title: Validation of the urostomy education scale: the European experience. The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery Alvimopan accelerates gastrointestinal recovery after radical cystectomy: a multicenter randomized placebo-controlled trial. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Preoperative Intensive, Community-Based vs. Traditional Stoma Education: A Randomized, Controlled Trial Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial. Restrictive Deferred Hydration Combined with Preemptive Norepinephrine Infusion during Radical Cystectomy Reduces Postoperative Complications and Hospitalization Time: A Randomized Clinical Trial Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection No advantage is gained by preoperative bowel preparation in radical cystectomy and ileal conduit: a randomized controlled trial of 86 patients Ultrasound-guided continuous transverse abdominis plane block for abdominal surgery Intraoperative continuous norepinephrine infusion combined with restrictive deferred hydration significantly reduces the need for blood transfusion in patients undergoing open radical cystectomy: results of a prospective randomised trial. Alvimopan, a peripherally acting mu-opioid receptor antagonist, compared with placebo in postoperative ileus after major abdominal surgery Bowel preparation versus no preparation before ileal urinary diversion. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial Clinical trial: alvimopan for the management of post‐operative ileus after abdominal surgery: results of an international randomized, double‐blind, multicentre, placebo‐controlled clinical study Effects of immediate postoperative enteral nutrition on body composition, muscle function, and wound healing. The Analgesic Efficacy of Transversus Abdominis Plane Block After Abdominal Surgery: A Prospective Randomized Controlled Trial A new concept for early recovery after surgery for patients undergoing radical cystectomy for bladder cancer: results of a prospective randomized study. Superior functional outcome after radical cystectomy and orthotopic bladder substitution with restrictive intraoperative fluid management: a followup study of a randomized clinical trial. Epidural versus Continuous Transversus Abdominis Plane Catheter Technique for Postoperative Analgesia after Abdominal Surgery Comparison of Morphine, Ketorolac, and Their Combination for Postoperative Pain: Results from a Large, Randomized, Double-blind Trial Effect of preoperative nutritional deficiency on mortality after radical cystectomy for bladder cancer. Maintaining perioperative normothermia Does preoperative teaching and stoma site marking affect surgical outcomes in patients undergoing ostomy surgery? Prediction of 90-day mortality after radical cystectomy for bladder cancer in a prospective European multicenter cohort. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery Elimination of preoperative mechanical bowel preparation in patients undergoing cystectomy and urinary diversion. Phase III Trial of Alvimopan, a Novel, Peripherally Acting, Mu Opioid Antagonist, for Postoperative Ileus After Major Abdominal Surgery Chewing gum has a stimulatory effect on bowel motility in patients after open or robotic radical cystectomy for bladder cancer: a prospective randomized comparative study. Urinary functional outcome following radical cystoprostatectomy and ileal neobladder reconstruction in male patients. Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Parenteral nutrition does not improve postoperative recovery from radical cystectomy: results of a prospective randomised trial.
abstract: Bladder cancer is the fourth most common cancer among European males . Once diagnosed with muscle invasive bladder cancer , a radical cystectomy is the first line treatment , which results in a urostomy . The placement of a urostomy and the care required impacts the patient 's life . Previous research vali date d the Urostomy Education Scale  as the first st and ardized tool capable of documenting the patients ' level of stoma self-care skills and useful to guide patient education interventions . A Danish-Dutch Fellowship was established to support and provide further evidence of applicability of the Urostomy Education Scale PURPOSE : Colorectal surgery is associated with postoperative ileus , which contributes to delayed discharge . This study was design ed to investigate the effect of thoracic epidural anesthesia and analgesia on gastrointestinal function after colorectal surgery under st and ardized controlled postoperative care . METHODS : Forty-two patients diagnosed with either colonic cancer , diverticulitis , polyps , or adenoma , and scheduled for elective colorectal surgery , were r and omly assigned to either postoperative patient-controlled analgesia ( PCA ) with intravenous morphine ( n=21 ) or epidural analgesia with a mixture of bupivacaine and fentanyl ( n=21 ) . Postoperative early oral feeding and assistance to mobilization were offered to all patients . Pain visual analog scale ( 1–100 mm ) , passage of flatus and bowel movements , length of hospital stay , and readiness for discharge were recorded . RESULTS : Pain visual analog scale ( visual analog scale , 1–100 mm ) at rest , on coughing , and daily on mobilization was significantly lower in the epidural group compared with the patient-controlled analgesia group . Median values for the visual analog scale group were 7 ( 95 percent confidence interval , 2–18 ) mm , 19 ( 95 percent confidence interval , 4–38 ) mm , and 10 ( 95 percent confidence interval , 5–33 ) mm , respectively , and , for the patient-controlled analgesia group , were 24 ( 95 percent confidence interval , 18–51 ) mm , 59 ( 95 percent confidence interval , 33–74 ) mm , and 40 ( 95 percent confidence interval , 29–79 ) mm , respectively ( P<0.01 ) . Intake of protein and calories and time out of bed were similar in both groups . Mean time intervals ± st and ard deviation from surgery to first flatus and first bowel movement occurred earlier in the epidural group , 1.9±0.6 days and 3.1±1.7 days , respectively , compared with patient-controlled analgesia , 3.6±1.5 days and 4.6 ± 1.6 days , respectively ( P<0.01 ) . Postoperative complications occurred in 33 percent of the patient-controlled analgesia group and 28 percent of the epidural group . There was no significant difference in length of hospital stay between the two groups with a mean of 7.3±3.7 days in the patient-controlled analgesia group and 8.5±4.2 days in the epidural group . Readiness for discharge was similar in both groups . CONCLUSION : Thoracic epidural analgesia has distinct advantages over patient-controlled analgesia morphine in providing superior quality of analgesia and shortening the duration of postoperative ileus . However , discharge home was not faster , indicating that other perioperative factors influence the length of hospital stay BACKGROUND Radical cystectomy ( RC ) for bladder cancer is frequently associated with delayed gastrointestinal ( GI ) recovery that prolongs hospital length of stay ( LOS ) . OBJECTIVE To assess the efficacy of alvimopan to accelerate GI recovery after RC . DESIGN , SETTING , AND PARTICIPANTS We conducted a r and omized double-blind placebo-controlled trial in patients undergoing RC and receiving postoperative intravenous patient-controlled opioid analgesics .  INTERVENTION Oral alvimopan 12 mg ( maximum : 15 inpatient doses ) versus placebo . