Perioperative Optimization for Radical Cystectomy Patients (Part 1)

In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Angie Smith from UNC School of Medicine discuss peri-operative measures to optimize radical cystectomy outcomes.

First, the doctors start by explaining their approaches to initial cystectomy discussions with bladder cancer patients. Dr. Smith usually provides a walkthrough of the surgery and discusses complication rates with her cystectomy patients. Because sexual dysfunction and infertility are possible long-term complications of the procedure, she emphasizes the importance of transparency and expectation management in patients.

Next, the doctors discuss the optimal timing for a cystectomy. Dr. Smith and Dr. Bagrodia usually wait at least 4 to 6 weeks after chemotherapy to perform a cystectomy. However, because Dr. Smith believes that timing is the most crucial factor in a cystectomy, she prefers to perform surgery sooner rather than later. For this reason, she performs both open and robotic surgery, depending on which approach can be done sooner. Furthermore, to anticipate a patient’s post-operative regimen, Dr. Smith uses the comprehensive geriatric assessment because she prioritizes the functional status of a cystectomy patient most. In addition to this assessment, she will evaluate a patient’s activities of daily living, hearing and vision deficits, and fall risk.

Finally, Dr. Smith emphasizes the importance of involving multiple interdisciplinary health professionals, such as medical and radiation oncology, nutritionists, wound/ostomy/continence nurses, geriatricians, and pelvic floor physical therapists. She notes that “prehabilitation”, or using physical therapy to improve a patient’s strength and fitness before surgery, is a new feasible pre-operative strategy, but its effects on distal post-operative outcomes have not yet been determined.