Effect of a Radical Cystectomy Care Pathway on Postoperative Length of Stay and Outcomes.

OBJECTIVE: To determine whether an enhance recovery protocol for radical cystectomy patient affected the length of stay or the number and type of readmissions that occurred after hospital discharge. MATERIALS AND METHODS: We prospectively assessed 152 cystectomy patients after initiation of the pathway. These patients were compared with the previous 147 patient operated on before the pathway initiation. Eligible patients were those undergoing radical cystectomy with any diversion at our institution. Univariate tests were performed using Wilcoxon sum-rank and chi-square tests. Multivariate analyses were performed using logistic regression models to assess for patient factors related to readmissions. RESULTS: With institution of the pathway, length of stay decreased from 10 to 7.1 days. Our readmission rates did not change significantly. Patients were readmitted for different reasons after pathway implementation, with the rate of urinary tract infection-related readmissions increasing from 14.3% to 40.4%, but with a concomitant decrease in the rate of readmissions for wound and deep space infections from 42.9% to 23.4%. Our venous thromboembolism rate decreased from 6.8% to 3.3% with implementation of the protocol. CONCLUSION: Implementation of a cystectomy care pathway significantly decreased length of stay without an increased rate of readmissions at 30 days. No patient factors predisposed to an increased rate of readmission. Pathway implementation led to a decrease in wound and deep space infection readmissions, but was associated with an increase in urinary tract infection readmissions. Further studies are examining if early intervention can further decrease readmission rates.

Randomized controlled trial of oxybutynin extended release versus placebo for urinary symptoms during intravesical Bacillus Calmette-Guérin treatment.

PURPOSE: Intravesical bacillus Calmette-Guérin is used to decrease recurrence rates of nonmuscle invasive urothelial carcinoma. Irritative urinary symptoms are a common side effect of treatment and frequently limit treatment tolerance. While anticholinergic medications may be used for symptom prophylaxis, to our knowledge they have not been evaluated in a randomized controlled trial. MATERIALS AND METHODS: A total of 50 bacillus Calmette-Guérin naïve patients were randomized to 10 mg extended release oxybutynin daily or placebo starting the day before 6 weekly bacillus Calmette-Guérin treatments. A questionnaire assessing urinary symptoms (frequency, burning on urination, urgency, bladder pain, hematuria), systemic symptoms (flu-like symptoms, fever, arthralgia) and medication side effects (constipation, blurred vision, dry mouth) was recorded daily throughout the therapeutic course. A linear mixed repeated measures model tested the differences between each point and baseline score. RESULTS: The treatment group had a greater increase in urinary frequency and burning on urination compared to placebo (p = 0.004 and p = 0.04, respectively). There were no significant differences between groups for other urinary symptoms, which increased in severity after bacillus Calmette-Guérin but concomitantly returned to baseline in both groups. The treatment group experienced increases in fever, flu-like symptoms, dry mouth and constipation compared to placebo (p <0.0001, p = 0.0008, p = 0.045 and p = 0.001, respectively). There were otherwise no significant differences in nonurinary symptoms or medication adverse reactions. CONCLUSIONS: Oxybutynin increased urinary frequency and burning on urination compared to placebo in patients receiving intravesical bacillus Calmette-Guérin treatment. Our results do not support the routine use of oxybutynin as prophylaxis against urinary symptoms during bacillus Calmette-Guérin therapy.