re-exploration for a dislodged jejunal feeding tube. Data presented on return of bowel function is not well described, but in the 10 patients completing the protocol it seemed to be by day 4 and in the other patients by day 5.

Comment: This study has a well-founded hypothesis, but unfortunately it is problematic from many standpoints. It is not randomized, there is no control group and outcomes are poorly described. While it describes the population as elderly, the mean age was only 70, and patients as young as 52 years were included. Three previous papers describing cystectomy in the elderly have shown the procedure to be as safe as in younger patients, when controlled for co-morbidities. Furthermore, many of the protocol features described are standard already. Additional aspects, such as parenteral nutrition for 24 hours prior to starting enteral nutrition, are costly and perhaps not warranted. The return of bowel function on days 4-5 is perhaps not significantly better than that in any high-volume cystectomy center. Without randomization and controls, their results will not be clarified.

Surg Oncol 2004;13:197-200