Perioperative Care of the Surgical Patient: Genitourinary Cancers





Introduction


Good perioperative planning, which begins at the time the decision is made to perform surgery and continues through the postoperative recovery phase after discharge, is crucial to achieving successful outcomes in urological cancer surgery. Improvements in surgical technology and technique paired with enhanced recovery and perioperative optimization programs have been shown to reduce patient morbidity and mortality following major urological surgery.


Common urological malignancies and surgical management options are outlined in Table 26.1 . Frequent endoscopic procedures are common in the treatment of bladder cancer; however, owing to the aging population that this condition affects, perioperative morbidity can be misleadingly high. Patients at risk of anesthetic and surgical complications can be identified via predictive indices, such as the Charlson Comorbidity Index (CCI), patient Eastern Cooperative Oncology Group (ECOG) status, and American Society of Anesthesiology (ASA) scores. Early identification of common issues, such as anticoagulation, diabetic control, and pain management needs, allows for adequate preparation and better control when issues arise.




Fig. 26.1


A proposed pathway for management of perioperative pain while limiting narcotic needs.

(From Theisen KM, et al. Excessive opioid prescribing after major urologic procedures. Urology . 2019;123:101–107.)


The practice landscape in urological cancer surgery has changed dramatically over the last 15 years, where a significant rise in the adoption of minimally invasive approaches has been seen. , This has resulted in a change in the nature of complications following major urological cancer surgery. Radical prostatectomy (RP) was previously considered a procedure that carried significant morbidity and risks, whereas most centers that practice robotic RP now only require their patients to have overnight admissions. Radical cystectomy (RC), on the other hand, has surpassed RP as having the highest surgical complication rate. This has led to a strong body of research looking at the impact of Enhanced Recovery After Surgery (ERAS) protocols in RC surgery. ,


Perioperative Assessment and Optimization


Perioperative assessment commences the moment surgical intervention for treatment of the given malignancy is proposed. This is initiated by the urologist or other treating clinician upon meeting the patient, however, can quickly expand to include a much larger multidisciplinary team. Establishing fitness for surgery is a complex and multifactorial decision that can be made within moments in some instances or take months in others. In the first instance, a thorough history of the presenting complaint, past medical history, and medications, as well as physical examination, are essential.


Cardiopulmonary evaluation is important prior to any major urological surgery. Pulmonary function testing may be beneficial for patients with chronic obstructive pulmonary disease (COPD) to determine their baseline function prior to surgery or to assess those with undiagnosed COPD; however, spirometry alone does not determine postoperative risk. Particular attention should be paid to patients with germ-cell tumors who have undergone neoadjuvant chemotherapy with bleomycin, etoposide, and cisplatin (BEP). Pulmonary fibrosis is a well-documented side effect of bleomycin; therefore preoperative pulmonary function tests should be considered prior to proceeding with anesthetic for retroperitoneal lymph node dissection (RPLND). Many patients undergoing urological cancer surgery have preexisting risk factors for cardiovascular disease. Furthermore, it may also be necessary to cease preventative antiplatelet and anticoagulant therapy prior to surgery due to risk of intra- and postoperative bleeding. Guidelines highlight the need for clinicians to weigh up these risks on an individual basis. Bridging anticoagulation should be used for patients at especially high risk in the perioperative period.


Validated perioperative assessment scoring systems are now widely used across all surgical specialties as a guide to surgical planning, perioperative care interventions, and as an adjunct to informed patient decision-making ( Box 26.1 ). A range of nonsurgical management options exist for some urooncological conditions, most commonly radiotherapy used for the treatment of prostate and bladder cancer, as well as ablative options for renal cancer. As such, perioperative consideration together with the patient serves an important role in guiding the best standard of care. The multidisciplinary team meeting (MDTM) is recognized as a gold standard for cancer care delivery globally. It provides a forum for interdisciplinary discussion regarding patient care and involves surgeons, medical oncologists, radiation oncologists, pathologists, radiologists, and specialty cancer nurses, among others. Decision-making at the MDTM can be significantly impacted, however, in the event of lack of patient-specific information or knowledge of the patient’s wishes.



