We finish our discussion with Dr. Angie Smith from University of North Carolina at Chapel Hill about peri-operative optimization of radical cystectomies. She discusses pre-operative incentive spirometry, opioid and NSAID regimens, post-operative drains and stents, and the importance of multidisciplinary collaboration.

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SHOW NOTES

In this episode of BackTable Urology, Dr. Bagrodia and Dr. Angie Smith finish their discussion on optimizing radical cystectomy outcomes using peri-operative measures.

First, Dr. Smith emphasizes the importance of getting her cystectomy patients actively invested in their pre-operative and post-operative care. Pre-operatively, she recommends nutrition counseling, as carb loading and amino nutrition within 3-5 days before surgery have been shown to promote tissue healing. She also recommends engaging patients in pre-operative incentive spirometry, giving them a chance to learn to use their post-operative spirometers correctly. However, she does not have her patients undergo bowel prep before surgery.

Post-operatively, she emphasizes the importance of involving a multidisciplinary medical team in the patient’s recovery process. First, she recommends collaborating with anesthesia for pain management and to reduce post-operative nausea. She notes that although Tylenol is effective in mitigating post-operative pain, she sometimes sends patients home with a small opioid prescription for 1 week. She also continues to consult nutritionists and aims to have her patients on a regular diet two days after the surgery. Because long-term drains have a higher susceptibility to infection, she removes them after the first post-operative week. Finally, she involves physical/occupational therapists in the post-operative care of patients. One practice she has incorporated into her post-operative counseling is explaining to the patient why physical therapy is important, in addition to explaining general instructions, in order to increase patient compliance.

Patients who experience dehydration, acidosis, and nausea have a higher chance of readmission. Once her patients return home, she and a triage nurse monitor their hydration and sodium bicarbonate levels closely. Lastly, she invites cystectomy patients back for a survivorship care visit 6 weeks after surgery to look for pending obstructions with ultrasound.