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Introduction of a tailored enhanced recovery protocol to reduce short-term complications following radical cystectomy and intestinal urinary diversion with vescica ileale padovana (VIP) neobladder.
Cerruto,M. A.;De Marco,V.;D'Elia,C.;Bizzotto,L.;Cavalleri,S.;Curti,P.;Novella,G.;Balzarro,M.;Artibani,W.
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INTRODUCTION AND AIM OF THE STUDY: Different fast track programs for patients undergoing radical cystectomy (RC) can be found in the current literature. With the aim at reducing short term complications of radical cystectomy (RC) and intestinal urinary diversion with Vescica Ileale Padovana (VIP) neobladder we described and assessed a tailored enhanced recovery protocol (ERP) in a series of consecutive patients. MATERIALS AND METHODS: After an exhaustive literature research an ERPwas introduced in our institution on December 2010 focusing: on reduced bowel preparation, standardized feeding and analgesic regimens. We analysed the impact of our ERP and report the outcomes with all patients consecutively undergoing RC and VIP neobladder fromDecember 2010 to July 2012 at our Urologic Unit, who met the following inclusion criteria: ASA score (less-than or equal to)T3; absence of malnutrition according to the Mini Nutritional Assessment Short Form (MNA-SF) criteria; absence of inflammatory bowel diseases. RESULTS: The literature search rendered a total of 712 articles related to fast-track surgery, 10655 to enhanced recovery, and 8805 to cystectomy. Combining the search strings we retrieved only 2 cohort studies, and a German review article, used to develop our VIP-neobladder tailored ERP, showed in Table 1. thirty-one consecutive patients undergoing RC and VIP neobladderwith curative intentwere recruited to undergo our ERP. Mean age of patients was 62.16 years with 19.35% of patients older than age 70 years. The mean operating time was 247.10 minutes (range 200-360 minutes). The mean estimated intraoperative blood loss was 633.87 mL (150-2000). No patients died due to surgical complications. Overall 9 of 31 patients experienced complications (29.03%) (table 2), none requiring surgical intervention. We did no record major medical complications. According to Clavien grading, all complications were grade (less-than or equal to)2. Overall, 11 patients (35,4%) obtained normal bowel movements on POD 1, 12 (38.7%) on POD2, and 8 (25.8%) on POD. Bowel functionwas comparable in patients with and without use of chewing gum (table 3). A limitation of our case series is the small number of patients recruited, needing larger and specific case series and randomised controlled trials for finding validation. INTERPRETATION OF RESULTS: To date, fast track programs employed in urological procedures have been rather limited. Moreover comparative data are difficult to find, as many studies are based in the USA, applied different enhanced recovery protocols and are addressed to patients with distinct kinds of urinary diversion, such as with ileal conduit or modified Indiana. Moreover, many studies don't used a standardized classification for complications recording. Our study has the drawback that the analysed patient cohort was too small to assess some perioperative factors predicting the success of a ERP and early postoperative complications. Successful employment of a fast track program applied to our patients undergoing radical cystectomy and VIP neobladder justify the need to designed larger and specific case series and randomised controlled trials to corroborated these preliminary results. CONCLUSIONS: The introduction of our ERP has been proven to be feasible and effective in the management of patients undergoing RC and intestinal urinary diversion with VIP neobladder. The quality of the postoperative course was enhanced by the absence of the nasogastric tube, the control of nausea and vomiting and early postoperative feeding. Postoperative pain relief was managed with well results, making possible an earlymobilization. All these findings led to a more rapid recovery of the bowel function without the occurrence of significant complications. Our protocol was well tolerated. (Table presented).
Neurourol Urodyn.
S18 [Abstract 20 from the 37th Annual Congress of the Italian Urodynamic Society (Continence, Neuro-Urology, Pelvic Floor) Palazzo della Cultura, Latina, Italy, June 20–22, 2013]
vasoactive intestinal polypeptide;analgesic agent;urinary diversion;society;continence;urology;pelvis floor;cystectomy;human;patient;case study;postoperative complication;feeding;randomized controlled trial;intestine;surgery;United States;nutritional asse????
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