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The two-component primary end point was time to upper ( first tolerance of solid food ) and lower ( first bowel movement ) GI recovery ( GI-2 ) . Time to discharge order written , postoperative LOS , postoperative ileus (POI)-related morbidity , opioid consumption , and adverse events ( AEs ) were evaluated . An independent adjudication of cardiovascular AEs was performed . RESULTS AND LIMITATIONS Patients were r and omized to alvimopan ( n=143 ) or placebo ( n=137 ) ; 277 patients were included in the modified intention-to-treat population . The alvimopan cohort experienced quicker GI-2 recovery ( 5.5 vs 6.8 d ; hazard ratio : 1.8 ; p<0.0001 ) , shorter mean LOS ( 7.4 vs 10.1 d ; p=0.0051 ) , and fewer episodes of POI-related morbidity ( 8.4 % vs 29.1 % ; p<0.001 ) . The incidence of opioid consumption and AEs or serious AEs ( SAEs ) was comparable except for POI , which was lower in the alvimopan group ( AEs : 7 % vs 26 % ; SAEs : 5 % vs 20 % , respectively ) . Cardiovascular AEs occurred in 8.4 % ( alvimopan ) and 15.3 % ( placebo ) of patients ( p=0.09 ) . Generalizability may be limited due to the exclusion of epidural analgesia and the inclusion of mostly high-volume centers utilizing open laparotomy . CONCLUSIONS Alvimopan is a useful addition to a st and ardized care pathway in patients undergoing RC by accelerating GI recovery and shortening LOS , with a safety profile similar to placebo . PATIENT SUMMARY This study examined the effects of alvimopan on bowel recovery in patients undergoing radical cystectomy for bladder cancer . Patients receiving alvimopan experienced quicker bowel recovery and had a shorter hospital stay compared with those who received placebo , with comparable safety . TRIAL REGISTRATION Clinical Trials.gov identifier NCT00708201 BACKGROUND Reporting methodology is highly variable and nonst and ardized , yet surgical outcomes are utilized in clinical trial design and evaluation of healthcare provider performance . OBJECTIVE We sought to define the type , incidence , and severity of early postoperative morbidities following  radical cystectomy ( RC )  using a st and ardized reporting methodology . DESIGN , SETTING , AND PARTICIPANTS Between 1995 and 2005 , 1142 consecutive RCs were entered into a prospect i ve complication data base and retrospectively review ed for accuracy . All patients underwent RC/urinary diversion by high-volume fellowship-trained urologic oncologists . MEASUREMENTS All complications within 90 d of surgery were analyzed and grade d according to the Memorial Sloan-Kettering Cancer Center complication grading system . Complications were defined and stratified into 11 specific categories . Univariate and multivariate regression models were used to define predictors of complications . RESULTS AND LIMITATIONS Sixty-four percent ( 735/1142 ) of patients experienced a complication within 90 d of surgery . Among patients experiencing a complication , 67 % experienced a complication during the operative hospital admission and 58 % following discharge . Overall , the highest grade of complication was grade 0 in 36 % ( n=407 ) , grade 1 - 2 in 51 % ( n=582 ) , and grade 3 - 5 in 13 % ( n=153 ) . Gastrointestinal complications were most common ( 29 % ) , followed by infectious complications ( 25 % ) and wound-related complications ( 15 % ) . The 30-d mortality rate was 1.5 % . CONCLUSIONS Surgical morbidity following RC is significant and , when strict reporting guidelines are incorporated , higher than previously published . Accurate reporting of postoperative complications after RC is essential for counseling patients , combined modality treatment planning , clinical trial design , and assessment of surgical success PURPOSE Conventional practice in colorectal surgery involves stoma education being imparted postoperatively . Proficiency in stoma management often delays patients ’ discharge following colorectal surgery . The aim of this r and omized , controlled trial was to compare preoperative intensive , community-based stoma education with conventional postoperative stoma education after elective colorectal surgery . METHODS Forty-two elective colorectal patients requiring a stoma were r and omized into an intensive preoperative teaching ( study ) or postoperative ( control ) group . Intervention for the study group included two preoperative visits in the community during which patients were taught with audiovisual aids to use and change the stoma pouching system . Goal -directed postoperative stoma education was st and ardized for both groups . Outcomes measured included time to stoma proficiency , postoperative hospital stay , unplanned stoma-related interventions in the community within six weeks of discharge , and preoperative and postoperative hospital anxiety and depression scores . Cost-effectiveness of the intervention was also evaluated . RESULTS All outcomes measured were improved in the study group , including time to stoma proficiency(5.5 vs. 9 days ; P = 0.0005 ) , hospital stay ( 8 vs. 10 days ; P = 0.029 ) , and unplanned stoma-related community interventions per patient ( median 0 vs. 0.5 ; P = 0.0309 ) . No adverse effects of the intervention were noted . The average cost saving per patient was £ 1,119 ( $ 2,104 ) for the study group compared with the control group . CONCLUSIONS Stoma education is more effective if undertaken in the preoperative setting . It results in shorter times to stoma proficiency and earlier discharge from the hospital . It also reduces stoma-related interventions in the community and has no adverse effects on patient well-being Abstract Objective : To evaluate the influence of preoperative abstinence on postoperative outcome in alcohol misusers with no symptoms who were drinking the equivalent of at least 60 g ethanol/day . Design : R and omised controlled trial . Setting : Copenhagen , Denmark . Subjects : 42 alcoholic patients without liver disease admitted for elective colorectal surgery . Interventions : Withdrawal from alcohol consumption for 1month before operation ( disulfiram controlled ) compared with continuous drinking . Main outcome measures : Postoperative complications requiring treatment within the first month after surgery . Perioperative immunosuppression measured by delayed type hypersensitivity ; myocardial ischaemia and arrhythmias measured by Holter tape recording ; episodes of hypoxaemia measured by pulse oximetry . Response to stress during the operation were assessed by heart rate , blood pressure , serum concentration of cortisol , and plasma concentrations of glucose , interleukin 6 , and catecholamines . Results : The intervention group developed significantly fewer postoperative complications than the continuous drinkers ( 31 % v 74 % , P=0.02 ) . Delayed type hypersensitivity responses were better in the intervention group before ( 37 mm2 v 12 mm2 , P=0.04 ) , but not after surgery ( 3 mm2 v 3 mm2 ) . Development of postoperative myocardial ischaemia ( 23 % v 85 % ) and arrhythmias ( 33 % v 86 % ) on the second postoperative day as well as nightly hypoxaemic episodes ( 4 v 18 on the second postoperative night ) occurred significantly less often in the intervention group . Surgical stress responses were lower in the intervention group ( P≤0.05 ) . Conclusions : One month of preoperative abstinence reduces postoperative morbidity in alcohol abusers . The mechanism is probably reduced pre clinical organ dysfunction and reduction of the exaggerated response to surgical stress BACKGROUND This study was undertaken to determine the impact of an intrathecal mixture of bupivacaine and morphine , when compared with systemic morphine , on the quality of postoperative analgesia and other outcomes in the context of the enhanced recovery after surgery ( ERAS ) programme for laparoscopic colonic resection . METHODS Fifty patients undergoing general anaesthesia were r and omly allocated  to receive either a spinal mixture of bupivacaine and morphine followed by oral oxycodone ( spinal group ) or patient-controlled analgesia ( PCA group ) . The primary outcome was consumption of opioids during the first three postoperative days . Secondary outcomes were pain scores , return of bowel function and dietary intake , readiness to hospital discharge , and length of hospital stay . RESULTS Postoperative opioid consumption in the spinal group was significantly less over the first three postoperative days ( P<0.001 ) . The quality of analgesia at rest in the first 24 h was better in the spinal group ( P<0.005 ) . Excessive sedation and respiratory depression were reported in two elderly patients with spinal analgesia . There were no differences between the two groups in other outcomes ( return of bowel function and dietary intake , readiness to hospital discharge , and length of hospital stay ) . CONCLUSIONS When ERAS programme is used for laparoscopic colonic resection , an intrathecal mixture of bupivacaine and morphine was associated with less postoperative opioid consumption , but has no other advantages over systemic opioids Background : Anesthetics and neuraxial anesthesia commonly result in vasodilation/hypotension . Norepinephrine counteracts this effect and thus allows for decreased intraoperative hydration . The authors investigated whether this approach could result in reduced postoperative complication rate . Methods : In this single-center , double-blind , r and omized , superiority trial , 166 patients undergoing radical cystectomy and urinary diversion were equally allocated to receive 1 ml·kg−1·h−1 of balanced Ringer ’s solution until the end of cystectomy and then 3 ml·kg−1·h−1 until the end of surgery combined with preemptive norepinephrine infusion at an initial rate of 2 µg·kg−1·h−1 ( low-volume group ; n = 83 ) or 6 ml·kg−1·h−1 of balanced Ringer ’s solution throughout surgery ( control group ; n = 83 ) . Primary outcome was the in-hospital complication rate . Secondary outcomes were hospitalization time , and 90-day mortality . Results : In-hospital complications occurred in 43 of 83 patients ( 52 % ) in the low-volume group and in 61 of 83 ( 73 % ) in the control group ( relative risk , 0.70 ; 95 % CI , 0.55–0.88 ; P = 0.006 ) . The rates of gastrointestinal and cardiac complications were lower in the low-volume group than in the control group ( 5 [ 6 % ] vs. 31 [ 37 % ] ; relative risk , 0.16 ; 95 % CI , 0.07–0.39 ; P < 0.0001 and 17 [ 20 % ] vs. 39 [ 48 % ] , relative risk , 0.43 ; 95 % CI , 0.26–0.60 ; P = 0.0003 , respectively ) . The median hospitalization time was 15 days [ range , 11 , 27d ] in the low-volume group and 17 days [ 11 , 95d ] in the control group ( P = 0.02 ) . The 90-day mortality was 0 % in the low-volume group and 4.8 % in the control group ( P = 0.12 ) . Conclusion : A restrictive-deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy and urinary diversion significantly reduced the postoperative complication rate and hospitalization time The aim of this trial was to compare  multimodal optimization  with  conventional perioperative management  in a consecutive series of patients undergoing a wide range of colorectal procedures Objective Bowel preparation ( BP ) is performed routinely before intestinal surgery to reduce the risk of postoperative infectious complications . We studied the effect of BP on patients who underwent radical cystectomy and ileal conduit surgery .  Our goal was to determine whether BP in these patients provided any benefits postoperatively . Methods Between Match 2006 and January 2009 , 86 patients scheduled for radical cystectomy and ileal conduit were r and omized to preoperative BP ( group A ) or surgery without BP ( group B ) . Outcomes studied included operative time , recovery of patient and surgical complications . Results Eighty-six patients were included in the study , 47 in group A and 39 in group B. All surgeries were performed successfully using ileum . Postoperative complications were documented in 5 and 6 patients in groups A and B , respectively . Anastomotic leak occurred in 1 patient in group A , leading to multiple organ dysfunction and sepsis , with a fatal outcome . One case of ileus and three wound infections were also seen in group A. In group B , wound infection and ileus occurred in two patients each , anastomotic leak developed in 1 patient result ing to reoperation and one patient died from pulmonary embolism . No statistical difference in the frequency of complications and recovery of patient was observed between the 2 groups . Conclusions Our results suggest that no advantage is gained by preoperative BP in radical cystectomy and ileal conduit Introduction : Transversus abdominis plane ( TAP ) block is a new regional analgesic technique for postoperative pain in abdominal surgery . Its efficacy is not clear , and thus it needs to be explored for its regular utilisation on prolonged period . The objective was to study the continuous local anaesthetic infusion effect on postoperative analgesia . Continuous use of TAP block as an analgesic technique has not been evaluated prospect ively in clinical trials . This study evaluates the efficacy of ultrasound-guided TAP block in comparison with PCA fentanyl in major abdominal surgery . Material s and Methods : There were 20 patients in the study , allocated to TAP and control groups . The parameters measured were pain scores on a numerical rating scale ( NRS ) of 0 - 10 at various time intervals and the amount of fentanyl used as rescue analgesia . Patient satisfaction scores were recorded in the TAP block group and along with any complications related to the block . Results : The postoperative median pain scores on coughing on day one were 6.0 for control group and 2.0 for the TAP group ( P = 0.02 ) ; on day two , the equivalent scores were 7.0 and 2.0 ( P = 0.01 ) . The fentanyl requirement at one hour was 203 μ for the control group and 78 μg for the TAP group ( P = 0.03 ) ; at day one , the control and TAP requirements were 1237 μg and 664 μg respectively ( P = 0.01 ) . Three TAP patients rated their satisfaction as ‘ excellent ’ , four as ‘ satisfied , and two as ‘ poor ’ . Conclusion : TAP block is a promising technique for postoperative analgesia in major abdominal surgeries . Our study demonstrated lower pain scores in the TAP group with reduced fentanyl requirement . Further , a large scale study is needed to establish the efficacy of TAP block in this setting BACKGROUND Open radical cystectomy ( ORC ) is associated with substantial blood loss and a high incidence of perioperative blood transfusions . Strategies to reduce blood loss and blood transfusion are warranted . OBJECTIVE To determine whether continuous norepinephrine administration combined with intraoperative restrictive hydration with Ringer 's maleate solution can reduce blood loss and the need for blood transfusion . DESIGN , SETTING , AND PARTICIPANTS This was a double-blind , r and omised , parallel-group , single-centre trial including 166 consecutive patients undergoing ORC with urinary diversion ( UD ) . Exclusion criteria were severe hepatic or renal dysfunction , congestive heart failure , and contraindications to epidural analgesia . INTERVENTION Patients were r and omly allocated to continuous norepinephrine administration starting with 2 μg/kg per hour combined with 1 ml/kg per hour until the bladder was removed , then to 3 ml/kg per hour of Ringer 's maleate solution ( norepinephrine/low-volume group ) or 6 ml/kg per hour of Ringer 's maleate solution throughout surgery ( control group ) . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Intraoperative blood loss and the percentage of patients requiring blood transfusions perioperatively were assessed . Data were analysed using nonparametric statistical models . RESULTS AND LIMITATIONS Total median blood loss was 800 ml ( range : 300 - 1700 ) in the norepinephrine/low-volume group versus 1200 ml ( range : 400 - 2800 ) in the control group ( p<0.0001 ) . In the norepinephrine/low-volume group , 27 of 83 patients ( 33 % ) required an average of 1.8 U ( ±0.8 ) of packed red blood cells ( PRBCs ) . In the control group , 50 of 83 patients ( 60 % ) required an average of 2.9 U ( ±2.1 ) of PRBCs during hospitalisation ( relative risk : 0.54 ; 95 % confidence interval [ CI ] , 0.38 - 0.77 ; p=0.0006 ) . The absolute reduction in transfusion rate throughout hospitalisation was 28 % ( 95 % CI , 12 - 45 ) . In this study , surgery was performed by three high-volume surgeons using a st and ardised technique , so whether these significant results are reproducible in other centres needs to be shown . CONCLUSIONS Continuous norepinephrine administration combined with restrictive hydration significantly reduces intraoperative blood loss , the rate of blood transfusions , and the number of PRBC units required per patient undergoing ORC with UD Background Alvimopan is a peripherally acting mu-opioid receptor ( PAM-OR ) antagonist for accelerating gastrointestinal recovery after surgery . Methods Patients undergoing open laparotomy ( bowel resection , n = 418 ; hysterectomy , n = 197 ) were r and omized to receive alvimopan 6 or 12 mg or placebo orally ≥2 h before surgery and then b.i.d . until hospital discharge ( up to 7 days ) . The primary efficacy endpoint was time to gastrointestinal ( GI ) recovery ( measured by toleration of solid food and passage of flatus/stool ; GI-3 ) . Secondary endpoints included time to GI-2 recovery ( toleration of solid food and passage of stool ) and hospital discharge order written ( DCO ) . Results Alvimopan did not significantly accelerate GI-3 compared with placebo [ 6 mg : hazard ratio ( HR ) = 1.20 , p = 0.080 ; 12 mg : HR = 1.24 , p = 0.038 ) . However , after adjustment for significant covariates ( sex/surgical duration ) , benefits were significant for both doses ( 6 mg : HR = 1.24 , p = 0.037 ; 12 mg : HR = 1.26 , p = 0.028 ) . Alvimopan also significantly accelerated time to GI-2 ( 6 mg : HR = 1.37 , p = 0.008 ; 12 mg : HR = 1.33 , p = 0.018 ) and DCO ( 6 mg : HR = 1.31 , p = 0.008 ; 12 mg : HR = 1.28 , p = 0.015 ) . Adverse events were similar between groups . Conclusions Alvimopan ( 6 or 12 mg ) accelerates GI recovery and is well tolerated in patients undergoing open laparotomy OBJECTIVES To compare the outcome and complications of  urinary diversion  using ileum , with and without bowel preparation . Recent studies have question ed the necessity of bowel preparation , especially for urinary diversion when ileum is used . METHODS In this clinical trial , 30 c and i date s for urinary diversion underwent a 3-day st and ard bowel preparation ( group 1 ) , and 32 were admitted 24 hours before surgery and received only a soft diet , with no oral intake , 8 hours before surgery ( group 2 ) . They were followed up for at least 6 months and were evaluated for outcome and surgical complications . RESULTS All surgical operations were performed successfully using ileum .  Postoperative complications were documented in 2 and 4 patients in groups 1 and 2 , respectively ( relative risk 0.69 , 95 % confidence interval 0.37 to 1.31 , P = 0.41 ) . Anastomotic leak , enterocutaneous fistula , and wound infection and dehiscence occurred in 1 patient in group 1 , leading to reoperation . One case of ileus was also seen in group 1 . In group 2 , wound infection and dehiscence occurred 2 in patients and ileus in 2 others . CONCLUSIONS This study failed to demonstrate any advantage of bowel preparation for urinary diversion when we use the ileal segment . Furthermore , a meticulous use of ileum can be done without the need for a colon segment in bladder substitution procedures PURPOSE  Radical cystectomy  remains associated with significant morbidity . Most series report outcomes with relatively short-term followup that may underestimate the true magnitude of the procedure and many report length of hospital stay but ignore readmission rates . We analyzed the predictors of early ( 30 days or less ) , late ( 31 to 90 days ) and cumulative 90-day hospital readmissions , as well as morbidity and mortality rates . MATERIAL S AND METHODS We review ed our prospect ively collected data base of 753 patients who underwent radical cystectomy for urothelial cancer between January 2001 and December 2007 . We examined the relationship between clinical variables and readmission rates during the early , late and 90-day postoperative period , and review ed mortality and perioperative morbidity rates . RESULTS There were 200 ( 26.6 % ) patients readmitted in the first 90 days following radical cystectomy . Of these patients 148 ( 19.7 % ) were readmitted early , 81 ( 10.8 % ) were readmitted late , and 29 ( 3.9 % ) had an early and late readmission . Logistical regression revealed gender ( OR 1.50 , 95 % CI 1.00 - 2.27 , p = 0.05 ) , age adjusted Charlson comorbidity index ( OR 1.19 , 95 % CI 1.06 - 1.34 , p = 0.003 ) and any postoperative complications before discharge home ( OR 1.84 , 95 % CI 1.19 - 2.83 , p = 0.006 ) as independent predictors of 90-day readmission . The 30 and 90-day mortality rates were 2.1 % ( 16 ) and 6.9 % ( 52 ) , respectively . CONCLUSIONS Readmission rates after radical cystectomy are significant , approaching 27 % within the first 90 days . Gender and age adjusted Charlson comorbidity index were independent predictors providing preoperative information identifying patients more likely to require readmission or possibly to benefit from a longer initial hospital stay BACKGROUND Low concentrations of albumin in serum and long gastric emptying times have been returned to normal in dogs by salt and water restriction , or a high protein intake . We aim ed to determine the effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection in human beings . METHODS We r and omly allocated ten patients to receive postoperative intravenous fluids in accordance present hospital practice ( > or = 3 L water and 154 mmol sodium per day ) and ten to receive a restricted intake ( < or = 2 L water and 77 mmol sodium per day ) . All patients had no disease other than colonic cancer . The primary endpoint was solid and liquid-phase gastric emptying time , measured by dual isotope radionuclide scintigraphy on the fourth postoperative day . Secondary endpoints included time to first bowel movement and length of postoperative hospital stay . Analysis was by intention to treat . FINDINGS Median solid and liquid phase gastric emptying times ( T(50 ) ) on the fourth postoperative day were significantly longer in the st and ard group than in the restricted group ( 175 vs 72.5 min , difference 56 [ 95 % CI 12 - 132 ] , p=0.028 ; and 110 vs 73.5 min , 52 [ 9 - 95 ] , p=0.017 , respectively ) . Median passage of flatus was 1 day later ( 4 vs 3 days , 2 [ 1 - 2 ] , p=0.001 ) ; median passage of stool 2.5 