BOX 26.1

Validated Perioperative Assessment Scoring Systems


Assessment Tools


American Society of Anesthesiology (ASA) Physical Classification


Charlson Comorbidity Index (CCI)


Functional Status


Fried Frailty Score


Surgical Risk Calculator



Assessment of global “surgical fitness” is a deviation from the traditional approach of preoperative assessment based on organ system. This can be particularly useful in an elderly demographic of patients and has been studied with regard to those undergoing RC. , Functional status and frailty are both associated with increased postoperative morbidity and mortality. Frailty is a distinct syndrome separate to comorbidity and disability, resulting in decreased physiologic reserve and resistance to stressors. Combined, this results in increased vulnerability and poorer health outcomes. Frailty has been shown to be an independent predictor of complications following RC. ,


Enhanced Recovery and Postoperative Care


ERAS protocols are a seasoned concept in the postoperative care of urological patients. These are standardized, evidence-based programs designed to accelerate recovery times, improve outcomes, and reduce health care costs. Broadly, ERAS protocols are multimodal, and integrate preoperative, intraoperative, and postoperative care principles with the goal of minimizing the surgical stress response, thereby optimizing recovery. They utilize the expertise of a multidisciplinary team, while simultaneously providing clear guidance for progression of postoperative management to the clinical team involved. This includes aspects of postoperative care, such as diet initiation and progression, fluid management, early ambulation, and urinary catheter management to list a few.


There is a large body of research investigating the efficacy of ERAS protocols in the setting of RC , , , and RP ­surgeries. , In urological surgery, ERAS pathways have been demonstrated to reduce duration of hospital stay by up to 30% and without increasing postoperative complications or readmission rates. , The early success of ERAS protocols can be seen in the trajectory of care for patients who have undergone RP and partial nephrectomy (PN). Evidence-based perioperative care pathways in urology were introduced with the aim of reducing hospital length of stay (LOS). RP, which was once thought to be a considerably morbid operation, previously required an average LOS of 6 days. Today, robotic approaches often involve only overnight hospital admissions. ERAS protocols have since been studied and adopted in partial nephrectomy (PN), radical nephrectomy (RN), and radical cystectomy (RC). , These studies have demonstrated the feasibility of ERAS protocols in reducing hospital LOS in the setting of these major urological surgeries. Additionally, hospital readmission and complication rates were not increased with the implementation of ERAS protocols regardless of surgical approach. , , Elements of ERAS pertaining to urological surgery are summarized in Table 26.2 .



Table 26.1

Common Urological Malignancies and Surgical Management




























Urological Malignancy Surgical Management Patient Demographic
Renal Radical nephrectomy
Open, laparoscopic, robotic
Partial nephrectomy
Open, laparoscopic, robotic
inferior vena cava thrombectomy
1.5:1 male predominance
Peak incidence 60–70 years
Risk factors: smoking, obesity, hypertension
Urothelial Cystectomy (and urinary diversion)
Endoscopic procedures
Transurethral resection of bladder tumor
Rigid cystoscopy and diathermy
Endoscopic laser ablation
Ureterectomy
4:1 male predominance
Risk factors: smoking, occupational exposure, radiotherapy
Prostate Radical prostatectomy
Open, laparoscopic, robotic
Pelvic lymph node dissection
Second most commonly diagnosed cancer in men
Prevalence 59% by age >79 years
Testicular Orchidectomy
Partial orchidectomy
Retroperitoneal lymph node dissection
Most common solid malignancy in men aged 20–40 years
Risk factors: undescended testis, family history
Penile Radical penectomy
Partial penectomy
Lymph node dissection
Peak incidence at ages 60–70 years
Risk factors: human papilloma virus


Table 26.2

Urology-Specific Enhanced Recovery After Surgery (ERAS) Elements (from Saidian and Nix )
































































