Radical Cystectomy PSH 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

  • Smoking Cessation

    • Quit at first visit

  • EtOH Abstinence

    • Quit at first visit

  • Enterostomal Therapy

    • Meeting at first visit

  • Survivorship

    • Bladder Cancer Advocacy Network

  • Inpatient expectations

    • Minimal narcotics

    • Favoring Tylenol, NSAIDs, Gabapentin

    • Length of stay 3-4 days

• Nutrition

  • Dietician Counseling

    • Meeting at first visit

• Optimization

  • Co-morbidity Clearances

  • Daily Incentive Spirometry

  • Physical Therapy

  • Daily Exercise

    • Pedometer

Section 4: Morning of Surgery

• Nutrition

  • Boost Breeze Carbohydrate Loading

    • 2-4 hours prior to coming to hospital

  • Clear Liquids

    • Until 2 hours prior to incision

• Bowel Recovery

  • Entereg

    • 12mg po in holding area

• VTE Prophylaxis

  • Lovenox

    • 40mg SQ injection if eGFR>30

  • Heparin

    • 5,000u SQ injection if eGFR<30

• Pain Control

  • PO Analgesic Cocktail

    • Tylenol 1000mg + Gabapentin 600mg + motrin

    • Scopolamine patch 1.5mg

  • Epidural Anesthesia (Lidocaine or Bupivacaine)

    • TAP Blocks if epidural contra-indicated or unsuccessful

Section 5: Intraoperative Care

• Anesthesia

  • Fluid Management Goals

    • Urine output monitoring for near-zero fluid balance (0.5 ml/kg/hour)

    • Goal is 2-3 liters total

  • 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

  • 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

    • Ibuprofen 10 mg/kg IV

    • Dexamethasone 4 mg IV

    • Zofran 4mg IV

    • Avoid N₂O

    • Avoid long acting opioids (hydromorphone)

    • Orogastric tube

      • Removed at the end of case

  • Forced air warming to maintain normothermia

  • Maintain normoglycemia (< 180)

  • SCDs

• Surgeon

  • Infiltration of incision sites with marcaine

  • Minimal bowel manipulation

Section 6: PACU/POD #0

• KUB for ureteral stent placement

• Goal urine output 0.5 ml/kg/hour

• Diet: Clear sips (from medicine cups) once alert

  • • 200cc maximum

• IVF: D51/2 NS @ 125cc/hr

• Pain team to manage epidural and PCA orders

  • • Tylenol 1000mg IV q6 x 6 doses

    • Toradol 15mg IV q6 x 6 doses if eGFR >30

    • Dilaudid IV (for severe, refractory

• 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

  • • Home health IVF/ostomy care

    • Daily Lovenox x4 weeks

• Pain Management

• • Pain team to control PCA/Epidural Orders

  • 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:

• • Indiana Pouch

    • MD to flush BID

  • Neobladder

    • MD to flush BID

• Diet: Clear liquid diet

• IVF: D51/2 NS @ 125

• Bowel Recovery

• • Entereg 12mg po q12 hours

• VTE Prophylaxis

• • Lovenox

    • 40mg SQ injection daily if eGFR>30

  • Heparin

    • 5,000u SQ injection q8 hours if eGFR<30

• Labs

• • H/H

  • BMP

Section 8: POD #2

• Diet: Regular diet or ADA 1800 if diabetic

• IVF: D51/2NS @75cc/hr

• Pain Control

  • Pain management to DC epidural/PCA

  • Celecoxib 200mg po BID if eGFR >30

    • Hold for UOP <120cc over 4 hours

• Labs

  • H/H

Section 9: POD #3

• IVF: Hep-lock IV

• Bowel Recovery

  • Milk of Magnesia

    • 30-60cc po daily

  • Dulcolax

    • 1 rectal suppository daily

  • DC Entereg if RBF

• Labs

  • No labs

Section 10: POD 4

• Labs

  • H/H

  • BMP

• Discharge to home

  • Oral bicarbonate/acetate?

Section 11: After Discharge

• Home Day #1

  • Triage RN to call patient at home

    • Status update

    • Appointment confirmation