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UPJ INSIGHT Naloxegol versus Alvimopan for Enhancing Postoperative Recovery following Radical Cystectomy for Bladder Cancer

By: Peter S. Kirk, MD, MS; Dima Raskolnikov, MD; Sarah P. Psutka, MD, MSc; John L. Gore, MD, MS; Yaw A. Nyame, MD, MS, MBA; Janet Kelly, PharmD; Jonathan L. Wright, MD, MS | Posted on: 01 Oct 2022

Kirk PS, Wang A, Raskolnikov D, et al. Naloxegol versus alvimopan for enhancing postoperative recovery following radical cystectomy for bladder cancer. Urol Pract. 2022;9(5)364-370.

Study Need and Importance

Radical cystectomy, the standard of care for muscle-invasive bladder cancer, is a complex procedure associated with significant morbidity and frequent complications. In order to reduce complications and postoperative hospital stays, enhanced recovery after surgery (ERAS) pathways have been widely implemented. One important component of these is the use of a μ-opioid receptor antagonist, alvimopan, to reduce the occurrence of ileus and hasten return of bowel function. Naloxegol is a significantly less expensive medication within the same class which is currently used in the treatment of opioid-induced constipation. We undertook this study to compare the effects of these 2 medications among patients following radical cystectomy at a single institution.

What We Found

There were 117 patients included in this study over 20 months, halfway through which our practice was transitioned from alvimopan to naloxegol as the standard medication in our ERAS pathway. A total of 59 patients received alvimopan and 58 received naloxegol. We did not observe significant differences in baseline factors between the 2 groups. Both groups had a median postoperative length of stay of 6 days (p=0.3; see Figure) and time to flatus of 2 days (p=0.2), and similar rates of ileus (14% versus 17%, p=0.6). μ-Opioid receptor antagonist was not associated with ileus or postoperative length of stay in multivariable models. Cost difference was −$344.20/day, equivalent to a $2,065.20 savings over a 6-day hospital stay with naloxegol.

Figure. Distribution of postoperative length of stay.


This is a nonrandomized, retrospective, single-institution study which utilizes one of these medications in an off-label fashion. In order to better understand the differences between medications in this setting prior to more widespread adoption of our approach, future work will need to incorporate prospective, randomized approaches adequately powered to assess equivalence.

Interpretation for Patient Care

There were no observed differences in postoperative outcomes or length of stay following the substitution of naloxegol for alvimopan in an ERAS pathway for radical cystectomy patients; however, there were significant cost savings associated with this change. Future work is needed to more rigorously compare these medications in this setting.