SUO 2017: Benefits of Alvimopan in Men Undergoing Retroperitoneal Lymph Node Dissection

Washington, DC ( With an increasing emphasis on improving post-operative courses after major operations, the ERAS pathway has been enthusiastically taken up by the bladder cancer community. However, a key component of the ERAS pathway is the use of pre-operative alvimopan (Entereg), a mu-receptor opioid antagonist. Having demonstrated efficacy in GI surgery and the radical cystectomy literature at reducing hospital length of stay and postoperative morbidity, the authors from this study assessed its utility following RPLND for testicular cancer.

Completed at Indiana University, a major center for testicular cancer management, the authors prospectively trialed the use of almivopan in 14 consecutive patients treated with RPLND between May and July 2017. All patients were given almivopan preoperatively and twice daily until return of bowel function, along with acetaminophen and gabapentin, minimizing opioid use. They were compared to the 33 prior RPLNDs over a 5 month period, and the primary outcome was hospital LOS, date of first bowel movement (BM), and amount of opiate use. 

In terms of demographics, 65.9% of the cases were post-chemotherapy. Concomitant procedures were completed in 9 procedures, but only one involved bowel (duodenal resection). The two groups were relatively similar in terms of pathologic features and basic demographics, with no significant differences. 

Overall median LOS was similar between both groups (3 days in the almivopan group and 4 days in the control group). While there was no difference in time to return of bowel function, there was a reduction in the use of IV narcotics in the almivopan group (11.3 mg vs. 16.1 mg, p = 0.05). 

Based on this initial small series, there does not appear to be much benefit to the use of almivopan in a surgery that does not traditionally involve bowel resection or manipulation. While there was a reduction in narcotic use, it did not translate to reduced LOS or earlier return of bowel function. At this time, minimizing operative time and early ambulation are still cornerstones of recovery following RPLND, even at high volume centers. 

Presented by: Adam C. Calaway, MD

C0-Authors: Clint Cary , Richard Bihrle  and Richard Foster
Affiliation: Indiana University, Indianapolis, Indiana

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington,