Radical Cystectomy ERAS Pathway

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


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


· 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