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Radical Cystectomy with Incontinent or Continent Urinary Diversion
Section 1: Indications
· Patients with a diagnosis of urothelial carcinoma clinical stage T1-T4NanyM0.
· Properly counseled patients with non-muscle invasive high grade T1 urothelial carcinoma or carcinoma in situ who are deemed to be cystectomy candidates.
· Patients must have an Eastern Cooperative Oncology Group (ECOG) performance status of 0-3.
Section 2: Approach
· Patients must have a clinical decision to proceed with radical cystectomy by any conventional approach (open, laparoscopic, robot-assisted laparoscopic).
· Any urinary diversion necessitating the use of bowel in the creation of a neobladder, reservoir, or urinary conduit is applicable.
Section 3: Pre-Admission Checklist
· Education
o Smoking Cessation
* Quit at first visit
o EtOH Abstinence
* Quit at first visit
o Enterostomal Therapy
* Meeting at first visit
o Survivorship
* Bladder Cancer Advocacy Network
· Nutrition
o Dietician Counseling
* Meeting at first visit
· Optimization
o Co-morbidity Clearances
o Daily Incentive Spirometry
o Physical Therapy
o Daily Exercise
* Pedometer
Section 4: Morning of Surgery
· Nutrition
o Boost Breeze Carbohydrate Loading
* 2-4 hours prior to coming to the hospital
o Clear Liquids
* Until 2 hours prior to incision[PSG1]
· Bowel Recovery
o Entereg
* 12mg po in holding area
· VTE Prophylaxis (Can we do this after epidural placement?)
o Lovenox
* 40mg SQ injection if eGFR>30
o Heparin
* 5,000u SQ injection if eGFR<30[PSG2]
· Pain Control
o PO Analgesic Cocktail
* Tylenol 1000mg + Gabapentin 600mg + diclofenac 100 mg
* Scopolamine patch 1.5 mg
o Epidural Anesthesia (Lidocaine or Bupivacaine?)
* TAP Blocks if epidural contra-indicated or unsuccessful
Section 5: Intraoperative Care
· Anesthesia
o Fluid Management Goals
* Urine output monitoring for near-zero fluid balance (0.5 ml/kg/hour)
* Goal 2-3 L Total
o Antibiotic Prophylaxis
* Cefoxitin 1gm IV 30-60 mins prior to incision, re-dose at q2 hour interval
* Flagyl 500mg IV 30-60 mins prior to incision, re-dosed at q8 hour interval
o Induction
* Magnesium 30 mg/kg IV loading, 10 mg/kg IV q1h
* Ketamine 0.3 mg/kg IV loading, 0.15 mg/kg IV q1h[PSG3]
* Ibuprofen 10 mg/kg IV
* Dexamethasone 4 mg IV
* Zofran 4mg IV x 1
* Avoid N2O
* Avoid long acting opioids (hydromorphone)
* Orogastric tube
· Removed at the end of case
o Forced air warming to maintain normothermia
o Maintain normoglycemia (< 180)
o SCDs
· Surgeon
o Infiltration of incision sites with marcaine[PSG4]
o Minimal bowel manipulation
Section 6: PACU/POD #0[PSG5]
· Goal urine output 0.5 ml/kg/hour
· Diet: Clear sips once alert
o 200 cc maximum
· IVF: D51/2 NS @ 125cc/hr
· Pain team to manage epidural
o Tylenol 1000mg IV q6 x 6 doses
o Toradol 15mg IV q6 x 6 doses if eGFR >30
o Dilaudid IV prn breakthrough pain
· Goal normal blood pressure
· Incentive spirometry 10x/hour while awake
· HOB 45 degrees while in bed
· OOB to chair for 6 hours/day while awake
Section 7: POD #1
· Activity: Ambulate every 4-6 hours while awake
· Diabetic teaching
· Wound/Ostomy Consultation
· Physical Therapy Consultation
· Case Management Consultation
o Home health IVF/ostomy care
o Daily Lovenox x 4 weeks
· Pain Management
o Pain team to control PCA/Epidural Orders
o Gabapentin
* 300mg po every 8 hours if eGFR >60
* 300mg po every 12 hours if eGFR 30-60
* 300mg po every 24 hours if eGFR 15-30
* Do not administer if eGFR <15
* Hold for somnolence/dizziness
· Flushing:
o Indiana Pouch
* MD to flush BID
o Neobladder
* MD to flush BID
· Diet: Clear liquid diet
· IVF: D51/2 NS @ 125
· Bowel Recovery
o Entereg 12mg po q12 hours
· [PSG6] VTE Prophylaxis
o Lovenox
* 40mg SQ injection daily if eGFR>30
o Heparin
* 5,000u SQ injection q8 hours if eGFR<30
· Labs
o H/H
o BMP
Section 8: POD #2
· Diet: Regular diet or ADA 1800 if diabetic
· IVF: D51/2NS @75cc/hr
· Pain Control
o Pain management to DC epidural/PCA
o Celecoxib 200mg po BID if eGFR >30
* Hold for UOP <120cc over 4 hours
· Labs
o H/H
Section 9: POD #3
· IVF: Hep-lock IV
· Bowel Recovery
o Milk of Magnesia
* 30-60cc po daily
o Dulcolax
* 1 rectal suppository daily
o DC Entereg if RBF
· Labs
o No labs
Section 10: POD 4
· Labs
o H/H
o BMP
· Discharge to home
o Oral bicarbonate/acetate?
Section 11: After Discharge
· Home Day #1
o Triage RN to call patient at home
* Status update
* Appointment confirmation
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