days later ( 6.5 vs 4 days , 3 [ 2 - 4 ] , p=0.001 ) ; and median postoperative hospital stay 3 days longer ( 9 vs 6 days , 3 [ 1 - 8 ] , p=0.001 ) in the st and ard group than in the restricted group . One patient in the restricted group developed hypokalaemia , whereas seven patients in the st and ard group had side-effects or complications ( p=0.01 ) . INTERPRETATION Positive salt and water balance sufficient to cause a 3 kg weight gain after surgery delays return of gastrointestinal function and prolongs hospital stay in patients undergoing elective colonic resection Aliment Pharmacol Ther 28 , 312–325 Thirty-two patients undergoing bowel resection were r and omized to receive either immediate postoperative nasojejunal feeding with full strength Osmolite solution for 56 hours ( n = 16 ) or routine postoperative hypocaloric fluids and gradual re introduction of diet  ( n = 16 ) . Body composition changes were measured at 14 days after operation with in vivo neutron activation analysis , the wound healing response by subcutaneous implantation of Gortex tubes , and muscle function by grip strength , maximum ventilatory volume , and stimulation of the ulnar nerve at the wrist . Postoperative fatigue up to 3 months after operation was assessed using a 10-point analogue . Successful immediate enteral nutrition was established in 12 of the 16 patients . Enterally fed patients had a mean daily caloric intake of 1179 + /- 388 kcal/d ( mean + /- SD ) over the first 4 postoperative days compared with 382 + /- 71 kcal/d for the controls ( p less than 0.0001 ) . The amount of hydroxyproline accumulating in the Gortex tubes was also significantly greater ( 2.5 + /- 1.1 nmol/g tube vs 1.5 + /- 0.8 nmol/g tube ; p less than 0.02 ) . However , the amount and composition of the weight lost was not significantly different . Muscle function was not preserved , and postoperative fatigue occurred to an equal extent in both groups . Complications were similar in both groups , except for a preponderance of bowel obstructions in the controls . The time to passage of first flatus and first bowel motion , although shorter in the fed group , did not reach significance ( p = 0.07 ) . We conclude that immediate enteral nutrition is feasible and results in an improved wound healing response . ( ABSTRACT TRUNCATED AT 250 WORDS BACKGROUND : The transversus abdominis plane ( TAP ) block is a novel approach for blocking the abdominal wall neural afferents via the bilateral lumbar triangles of Petit . We evaluated its analgesic efficacy in patients during the first 24 postoperative hours after abdominal surgery , in a r and omized , controlled , double-blind clinical trial . METHODS : Thirty-two adults undergoing large bowel resection via a midline abdominal incision were r and omized to receive st and ard care , including patient-controlled morphine analgesia and regular nonsteroidal antiinflammatory drugs and acetaminophen ( n = 16 ) , or to undergo TAP block  ( n = 16 ) in addition to st and ard care ( n = 16 ) . After induction of anesthesia , 20 mL of 0.375 % levobupivacaine was deposited into the transversus abdominis neuro-fascial plane via the bilateral lumbar triangles of Petit . Each patient was assessed by a blinded investigator in the postanesthesia care unit and at 2 , 4 , 6 , and 24 h postoperatively . RESULTS : The TAP block reduced visual analog scale pain scores ( TAP versus control , mean ± sd ) on emergence ( 1 ± 1.4 vs 6.6 ± 2.8 , P < 0.05 ) , and at all postoperative time points , including at 24 h ( 1.7 ± 1.7 vs 3.1 ± 1.5 , P < 0.05 ) . Morphine requirements in the first 24 postoperative hours were also reduced ( 21.9 ± 8.9 mg vs 80.4 ± 19.2 mg , P < 0.05 ) . There were no complications attributable to the TAP block . All TAP patients reported high levels of satisfaction with their postoperative analgesic regimen . CONCLUSIONS : The TAP block provided highly effective postoperative analgesia in the first 24 postoperative hours after major abdominal surgery PURPOSE Early recovery after surgery concepts have gained wide acceptance in various surgical specialties . However , limited data are available for radical cystectomy . A new early recovery after surgery concept was compared to a more conservative regimen in patients undergoing radical cystectomy for bladder cancer . MATERIAL S AND METHODS A total of 101 consecutive patients were prospect ively r and omized to early recovery after surgery  ( 62 ) or a conservative regimen  ( 39 ) ( intended r and omization ratio was 2 early recovery after surgery-to-1 conservative regimen ) . Primary end points were differences in quality of life , and secondary end points included postoperative morbidity , dem and for analgesics , time spent in the intermediate care unit , mobility and number of gastrointestinal events during hospital stay . RESULTS Quality of life parameters , as measured by the EORTC ( European Organization for the Research and Treatment of Cancer ) Quality of Life question naire QLQ-30 did not change significantly between postoperative days 3 and 7 and at discharge from hospital in the conservative regimen group , whereas a significant improvement was observed in the early recovery after surgery group . Postoperative morbidity was lower in the early recovery after surgery group in terms of wound healing disorders ( p = 0.006 ) , fever ( p = 0.004 ) and thrombosis ( p = 0.027 ) . The dem and for analgesics was significantly lower in the early recovery after surgery group . The amount of food consumed in relation to the amount of food offered was significantly higher for the early recovery after surgery group as early as day 3 ( p = 0.02 ) . Time spent in the intermediate care unit was significantly shorter for the early recovery after surgery group ( p < 0.001 ) . There were no significant differences between the groups with respect to gastrointestinal events . The main limitations of this study were the lack of long-term data as well as the single center approach . CONCLUSIONS Early recovery after surgery of patients who underwent radical cystectomy appears to have significant benefits compared to a conservative regimen in terms of postoperative morbidity , quality of life , use of analgesics and time spent in the intermediate care unit PURPOSE Continuous intraoperative norepinephrine infusion combined with restrictive deferred hydration improves surgical field visibility , and significantly decreases intraoperative blood loss and postoperative complications in patients undergoing radical cystectomy and urinary diversion . We determined whether the intraoperative fluid regimen would affect functional results ( continence and erectile function ) 1 year after orthotopic ileal bladder substitution . MATERIAL S AND METHODS We analyzed a subgroup of 93 patients who received an ileal orthotopic bladder substitute .  