Brazilian Society of Urology Recommendations on Perioperative Procedures of Prostate, Bladder, and Kidney Cancer Surgery
By: Marcus Vinicius Sadi, MD, Federal University of São Paulo, Brazil; Ubirajara Ferreira, MD, Campinas University (UNICAMP), São Paulo, Brazil, Brazilian Urological Society, Rio de Janeiro | Posted on: 18 May 2023
Urologic oncologic surgeries are complex procedures that require careful planning in order to minimize the risk of complications and ensure a successful outcome. One of the most important tools for achieving this goal is a comprehensive manual that outlines the proper care and management of patients before, during, and after surgery. A review from the Brazilian Society of Urology (SBU) manual for prostate, bladder, and kidney tumors is summarized.
Prostate Cancer Surgery
In laparoscopic or robotic prostatectomy with the DaVinci SI system, the patient should be positioned with the lower limbs in a lithotomy position with padded boots. A slight flexion of the hips decreases the possibility of obturator and femoral nerve lesion. With the Xi, a supine position is preferred with slightly abducted legs. Brachial plexus lesions can be prevented with careful use of protection on the acromioclavicular joint.1,2
The surgery is performed with the patient under general anesthesia. The greatest difficulties are associated with the use of pneumoperitoneum with the patient in the Trendelenburg position. Epidural block promotes better postoperative pain control, especially in obese patients. Intravenous hydration should be judicious and kept to a minimum, as it reduces the occurrence of facial, larynx, and cerebral edema.2
Postoperative care includes a liquid diet in the immediate postoperative period and a normal diet on the first postoperative day. A closed suction drain may be used and should be removed when drainage output is ≥50 mL/d. This recommendation is valid for cystectomies and nephrectomies, as well.
The Foley catheter is removed 7-10 days postoperatively in most situations. In patients with exaggerated discomfort due to the urethral catheter, anticholinergics may help relieve the symptoms.
The concept of penile rehabilitation emerged several years ago. According to the guidelines of the 2015 International Consultation for Sexual Medicine, in which SBU members were actively involved in the recommendations, existing data are inadequate to support any ideal specific regimen (drug, concentration, and time interval).3 Currently, the SBU has no specific recommendations on penile rehabilitation after radical prostatectomy.4
Bladder Cancer Surgery
The SBU appreciates the resurgence of greater scrutiny related to the quality of transurethral resection of bladder tumor performed by urologists, mainly due to the potential use of new drugs from the clinical oncology community. So training will be of utmost importance. Whether bipolar energy or new approaches such as en bloc resection have the potential to improve the quality of tissue for histopathology remains to be evaluated due to the conflicting results available.5
Several clinical guidelines for antibiotic prophylaxis and bowel preparation for radical cystectomies exist but results are inconsistent.6 The SBU recommends the use of first- or second-generation cephalosporins until all the stents are removed.
Patient positioning for radical cystectomy, either open or minimally invasive, uses a similar approach to that recommended for prostate surgery. In women, the surgeon should have access to the vagina.
Total intravenous anesthesia may promote better oncological results compared to inhalational anesthesia. However, the combined use of epidural anesthesia seems to increase the risk of complications, but data are not clear.7,8
Enhanced Recovery After Surgery protocol is recommended, but not enforced by SBU. Measures for the early recovery of intestinal motility involve chewing gum, avoiding opioids, early ambulation, early introduction of clear liquid diet, and use of prokinetic medications.
A perioperative prophylaxis with unfractionated or low molecular weight heparin is indicated for all cancer patients who will undergo major surgical interventions. The recommended scheme is enoxaparin (low molecular weight heparin) at a dosage of 40 mg for patients around 200 lbs with normal renal function, subcutaneously, in the immediate preoperative period and a single daily dose, for 10 days or up to 30 days, in higher-risk cases.
When Bricker is performed, a Foley catheter left for up to 7 days inside the ileostomy may be useful to prevent mucus accumulation.
