Reducing the mortality and morbidity of radical cystectomy and urinary diversion continues to challenge urologic oncologists today. In contrast to other major urologic oncology procedures, the routine use of intestinal segments for urinary diversion introduces a number of risks and challenges for postoperative recovery. Ileus, bowel obstruction, and other complications consistently rank among the most common and troublesome major complications in series of cystectomy and urinary diversion. Whereas the historical paradigm of bowel surgery was characterized by extreme conservativism, with prolonged nasogastric tube drainage and delayed initiation of enteral feeding until resumption of bowel function was established, standard postoperative care in general surgery has evolved towards earlier introduction of feeding, which in turn appears to be associated with improved outcomes in a variety of contexts [13–21].

A more aggressive approach to postoperative care after colorectal surgery has an established and standardized track record that has been widely adopted. Enhanced recovery after surgery, or ERAS, protocols have repeatedly shown improved postoperative outcomes, leading to widespread adoption of these clinical fast-track pathways in that context [13–19]. Key components of ERAS pathways [13] for patients undergoing colorectal surgery include:

Over the past decade, there have been many modifications and deviations to the fast-track clinical pathway described above, dependent upon the specific surgery performed, but the basic tenets of minimizing bowel preparations, single dose antibiotic prophylaxis, antithrombotic prophylaxis, minimizing gastric decompression, early reintroduction of oral intake, early mobilization, and maintaining adequate but minimal postoperative analgesia continue to have significant relevance in the postoperative care of patients undergoing a broad spectrum of gastrointestinal operations [13–21].

A randomized control trial comparing fast-track protocols after colonic surgery compared to older standard protocols was conducted by researchers in Zurich [13]. Muller et al. reported that utilizing fast-track protocols led to significantly reduced 30 day complications and shorter hospital stays, ultimately driving reduced healthcare costs [13]. This trend was also confirmed in a prospective observational study of more than 900 patients undergoing colonic surgery reported by Gustaffsson et al.; patients with high adherence to the ERAS protocol were found to have a 25 % lower risk of a postoperative complication and 50 % lower risk of postoperative symptoms delaying discharge [14].

In parallel with these clinical and economic benefits, fast-track pathways have also been shown to improve satisfaction of both providers and patients. Postoperative care employing fast-track programs require coordinated efforts between all stakeholders including physicians, nurses, dieticians, nursing assistants, patients, and family caregivers [19–21]. The coordinated efforts of all the individuals involved leads to more robust communication, ultimately enhancing patient care [19–21]. Furthermore, from a nursing perspective, nurses in fact play a larger role in postoperative recovery by encouraging early mobilization and oral intake [20, 21]. As a result, nurses feel more invested as the importance of their roles becomes highlighted in the successful implementation of postoperative fast-track recovery programs [20, 21]. Ultimately, as reflected in survey data, this leads to an overall greater patient satisfaction with their operative experience [21]. In a review of enhanced recovery protocols, authors Khan et al. examined ten studies investigating health-related quality of life (HRQoL) and patient satisfaction, with several studies demonstrating significantly reduced fatigue and pain in the first week after surgery [21]. After the first week of surgery, the authors did not find any statistically significant differences in the results of patient questionnaires [21] leading to the conclusion that these pathways may be particularly critical to improving the quality of life during the early days of the postoperative recovery [21].

Given the centrality of small or large bowel resection and anastomosis for urinary diversion to the recovery after cystectomy, and the significance of these aspects to the development of complications after cystectomy, implementing the strategies of postoperative care from our colleagues in general surgery is intuitive and lends itself to very similar parallels. While the issues central to gastrointestinal surgery are relatively less relevant in other major urologic oncology procedures such as nephrectomy or prostatectomy, the importance of these issues to the recover after radical cystectomy cannot be underestimated. As such, we strongly believe that the incorporation of insights from the general surgery literature into the postoperative care of patients undergoing radical cystectomy with urinary diversion for the treatment of bladder cancer provides an important avenue to improve outcomes, reduce costs, and enhance the patient’s experience and satisfaction.

Our postoperative cystectomy pathway has previously been reported in 362 patients undergoing radical cystectomy from either an open or a robot-assisted approach. Urinary diversions encompassed both ileal conduits and neobladders. The original “fast-track” pathway in our main descriptive report is outlined below:

A number of changes have been made to our initial experience which are outlined later in the chapter. However, even our initial experience highlights several significant shifts from the previously accepted norm. Major changes from traditional practice include immediate removal (or lack of placement) of an orogastric or nasogastric tube and the elimination of preoperative bowel preparation as previously described [13–19]. Initial experience of early nasogastric tube removal concomitantly with metoclopramide use was described by Donat et al. where the authors demonstrated that early nasogastric decompression had benefits with regards to earlier return of bowel function as well as fewer complications with atelectasis [22]. However with our series, we noted no benefit with prolonged NG tube decompression and elected to remove it at the end of the surgical operation starting from the 60th case [6]. Non-narcotic pain management was also an innovation to help prevent exacerbating delayed return of bowel function [6]. Additionally, with the introduction of minimally invasive surgery into the treatment of bladder cancer, particularly with the robot-assisted radical cystectomy, further reduction of narcotic pain requirements has been seen, ultimately facilitating more rapid return of bowel function as well as reducing the length of postoperative hospital stay.

Retrospective analysis of 362 patients with bladder cancers who underwent radical cystectomy with urinary diversion between 2001 and 2008 revealed that patients on the fast-track pathway had shorter time to flatus, bowel movement, and hospital discharge, compared to previously reported literature (see Table 13.1) [6]. Complication and readmission rates were comparable with benchmarks previously reported literature [6].

Patients receiving metoclopramide were less likely to experience nausea and vomiting compared to patients not receiving metoclopramide (see Table 13.2). However, the length of stay in the hospital was not significantly different in the two groups and no direct link made towards the progression to a postoperative ileus [6]. Furthermore, patients chewing gum starting on POD 1 experienced reduced time to flatus as well as time to bowel movement after radical cystectomy (see Table 13.3) [7]. These results are similar to literature published detailing the postoperative care after colorectal surgery [13–19]. Our clinical pathway was not modified on the basis of clinical staging, age, comorbidities, open versus robot-assisted surgery, or diversion type.