What is the recommended post-operative care for a patient with an ileal conduit (ileal conduit)?

Post-Operative Care for Ileal Conduit

Patients with an ileal conduit require comprehensive post-operative management including ureteral stent placement for 5-10 days, enterostomal therapy education, prophylactic antibiotics with second or third-generation cephalosporins, thromboembolism prophylaxis, and vigilant long-term surveillance for complications that increase dramatically over time. 1, 2

Immediate Post-Operative Management

Ureteral Stenting

• Ureteral stents should remain in place for 5-10 days post-operatively to ensure optimal drainage of the upper urinary tract, improve bowel recovery, and reduce metabolic acidosis 1, 2
• Removing stents immediately after completion of the uretero-ileal anastomosis results in worse drainage, delayed bowel recovery, and increased metabolic acidosis compared to the 5-10 day protocol 1

Antibiotic Prophylaxis

• Administer second or third-generation cephalosporins within 60 minutes of surgical incision given entry into both the urinary tract and intestine 1, 2
• Redose intraoperatively after 2 antibiotic half-lives to maintain adequate serum levels until incision closure 1
• Discontinue prophylactic antibiotics 24 hours after surgery 1

Thromboembolism Prophylaxis

• Deep vein thrombosis prophylaxis is mandatory due to the high-risk profile of these patients (malignancy, advanced age, major surgery, multiple comorbidities) 1, 2
• Thromboembolic events represent up to 8% of all cystectomy perioperative complications, though this likely underestimates subclinical events 1

Stoma and Appliance Management

Enterostomal Therapy

• All patients must meet with an enterostomal therapist trained in stoma care before surgery for preoperative stoma site marking and education 1, 2
• The enterostomal therapist should evaluate the patient's abdomen and mark the optimal stoma site preoperatively to minimize complications 1
• Multiple post-operative sessions with the enterostomal therapist are essential to reinforce teaching and troubleshoot difficulties 1
• If a specialized enterostomal therapist is unavailable, a nurse or physician with considerable experience managing urinary diversions must provide the necessary teaching 1

Early Recovery Protocols

Bowel Function

• Chewing gum post-operatively shortens time to flatus and first bowel movement, though it does not reduce overall morbidity or length of stay 1
• Enhanced recovery after surgery (ERAS) protocols significantly reduce complications (29.4% vs 64.5%), accelerate time to flatus (2 vs 3 days), and shorten time to liquid diet (2 vs 4 days) 3

Pain Management

• Multimodal opioid-sparing analgesia with thoracic epidural analgesia for 48-72 hours is recommended for superior pain relief and reduction of cardiopulmonary complications 1
• Baseline treatment should include acetaminophen and NSAIDs, though NSAIDs require caution due to reports of increased anastomotic leaks 1

Early Mobilization

• Encourage early mobilization to reduce postoperative thromboembolism risk and pulmonary complications, though specific protocols for cystectomy patients lack prospective data 1

Management of Early Complications

Anastomotic Leaks

• Small initial urinary leakage post-operatively is common and often self-limited 4
• Persistent ileo-ureteric anastomotic leaks require intervention, which may include angioplasty balloon catheters to occlude both ureters temporarily 4
• Urinary anastomotic leaks carry significant morbidity and mortality if not addressed promptly 4

Infection and Sepsis

• Monitor for symptomatic urinary tract infections including pyelonephritis, which occur in 23% of long-term survivors 5
• Broad-spectrum antibiotics should be initiated immediately if biliary fistula, biloma, or peritonitis develops 6

Long-Term Surveillance and Complications

Complication Timeline

• Within the first 5 years, complications develop in 45% of patients 5
• This percentage increases to 50% at 10 years, 54% at 15 years, and 94% in those surviving longer than 15 years 5
• In patients surviving more than 15 years, 50% develop upper urinary tract changes and 38% develop urolithiasis 5

Specific Long-Term Complications

• Kidney function/morphology complications occur in 27% of long-term survivors 5
• Stoma-related complications affect 24% of patients 5
• Bowel complications occur in 24% of patients 5
• Conduit/ureteral anastomotic complications develop in 14% of patients 5
• Urolithiasis affects 9% of patients overall, but increases to 38% in those surviving more than 15 years 5

Surveillance Protocol

• Vigorous long-term follow-up is mandatory given the high complication rate in long-term survivors 5
• Monitor renal function and upper tract morphology regularly, as hydronephrosis and compromised renal function can develop over time 3
• Studies lasting more than one decade are necessary to cover the entire morbidity spectrum 5

Critical Pitfalls to Avoid

• Never remove ureteral stents before 5 days post-operatively unless there is a specific complication requiring earlier removal 1
• Do not underestimate the importance of preoperative stoma marking, as improper placement significantly increases complications 1
• Avoid inadequate patient education about stoma care, as this directly impacts quality of life and complication rates 1
• Do not discontinue long-term surveillance after the first few years, as complication rates increase dramatically with time, reaching 94% in patients surviving more than 15 years 5
• Recognize that the ileal conduit remains the gold standard for urinary diversion with the fastest operative time and lowest complication rates, particularly for elderly patients and those with comorbidities 2