For neobladders, a large cystostomy tube can used to prevent mucous obstruction. Ureteral catheters should be maintained for a period of 1-2 weeks. The urethral Foley catheter is kept for up to 48 hours after cystostomy tube removal. For these patients with neobladder, there may be a need for early intermittent catheterization after hospital discharge.
In cases of cutaneous ureterostomies, a procedure with a recent sharp increase in some centers in Brazil, Double-J stents are maintained and changed periodically. Usually, after 3 months the ureteral orifices are well preserved; the stents can then be removed and the ureteral orifices are periodically dilated.
The interposition of intestinal segments in the urinary tract is associated with metabolic disorders. Hyperchloremic acidosis is common and especially important in patients with liver insufficiency, as there may be impairment of the ammonium cycle, with early onset of hepatic encephalopathy. This disorder can be corrected easily with oral alkalizing agents.
Kidney Cancer Surgery
In minimally invasive surgery, the patient is in a modified lateral decubitus. Pressure points should be padded to avoid nerve damage, ulcers, and rhabdomyolysis. This risk is increased in the presence of overweight patients and prolonged surgeries.9 Care should be taken with the height of the patient arm, so that the robot arm does not collide with that of the patient. A nasogastric tube is recommended to minimize the risk of viscera perforation at the beginning of the laparoscopic access. The choice of anesthetic technique should prioritize patient safety, optimization of the surgical condition, and patient choice. Several common anesthetic practices still lack good scientific evidence.10
The Foley catheter is usually removed in the first postoperative period. Laboratory tests are used to assess the severity of eventual bleeding in the immediate postoperative period. Creatinine dosage of the drainage fluid may be useful in confirming possible urinary fistula in partial nephrectomies.
Postoperative imaging, usually a contrast CT, may be required in the presence of above normal bleeding, suspected pseudoaneurysms, urinary fistula, and, more rarely, adjacent organ lesions.
- Alemozaffar M, Sanda M, Yecies D, Mucci LA, Stampfer MJ, Kenfield SA. Benchmarks for operative outcomes of robotic and open radical prostatectomy: results from the Health Professionals Follow-up Study. Eur Urol. 2015;67(3):432-438.
- Irvine M, Patil V. Anaesthesia for robot-assisted laparoscopic surgery. Contin Educ Anaesth Crit Care Pain. 2009;9(4):125-129.
- Salonia A, Adaikan G, Buvat J, et al. Sexual rehabilitation after treatment for prostate cancer-part 2: recommendations from the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med. 2017;14(3):297-315.
- Sociedade Brasileira de Urologia. Disfunção erétil: tratamento medicamentoso. 2019. https://amb.org.br/wp-content/uploads/2021/08/DISFUNCAO-ERETIL-TRATAMENTO-MEDICAMENTOSO-FINAL-2019.pdf.
- Liem EI, de Reijke TM. Can we improve transurethral resection of the bladder tumour for nonmuscle invasive bladder cancer?. Curr Opin Urol. 2017;27(2):149-155.
- Chi AC, McGuire BB, Nadler RB. Modern guidelines for bowel preparation and antimicrobial prophylaxis for open and laparoscopic urologic surgery. Urol Clin North Am. 2015;42(4):429-440.
- Pfail JL, Katims AB, Gul Z, et al. Can anesthetics affect bladder cancer recurrence? Total intravenous versus volatile anesthesia in patients undergoing robot-assisted radical cystectomy: a single institution retrospective analysis. Urol Oncol. 2021;39(4):233.e1-233.e8.
- Shui M, Xue Z, Miao X, Wei C, Wu A. Intravenous versus inhalational maintenance of anesthesia for quality of recovery in adult patients undergoing non-cardiac surgery: a systematic review with meta-analysis and trial sequential analysis. PLoS One. 2021;16(7):e0254271.
- Spruce L. Back to basics: preventing perioperative pressure injuries. Aorn J. 2017;105(1):92-99.
- Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77-e137.