The subgroup was part of a r and omized trial in 167 patients initially allocated to continuous norepinephrine administration starting with 2 μg/kg per hour combined with 1 ml/kg per hour initially and 3 ml/kg per hour crystalloid infusion after cystectomy ( norepinephrine/low volume group of 51 ) or a st and ard crystalloid infusion of 6 ml/kg per hour throughout surgery ( 42 controls ) . We prospect ively assessed daytime and nighttime continence , and erectile function 1 year postoperatively in the 93-patient subgroup . RESULTS Daytime continence was reported by 44 of 51 patients ( 86 % ) in the norepinephrine/low volume group and by 27 of 42 controls ( 64 % ) ( p = 0.016 ) , and nighttime continence was reported by 38 ( 75 % ) and 25 ( 60 % ) , respectively ( p = 0.077 ) . Erectile function recovery was reported by 26 of 33 preoperatively potent patients ( 79 % ) in the norepinephrine/low volume group and by 11 of 29 controls ( 38 % ) ( p = 0.002 ) . CONCLUSIONS Patients who undergo radical cystectomy and orthotopic bladder substitution  with continuous norepinephrine infusion and restrictive hydration during surgery have significantly better daytime continence and erectile function 1 year postoperatively Transversus abdominis plane block is an effective postoperative analgesic technique after abdominal surgery , but no study has compared continuous transversus abdominis plane block with continuous epidural analgesia . We design ed a r and omised controlled trial comparing these techniques for major abdominal surgery . Patients in the epidural group received a bolus of 8 to 15 ml of ropivacaine 0.2 % and an infusion of 5 to 15 ml/hour and the transversus abdominis plane block group a bolus dose of 20 ml of ropivacaine 0.375 % bilaterally and an infusion of 0.2 % ropivacaine 8 ml/hour bilaterally , for three days . Both groups received paracetamol and patient controlled analgesia with fentanyl for three days . Primary outcomes were numerical rating scores for pain ( rest and dynamic over 72 hours ) and total fentanyl use ; complications and satisfaction scores were also noted . The study was terminated early after 42 patients had been r and omised ( epidural n=19 ; transversus abdominis plane block n=22 ; one excluded ) . No differences were found in regards to point pain scores or scores over time , either immediately postoperatively or in surgical wards ; total fentanyl requirement and Likert satisfaction scores were also similar in both groups . In this underpowered study we found comparable results between continuous transversus abdominis plane technique and epidural analgesia in regard to pain , analgesic use and satisfaction after abdominal surgery . To confirm this finding , r and omised trials with larger numbers of participants are needed Background : Meta-analyses report similar numbers needed to treat for nonsteroidal antiinflammatory drugs ( NSAIDs ) and opioids . Differences in baseline pain intensity among the studies from which these numbers needed to treat were derived may have confounded the results . NSAIDs have an opioid-sparing effect , but the importance of this effect is unclear . Therefore , the authors sought to compare the proportions of subjects who obtain pain relief with ketorolac versus morphine after surgery and to determine whether the opioid-sparing effect of an NSAID reduces the magnitude of opioid side effects . Methods : The study was a double-blind , r and omized controlled trial . The authors r and omly assigned 1,003 adult patients to receive 30 mg  ketorolac  or 0.1 mg/kg morphine intravenously . They calculated the proportion of subjects who achieved at least 50 % reduction in pain intensity 30 min after analgesic administration . Further , so long as pain intensity 30 min after analgesic administration was 5 or more out of 10 , patients received 2.5 mg morphine every 10 min until pain intensity was 4 or less out of 10 . The authors assessed the presence of opioid-related side effects . Results : Five hundred patients received morphine and 503 received ketorolac .  Fifty percent of patients in the morphine group achieved pain relief , compared with 31 % in the ketorolac group ( difference , 19 % ; 95 % confidence interval , 13–25 % ) . The ketorolac – morphine group required less morphine ( difference , 6.5 mg ; 95 % confidence interval , −5.8 to −7.2 ) and had a lower incidence of side effects ( difference , 11 % ; 95 % confidence interval , 5–16 % ) than the morphine group . Conclusions : Opioids are more efficacious analgesics than NSAIDs , although historic data for these two drugs yield similar numbers needed to treat . Adding NSAIDs to the opioid treatment reduces morphine requirements and opioid-related side effects in the early postoperative period PURPOSE Poor preoperative nutritional status is a risk factor for adverse outcomes after major surgery . We evaluated the effect of preoperative nutritional deficiency on perioperative mortality and overall survival in patients undergoing radical cystectomy for bladder cancer . MATERIAL S AND METHODS A total of 538 patients underwent radical cystectomy for urothelial carcinoma between January 2000 and June 2008 , and had nutritional parameters documented . Patients with preoperative albumin less than 3.5 gm/dl , body mass index less than 18.5 kg/m(2 ) or preoperative weight loss greater than 5 % of body weight were considered to have nutritional deficiency . Primary outcomes were 90-day mortality and overall survival . Survival was estimated using Kaplan-Meier analysis and compared using the log rank test . Cox proportional hazards models were used for multivariate survival analysis . RESULTS Of 538 patients 103 ( 19 % ) met the criteria for nutritional deficiency . The 90-day mortality rate was 7.3 % overall ( 39 deaths ) , with 16.5 % in patients with nutritional deficiency and 5.1 % in the others ( p < 0.01 ) . Nutritional deficiency was a strong predictor of death within 90 days on multivariate analysis ( HR 2.91 ; 95 % CI 1.36 , 6.23 ; p < 0.01 ) . Overall survival at 3 years was 44.5 % ( 33.5 , 54.9 ) for nutritionally deficient patients and 67.6 % ( 62.4 , 72.2 ) for those who were nutritionally normal ( p < 0.01 ) . On multivariate analysis nutritional deficiency cases had a significantly higher risk of all cause mortality ( HR 1.82 ; 95 % CI 1.25 , 2.65 ; p < 0.01 ) . CONCLUSIONS Nutritional deficiency , as measured by preoperative weight loss , body mass index and serum albumin , is a strong predictor of 90-day mortality and poor overall survival . Prospect i ve studies are needed to demonstrate the best indices of preoperative nutritional status and whether nutritional intervention can alter the poor prognosis for patients treated with radical cystectomy who have nutritional deficiencies Perioperative hypothermia can have a wide range of underappreciated , detrimental effects . These include increased rates of wound infection , morbid cardiac events , blood loss , and length of stay in both recovery and hospital . Maintaining core temperature at or above 36 ° C can be beneficial for the patient and cost effective . Frank et al studied high risk cardiac patients undergoing thoracic , abdominal , and vascular surgery.1 Patients r and omised to routine thermal care were , on average , 1.3 ° C cooler than patients warmed more aggressively . Despite this small difference the incidence of perioperative morbid cardiac events , assessed in a double blind fashion , was 300 % higher in the cooler group . Frank et al thought that this may be the a consequence of the dramatic increase in noradrenaline release seen in even mild hypothermia . It has also been said that the increase in noradrenaline may contribute to the higher number of wound infections seen in hypothermic patients . A r and omised study of patients undergoing colorectal surgery showed that 1.9 ° C hypothermia result ed in an infection rate of 19 % compared with 6 % in the normothermic Summary of Studies on Inﬂuence of Preoperative Teaching on Postoperative Outcomes Study Methods Outcomes Haugen , Bliss , & Savik 17 Chaudhri et al 18 Gulbiniene et al 19 Abbreviations : RCT , R and omized Clinical Trial ; HRQoL , Health Related Quality of Life . Cross-sectional survey of community-dwellingpersons with an incontinent ostomy RCT , compared traditional preoperativeeducation to intensive teaching interventionusing community-based nurses with expertisein colorectal and ostomy nursingCompared control group to group receivingpreoperative education and stoma sitemarking ;  method of group assignment notspeciﬁed in English- language abstract Preoperative education by WOC nurse associatedwith improved long-term adjustment to livingwith an ostomyIntensive  , community-based education reduced the time to pouching efﬁciency , length ofpostoperative hospital stay , and unplannedostomy-related interventions when compared totraditional preoperative educationPreoperative teaching alone did not improveHRQoL , but preoperative teaching combined withstoma site marking by a stoma therapist didimprove postoperative BACKGROUND Despite recent improvements , radical cystectomy ( RC ) is still associated with adverse rates for 90-d mortality . OBJECTIVE To vali date the performance of the Isbarn nomogram incorporating age and postoperative tumor characteristics for predicting 90-d RC mortality in a multicenter series and to generate a new nomogram based strictly on preoperative parameters . DESIGN , SETTING , AND PARTICIPANTS Data of 679 bladder cancer ( BCa ) patients treated with RC at 18 institutions in 2011 were prospect ively collected , from which 597 patients were eligible for final analysis . INTERVENTION RC for BCa . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS An established prediction tool , the Isbarn nomogram , was applied to our cohort . For the purpose of external validation , model discrimination was measured using the receiver operating characteristics-derived area under the curve . Calibration plots examined the relationship between predicted and observed probabilities . Univariable and multivariable logistic regression models were fitted to assess the impact of preoperative characteristics on 90-d mortality . RESULTS AND LIMITATIONS The 30- , 60- , and 90-d mortality rates in the development cohort ( n=597 ) were 2.7 % , 6.7 % , and 9.0 % , respectively . The Isbarn nomogram predicted individual 90-d mortality with an accuracy of 68.6 % . Our preoperative multivariable model identified age ( odds ratio [OR]:1.052 ) , American Society of Anesthesiologists score ( OR : 2.274 ) , hospital volume ( OR : 0.982 ) , clinical ly lymphatic metastases ( OR : 4.111 ) , and clinical ly distant metastases ( OR : 7.788 ) ( all p<0.05 ) as independent predictors of 90-d mortality ( predictive accuracy : 78.8 % ) . Our conclusions are limited by the lack of an external validation of the preoperative model . CONCLUSIONS The Isbarn nomogram was vali date d with moderate discrimination . Our newly developed model consisting of preoperative characteristics might outperform existing models . Our model might be particularly suitable for preoperative patient counseling . PATIENT SUMMARY The current report vali date d an established nomogram predicting 90-d mortality in patients with bladder cancer after radical cystectomy ( RC ) .  We developed a new prediction tool consisting of strictly preoperative parameters , thus allowing clinicians an optimal consultation for RC c and i date Subcostal transversus abdominis plane ( TAP ) catheters have been reported to be an effective method of providing analgesia after upper abdominal surgery . We compared their analgesic efficacy with that of epidural analgesia after major upper abdominal surgery in a r and omised controlled trial . Adult patients undergoing elective open hepatobiliary or renal surgery were r and omly allocated to receive subcostal TAP catheters ( n = 29 ) or epidural analgesia ( n = 33 ) , in addition to a st and ard postoperative analgesic regimen comprising of regular paracetamol and tramadol as required . The TAP group patients received bilateral subcostal TAP catheters and 1 mg.kg−1 bupivacaine 0.375 % bilaterally every 8 h. The epidural group patients received an infusion of bupivacaine 0.125 % with fentanyl 2 μg.ml−1 . The primary outcome measure was visual analogue pain scores during coughing at 8 , 24 , 48 and 72 h after surgery . We found no significant differences in median ( IQR [ range ] ) visual analogue scores during coughing at 8 h between the TAP group ( 4.0 ( 2.3–6.0 [ 0–7.5 ] ) ) and epidural group ( 4.0 ( 2.5–5.3 ) [ 0–8.5 ] ) ) and at 72 h ( 2.0 ( 0.8–4.0 [ 0–5 ] ) and 2.5 ( 1.0–5.0 [ 0–6 ] ) , respectively ) . Tramadol consumption was significantly greater in the TAP group ( p = 0.002 ) . Subcostal TAP catheter boluses may be an effective alternative to epidural infusions for providing postoperative analgesia after upper abdominal surgery INTRODUCTION The utility of a preoperative mechanical bowel preparation prior to bowel surgery has recently been question ed . The purpose of this study is to compare the perioperative outcomes between patients undergoing cystectomy with urinary diversion with or without preoperative mechanical bowel preparation .  METHODS Seventy patients underwent radical cystectomy and urinary diversion between May 2008 and August 2009 for bladder cancer . The first cohort of patients ( n = 37 ) underwent cystectomy and diversion during the period May 2008-December 2008 and underwent a preoperative mechanical bowel preparation including a clear liquid diet , magnesium citrate solution , and an enema before surgery . The second cohort of patients underwent surgery  during the period of January 2009-August 2009 ( n=33 ) . These patients were given a regular diet before surgery and did not undergo a mechanical bowel preparation except for the enema before surgery was performed to decrease rectal/colonic distention . Outcome measures included gastrointestinal and overall complications , and perioperative outcomes including recovery of bowel function . RESULTS There were no differences with regard to recovery of bowel function , time to discharge , or overall complication rates between the 2 groups . More specifically , the rate of GI complications was not different in prepped patients vs. nonprepped patients ( 22 % vs. 15 % ; P = 0.494 ) . There were no occurrences of bowel anastomotic leak , fistula , abscess , peritonitis , or surgical site infection in either group . One perioperative death occurred in the nonprepped group secondary to cardiovascular complications . CONCLUSIONS Preoperative mechanical bowel preparation prior to radical cystectomy with urinary diversion does not demonstrate any significant advantage in perioperative outcomes , including gastrointestinal complications . Further studies aim ed at measuring patient satisfaction and larger r and omized trials will be beneficial in evaluating the role of mechanical bowel preparation prior to urinary diversion PURPOSE Postoperative ileus presents significant clinical challenges that potentially prolong hospital stay , contribute to readmission , and increase morbidity . There is no approved treatment for postoperative ileus . Alvimopan is a novel , peripherally acting , mu opioid receptor antagonist currently in development for the management of postoperative ileus . METHODS Patients undergoing partial colectomy or simple or radical hysterectomy were r and omized to receive alvimopan 6 mg ( n = 152 ) , alvimopan 12 mg ( n = 146 ) , or placebo ( n = 153 ) orally 2 hours before surgery and twice daily thereafter until discharge or for up to seven days . The primary efficacy end point , time to return of gastrointestinal function , was a composite measure of passage of flatus or stool and tolerating solid food . Secondary end points included time to the hospital