1. An assessment of the complications of open radical cystectomy with and without naso-gastric tubes – is a naso-gastric tube still routinely required? Mr JM Patterson, Mr M Malki, Mr MD Haynes, Mr DJP Rosario and Mr JWF Catto Academic Urology Unit, University of Sheffield and Department of Urology, Royal Hallamshire Hospital Sheffield Teaching Hospitals NHS Foundation Trust

2. Introduction Cystectomy is a morbid procedure – RT, GIT and UT/renal complications; mortality Patients dislike nasogastric tubes and they are associated with respiratory complications ERAS protocols have been introduced to improve LoS and other morbidity factors Can morbidity be reduced by removing the routine use of NGT?

3. Methods and patients Null hypothesis: Not using NGT will prolong ileus and increase complications Prospective evaluation of 57 patients undergoing open radical cystectomy Single institution, 3 surgeons 2 surgeons stopped placing NGT, 1 continued 12 month study period, followed up for 6-18 months

4. Methods and patients No NGT (n=21)NGT (n=36)Overall Sex13 ♂ :8 ♀ 30 ♂ :6 ♀ 43 ♂ :14 ♀ Age70.1 (59-83)66.6 (55-80)67.9 Procedure duration4h (2.75-5)5.75h (4-9.33)5.1h Blood loss825ml (370-1700)1475ml (400-3870)1245ml Time to bowels open7.35d (med 6d)7.51d (med 7d)7.46d (med 7d) Time to NG out-4.6d Length of stay12.9d (med 13)13.3d (med 12)13.16d (med 12) Final pathology: 15 pT0, 9 pTis, 3 pTa, 4 pT1, 15 pT2, 7 pT3, 4 pT4. 13 N+ (4 pN1, 8* pN2, 1 pN3) *including an incidental lymphoma in pelvic nodes 1 M+ (separate vaginal nodule to main tumour-G3pT2). 11 incidental CaP 53 Urothelial Ca (+2 Neuroendocrine differentiated), 1 AdenoCa, 1 SqCCa 2 primary urethrectomy, 1 salvage cystectomy. All ♀ done as ant. exenteration

5. Results No difference in LoS (orthotopics excluded) No difference in time to return of GIT transit No difference in rates of DVT/PE or wound dehiscence (nil both groups), or cardiovascular or stomal complications However, other complications do differ

6. Results Complications – 1 death in each group 188 days post op in NGT- group – pT4 disease, 79yo 159 days post op in NGT+ group – post salvage surgery, complications included enterocutaneous fistulae, T3b sarcomatoid tumour, 72yo – NGT related 4 inserted in NGT- group (19%) – 2 only for 24h, 1 for chronic constipation, 1 for ileus 4 reinserted in NGT+ group (11%) – 1 resited in PACU, 2 for 24-48h only, 1 for SB complications

7. Results Complications No NGTNGT + Wound infection3 (14%)10 (28%) Chest infection1 (5%)4 (11%) Nutritional1 (5%) needed TPN4 (11%) needed TPN Other infections2 diarrhoea, 1 sepsis ?focus2 diarrhoea, 1 C Diff, 2 sepsis ?focus, 1 urosepsis Others1 persistent drain output, 1 revision UI anastomosis 1 enterocutaneous fistula, 2 scrotal haematoma, 1 revision stoma, 1 conversion neobladder to conduit, 1 laparotomy and adhesiolysis Overall10 in 8 patients (38%)30 in 18 patients (50%)

8. Discussion No result statistically significant Trend towards more complications in longer operations (mean duration 5.3 v 4.9h without complication), paralleled by blood loss NGT negatively associated with – respiratory complications – wound infections – overall complications

9. Conclusions Routine NGT placement after open radical cystectomy is not recommended – increased complications in this series – but up to 20% may need NGT insertion senior clinician decision to avoid unnecessary NGT Longer operating times seem to be correlated with blood loss, and increased complications