NARUS 2018: Enhanced recovery protocol for robotic cystectomy Protocol
The initial step is patient education. This includes appointment with the surgeon 48 hours before the procedure, where important information is given. Additionally, the patient undergoes dynamic stomal fitting and education – this improves stomal efficiency and improves cost.
It is important to preoperatively optimize the patient medically. This involves correction of anemia, smoking cessation and alcohol reduction, ideally 4 weeks before surgery, exercise and optimization of patient comorbidities. Additionally, preoperative malnutrition, which is present in 16-22% of bladder cancer patients, needs to be treated. Therefore, immune-nutrition is provided preoperatively. This stimulates the gut integrity, and prevents bacterial translocation. It contains large amounts of protein and L-arginine.
Further preoperative preparation includes no mechanical or antibiotic bowel prep, which has been shown not to improve outcomes. Additionally, carbohydrate loading is used as it decreases potop nausea and vomiting, it reduces postop catabolism and insulin resistance, and decreases thirst, and maintains lean body mass. Usually no solid food is allowed 6 hours prior to surgery and liquid is not allowed 2 hours prior to the procedure. The carbohydrate load starts 48 hours prior to surgery, and then continues 8 hours prior to surgery and finally again 3 hours prior to surgery.
Multimodal anesthesia and analgesia are most important. Gabapentin (Nurontin) is utilized, which is an anxiolytic. Celecoxib (NSAID) is used as well, together with acetaminophen and ketamine.
Additional perioperative considerations include deep vein thrombosis (DVT) prophylaxis with low molecular weight heparin, and antibiotic prophylaxis, usually with a 2nd/3rd generation cephalosporin for 24 hours.
Postoperative considerations include early removal of nasogastric tube decompression which has been shown to decrease postop fever, atelectasis, pneumonia and overall complications. It also decreases time to oral feeding. Patients are also given a proton pump inhibitor, and are fed early with a liquid diet initially, and later on advanced. Prokinetics are recommended as well to improve gut motility. These include metoclopramide, erythromycin, chewing gum and neostigmine. However, Alvimopan (Entereg), which is a peripherally acting µ-opioid receptor antagonist, has been shown to be the most successful prokinetic.
During the entire case, the goal directed fluid management (GDFM) is completely adopted, showing to optimize physiologic stability, cardiovascular volume, and end organ perfusion.
Some less clear cut issues include not leaving a drain, and performing peritoneum closure. These have been shown to decrease pain, reduce need for anesthetic, lower complication rate and result in earlier passage of flatus.
Speaker: Mark Delworth, The Urology Group, Cincinnati,Ohio, USA
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV