A Novel Prevention Bundle to Reduce Incisional Infections After Radical Cystectomy - Beyond the Abstract

Surgical site infection (SSI) is common post radical cystectomy (up to 33% in some studies) resulting in significant postoperative morbidity. Although there is a paucity of cystectomy-specific data, a number of perioperative practices, including prophylactic antibiotics, wound cleansing, gown and glove change, and separate sterile closure tray, have shown some benefit in reducing infection in surgical patients, particularly in patients undergoing bowel surgery. Furthermore, the benefits of wound protection have been well established in General Surgery literature. Because radical cystectomy involves reconstruction of the urinary tract through the use of bowel (usually ileum), we felt many of these practices could also be of benefit to our patient group.

We developed an SSI reduction bundle to reduce the incidence of incisional SSI in patients undergoing radical cystectomy at our institution. Our bundle included barrier wound protection, in the form of the Alexis® retractor, changing of surgical gowns and gloves prior to wound closure, washing of fascia with proviodine/saline mix prior to skin closure, and application of an antibiotic-impregnated dressing to the wound. The SSI previous bundle was successfully applied to all patients undergoing cystectomy after March 1st, 2018, and resulted in an 80% reduction in the incidence of incisional SSI.

A major strength of this study was the accuracy of the study outcomes. All charts were manually reviewed for infection within 30-days post-operatively using a strict Center for Disease Control (CDC) criteria. These results were then cross-checked with institutional NSQIP data, which uses the same CDC definition, to ensure accuracy. We were also able to show that the implementation of such a preventative bundle is both feasible and can result in improved clinical outcomes at a large tertiary center.

One limitation of our study is that we are unable to determine which component of the bundle contributes the most to the reduction in incisional SSI. Therefore, further study on the individual components of the bundle, particularly the benefit of wound protection in patients undergoing radical cystectomy, is warranted. Ideally, future investigation of our bundle or its components would be done in a randomized fashion to avoid the inherent biases of a non-randomized, retrospective study design.

Written by: James Ross, MD, Resident, Department of Urology, University of Ottawa, Ottawa, Ontario; Luke T. Lavallée, MDCM, MSc, FRCSC, Associate Scientist, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Urologic Oncologist, Division of Urology, Department of Surgery, The Ottawa Hospital, General Campus, Assistant Professor, University of Ottawa, Ottawa, Ontario

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