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