Hospitalization for a Radical Cystectomy and Diversion

Sharon McMullen, RN, BSN, BA, CCRN

What kind of hospital stay can you expect before, during, and after your radical cystectomy and urinary diversion? Glad you asked! What follows is a summary of the clinical pathway used at the University of Virginia Medical Center for patients undergoing radical cystectomy. A clinical (or critical) pathway is a tool used by all the members of your hospital healthcare team (doctors, nurses, pharmacists, physical therapists, etc.) to keep you on schedule following a major surgery.

In their 3/97 article in the Journal of Wound, Ostomy, and Continence Nursing entitled "Development and Implementation of a Clinical Pathway for Radical Cystectomy and Urinary System Reconstruction", Teresa Golden, RN, BSN and Catherine Ratliff, PhD, RN, CETN, CS of UVMC developed a clinical pathway for cystectomy patients. Thanks to Ms. Golden for sending me this article and answering my myriad of questions.

Please keep in mind that most major medical centers will have its own clinical pathway, which may vary from this one. Smaller community hospitals may not even use clinical pathways. This summary is intended to give you an idea of what you may encounter during your hospital stay.

At some date before the surgery, you will be screened for any co-existing conditions that may complicate the surgery. If you smoke, you will be encouraged to quit. If you have emphysema, the extent of your condition will be documented. All of the medications that you currently take will be recorded for reference during your hospitalization. You will begin to take vitamins. Plans for your recovery at home will be initiated. You will be given educational materials.

On the day before surgery, you will go into the hospital for a busy day of testing and bowel preparation. An anesthesiologist will speak with you regarding the risks of this surgery. An entero-stomal therapist will mark possible sites on your abdomen for a stoma (if you're getting one.) Several people, including doctors and nurses will do a medical history and physical exam on you. (This can be quite tedious. People will be asking you the same questions over and over but please be patient. The system is designed to decrease the risk that crucial information is overlooked.) Blood work, EKG, chest X-ray, and urinalysis tests will be done. A peripheral IV access will be placed and IV fluids will be started. Your bowel will be prepared with a combination of medications that you drink (like GoLytely), oral antibiotics, and enemas. You will be given compression stockings. You will have only clear fluids to drink until midnight and after midnight you will have nothing to eat or drink (except medications).

On the day of surgery, you will get an antibacterial shower and then you will go to the operating room for the surgery. You'll be in the OR for several hours under general anesthesia. After the surgery, you will go to the recovery room (PACU), then back to a room on the urology floor of the hospital. Through a central IV line (usually in the neck or groin) placed during surgery, you will be given IV medications to control pain and nausea and to prevent infection. Your vital signs (temperature, blood pressure, heart rate, and respiration rate) will be taken every 2-4 hours. You will wear nasal oxygen prongs.

To prevent bowel obstruction and perforation, you will have a naso-gastric tube (NGT) connected to wall suction. If necessary, you will have 1 or more Jackson-Pratt bulb drainage systems that remove excess fluid from the operative site. If you have a foley catheter draining urine from a continent voiding reservoir or a catheterized diversion, it will be flushed every 3 hours and as needed to prevent it from becoming clogged. The stents that keep your ureters open will drain to a collection bag and may also require flushing. Your urine output will be carefully collected (depending on which type of urinary diversion your surgeon creates) and recorded. You will stay in bed all day but your position will be changed every 2 hours.

Over the next 2 days (called post-op days 1 and 2), you will be weighed and have blood work drawn every morning. Your vital signs will be taken every 4 hours. You will continue to have IV fluids and medications as before. Your oxygen will be weaned off. Your surgical dressings will be changed. Your foley and stents will be flushed as needed. You will get out of bed and sit in a chair for 20 minutes at least twice a day. On post-op day 2, you will walk in the hallway with help.

On post-op day days 3 and 4, your vital signs will be taken every 8 hours. You will continue to walk in the hallways with help. Your dressings will be changed daily and removed for good when possible. Your NGT may be removed if your bowel begins to awaken. This is considered to have begun when you start to pass gas. (Please note that this is extremely variable. It takes far longer for many people's bowels to wake up after major surgery.) Once the NGT is removed, you will be allowed to have some ice chips. If you tolerate them, you will start on a clear liquid diet the next day. Each day your diet will be advanced as long as you tolerate it without nausea/vomiting.

On post-op days 5, 6, and 7, more of the tubes, drains, and dressings (like the central IV access, surgical clips, and the Jackson-Pratt) may be removed. You will continue to walk with help. Blood work will be done every other day. You will begin to participate in the care of your stoma (if you have one) and you will learn how to irrigate your stents and foley (if you have them). Specific plans for home care will be made.

Barring any complications, you will leave the hospital 7 days or so after your surgery.