ERAS Item Unique Application to Urological Surgery
Preoperative Patient education and counseling Detailed counseling about urinary diversion and expectations
Patient selection and optimization Most of the cystectomy patients are malnourished to some degree
Oral bowel preparation No benefit to oral bowel preparation in cystectomy patients
No high-level evidence for prostatectomy patients
Preoperative fasting and carbohydrate load None
Alvimopan administration Earlier first bowel movement, shorter LOS, and decreased incidence of ileus in cystectomy patients
Preanesthesia medications May consider use of preoperative gabapentin or oxybutynin for reducing catheter-related bladder pain
Antibiotic recommendations Clean-contaminated procedure; recommend second- or third-generation cephalosporin
Intraoperative Anesthesia recommendations None
Surgical approach Decreased LOS in robotic vs. open approach
Perioperative fluid management Goal-directed fluid therapy in RC patients shows decreased incidence of ileus and postoperative nausea and vomiting
Intraoperative hypothermia prevention None
Resection site drainage Peritoneal drainage is not necessary in patients undergoing RARP, even with extended PLND
NG tube Routine NG tube removal after RC surgery
Postoperative Urinary drainage In RP patients, cystogram must be considered prior to catheter removal or longer catheter times in patients with high risk of urinary anastomotic leakage
May be short-term benefits of suprapubic vs. urethral catheter; however, no long-term functional differences seen
Neobladder: recommend frequent irrigation of any newly formed neobladder. No official recommendations for catheter during or after surgery; however most, recommend 2 weeks minimum
Early ambulation Early ambulation can decrease thromboembolic events, pulmonary complications, and ileus risk
Early diet initiation No specific studies in urological surgery
Postoperative pain management Opioid-sparing protocols have been shown to reduce LOS in RC patients
Consideration of antimuscarinics of gabapentinoids for catheter-related bladder pain


Few studies have explored the relationship between intensive care unit (ICU) admission and adherence to ERAS protocols. , Evidence supporting planned ICU admission following RC is currently lacking. Cheng et al. studied the drivers of ICU admission following RC with ERAS protocols. Although the rate of unplanned ICU admissions after RC was low, they found that advanced age and CCI ≥ 3 were significantly associated with unplanned ICU admission after RC. In their cohort, a significantly higher proportion of past myocardial infarctions and congestive heart failure were seen in those who had unplanned ICU admissions. This highlights the importance of identification and optimization of cardiac disease during preoperative patient workup, particularly in older patients. Specific age cutoffs are not identified in the current literature.


Present data demonstrate the benefit and value of ERAS protocols in the setting of major urological cancer surgery. Gaps lie in the lack of procedure-specific ERAS guidelines. Further studies focusing on refining current protocols for urology, specifically preoperative medical optimization, perioperative nutritional management, management of urinary drainage, e.g., timing of stent removal in ileal conduits, earlier catheter removal in robotic-assisted radical prostatectomy (RARP), and the use of anesthetic alternatives such as spinal epidural anesthesia may further improve outcomes, reduce ICU admissions, and reduce overall hospital LOS.


Common Complications and Causes for Readmission


Hospital LOS and the rate of unplanned hospital readmissions are key indicators of health care costs and funding, as well as being important indicators of successful patient outcomes. For major urological surgeries, the hospital readmission rate has been reported to range from 5.5% for all urological cancer surgeries to up to 25% in RC alone. , The majority of readmissions occur within the first 2 weeks after discharge, and in the case of RC, almost a quarter of patients are readmitted within 30 days of discharge.


Common causes of complications and readmissions are thromboembolic events; wound breakdown; bleeding and hematoma; and renal/genitourinary, gastrointestinal, and infection/sepsis. , , Schmid et al. further break these complications down by type of surgery; their data demonstrated that RC carries the highest rates of complications and readmission, followed by RP and RN, then PN ( Table 26.3 ). Many other studies show similar findings to RC, regardless of surgical approach. Additionally, open procedures for RP or PN are more likely to experience hospital readmissions compared with their minimally invasive equivalents.


Jun 26, 2022 | Posted by in ANESTHESIA | Comments Off on Perioperative Care of the Surgical Patient: Genitourinary Cancers
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