Perioperative management of radical cystectomy patients: A questionnaire survey of the American Urological Association members.

Abstract

316 Background: Radical cystectomy (RC) is the standard treatment for patients with muscle invasive bladder cancer. RC is associated with more post-op complications and longer length of stay (LOS) after surgery than other urologic procedures. There is little information about peri-op pathways in the urologic literature. This study investigates practice patterns of urologists in the United States on peri-op management of bladder cancer patients undergoing RC. Methods: All AUA members were invited via email to an online survey from April to August 2012. The 31-items questionnaire of multiple choice and open-ended questions related to training, practice, and peri-op protocols. Results: A total of 375 urologists participated in the survey, 28.9% have oncology fellowship training, 46.4% training in robotic RC, and 30.1% perform robotics or laparoscopy. Of participants, 41.6% follow a clinical pathway however most utilize experience/training rather than an evidence-based protocol. Even with current evidence for enhanced recovery after surgery (ERAS) only 39.5% of respondents perform pre-op nutritional assessment. Most require a prolonged fast, no carbohydrate loading, and give all patients bowel prep pre-op. Most administer antibiotic prophylaxis before incision and continued 24 hrs, however only ~1/3 administer thromboprophylaxis pre-op, 15% give neither pre or post-op. Of respondents only 5% initiate a diet on post-op day (POD) 1 or before. 38.6% routinely send patients to ICU after surgery. Epidural, narcotics, or NSAIDs are commonly used for pain control, narcotics being the most common. Overall first flatus is reported on POD3 to 4, first bowel movement on POD4 to 5. Most patients are discharged on POD6 to 7. Urologists with oncology fellowship stated shorter LOS compared to those without (POD6.19 vs 6.64). Those doing open RC stated longer LOS compared to those doing robotic or laparoscopic RC (POD6.54 vs 6.03). Conclusions: ERAS studies have shown objective parameters that can improve peri-op outcomes. However, this survey shows significant individual differences in peri-op management of bladder cancer with the majority of urologists using personal experience as their primary guide.