discharge order written . Adverse events were monitored throughout the study . RESULTS Mean time to gastrointestinal recovery was significantly reduced in patients treated with alvimopan 6 mg vs. placebo ( hazard ratio = 1.45 ; P = 0.003 ) , with a smaller reduction seen with alvimopan 12 mg ( hazard ratio = 1.28 ; P = 0.059 ) . Mean time to the hospital discharge order written was significantly accelerated in patients treated with alvimopan 6 mg ( hazard ratio = 1.50 ; P < 0.001 ) . The most common treatment-emergent adverse events across all treatment groups were nausea , vomiting , and hypotension ; the incidence of nausea and vomiting was reduced by 53 percent in the alvimopan 12-mg group . CONCLUSIONS In patients undergoing major abdominal surgery , alvimopan accelerated gastrointestinal recovery and time to the hospital discharge order written compared with placebo and was well tolerated OBJECTIVES To determine whether chewing gum during the postoperative period facilitates the recovery of bowel function and has different efficacy according to operative method used in patients with radical cystectomy . METHODS From July 2007 to September 2009 , we r and omized open radical cystectomy ( ORC ) patients into Group AI ( ORC without gum chewing ) and Group AII ( ORC with gum chewing ) . Robot-assisted radical cystectomy ( RARC ) patients were r and omized into Group BI ( RARC without gum chewing ) and Group BII ( RARC with gum chewing ) . RESULTS A total of 32 ORC ( 17 Group AI and 15 Group AII ) and 28 RARC ( 13 Group BI and 15 Group BII ) patients were completed . The patient 's perioperative data between the control ( AI + BI ) and chewing gum ( AII + BII ) group showed no differences . The median time to flatus and to bowel movement were significantly reduced in chewing gum group compared with the control patients : 57.1 vs. 69.5 hours 76.7 vs. 93.3 hours . In the ORC patients , decrease in time to flatus and bowel movement were observed in gum chewing ( AII ) group than control ( AI ) group : 64.3 vs. 80.3 hours 83.8 vs. 104.2 hours . In RARC patients , decrease in time to flatus and bowel movement were found in gum chewing ( BII ) group than control ( BI ) group : 48.8 vs. 60.3 hours 69.1 vs. 84.6 hours . No adverse effects were observed with chewing gum . CONCLUSIONS Chewing gum had stimulatory effects on bowel motility after cystectomy and urinary diversion . Chewing gum was safe and could be used for postoperative ileus regardless of the operative method ( ORC or RARC ) PURPOSE Orthotopic neobladder reconstruction is the preferred method of urinary diversion after radical cystoprostatectomy . We evaluated urinary functional outcomes in male patients after orthotopic neobladder  using a patient question naire . MATERIAL S AND METHODS Between 2002 and 2009 patients with bladder cancer were enrolled in a clinical trial , r and omly assigned to undergo T pouch or Studer pouch diversion  after radical cystoprostatectomy . Male patients were mailed a question naire 12 or more months after surgery including items on urinary function , intermittent catheterization , number/size/wetness of pads and mucus leakage . RESULTS The question naire response rate was 68 % . Mean followup was 4.5 years ( range 1 to 8) . Only 22.3 % of patients did not use pads . In the daytime 47 % of patients used at least 1 pad , 32.2 % used small/mini pads and 22.6 % used diapers . At night 72 % used pads , 14.7 % used small/mini pads and 38.9 % used diapers . During the day and night 47 % said their pads were dry/barely wet . Overall 62.5 % of patients reported mucus leakage . Only 9.5 % of patients performed  clean intermittent self-catheterization  , of whom 70.6 % started clean intermittent self-catheterization within the first year after surgery . Increasing age and diabetes mellitus were predictors of urinary function ( p = 0.005 and 0.03 , respectively ) but did not affect pad use . CONCLUSIONS Ileal orthotopic neobladder offers good functional results but most patients wear at least 1 pad and many require diapers at night . Increasing age and diabetes mellitus predict worse urinary function but are not associated with pad use . Emptying failure is uncommon and occurs early in the postoperative period . Pad size/wetness and mucus leakage should be considered when evaluating urinary incontinence Background This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide grade d recommendations for items for an evidence d-based enhanced perioperative protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omised controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( quality of evidence and recommendations according to the GRADE system ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , International Association for Surgical Metabolism and Nutrition ( IASMEN ) and European Society for Clinical Nutrition and Metabolism ( ESPEN ) present a comprehensive evidence -based consensus review of perioperative care for colonic surgery BACKGROUND After radical cystectomy , patients are in a catabolic state because of postoperative stress response , extensive wound healing , and ileus . OBJECTIVE To evaluate whether recovery can be improved with total parenteral nutrition ( TPN ) in patients following extended pelvic lymph node dissection ( ePLND ) , cystectomy , and urinary diversion ( UD ) . DESIGN , SETTING , AND PARTICIPANTS We conducted a prospect i ve , r and omised , single-centre study of 157 consecutive cystectomy patients . INTERVENTION Seventy-four patients ( group A ) received TPN during the first 5 postoperative days , with additional oral intake ad libitum .  Eighty-three patients ( group B ) received oral nutrition alone . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was the occurrence of postoperative complications . Secondary outcomes were time to recovery of bowel function , biochemical nutritional ( serum albumin , serum prealbumin , serum total protein ) and inflammatory ( C-reactive protein ) parameters , length of hospital stay , and costs attributed to the TPN .  The Pearson χ(2 ) test was used for dichotomous variables ; the Wilcoxon rank sum test was used for continuous variables . RESULTS AND LIMITATIONS Postoperative complications occurred in 51 patients ( 69 % ) in group A and in 41 patients ( 49 % ) in group B ( p=0.013 ) , a difference result ing from group A having more infectious complications than group B ( 32 % vs 11 % ; p=0.001 ) . Serum prealbumin and serum total protein were significantly lower in group B on postoperative day 7 but not on postoperative day 12 . Time to gastrointestinal recovery and length of hospital stay did not differ between the two groups . The costs for TPN were € 614 per patient . A potential limitation is the use of a glucose-based parenteral nutrition without lipids . CONCLUSIONS Postoperative TPN is associated with a higher incidence of complications , mainly infections , and higher costs following ePLND , cystectomy , and UD versus oral nutrition alone
target: Intraoperatively , a fluid and opioid sparing protocol may reduce fluid shifts and avoid complications from paralytic ileus .
  Finally , enhanced recovery protocol s including novel medications , early feeding , and multi-modal analgesia approaches are associated with earlier postoperative convalescence .
  CONCLUSION RC is a complex and morbid procedure that may benefit from care re design .
background: OBJECTIVE To present an evidence -based review of the perioperative management of the radical cystectomy ( RC ) patient in the context of a care re design initiative .