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Guideline Summary
Guideline Title
Part 1. Cystectomy: indications and pre- and post-operative care. In: Incontinent urostomy.
Bibliographic Source(s)
Cystectomy: indications and pre- and post-operative care. In: Geng V, Cobussen-Boekhorst H, Fillingham S, Holroyd S, Kiesbye B, Vahr S. Incontinent urostomy. Arnhem (The Netherlands): European Association of Urology Nurses (EAUN); 2009 Mar. p. 5-18.
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Diseases or conditions requiring cystectomy and urinary diversion (incontinent urostomy)

Guideline Category
Evaluation
Management
Treatment
Clinical Specialty
Nursing
Surgery
Urology
Intended Users
Advanced Practice Nurses
Guideline Objective(s)
  • To provide guidelines clearly stating the level of evidence of each procedure and recommendation with the aim of improving current practices and delivering a standard and reliable protocol for incontinent urinary diversion care
  • To support practitioners who are already assessed as competent in incontinent urinary diversion care
  • To help urology nurses assess the evidence-based management of urostomy care and to incorporate the guidelines' recommendations into their clinical practice
Target Population

Adult patients who are undergoing cystectomy and incontinent urinary diversion

Note: This guideline focuses on incontinent urinary diversion, leaving the topic of continent urinary diversion for a future publication in this series. The guidelines contain only material on adults and not children.

Interventions and Practices Considered

Pre-operative Assessment

  1. Implementation of peri-operative care plan: standardizing forms, documents, tools
  2. Nutritional assessment: preoperative oral diet or total parenteral nutrition (TPN) in malnourished patients

Patient Preparation

  1. Fasting, assessment of fluid balance, and fluid therapy (as required)
  2. Bowel preparation
  3. Shaving

Post-operative Care

  1. Monitoring of ureteral stents
  2. Monitoring of fluid balance
  3. Nutritional support
  4. Monitoring of bowel function
  5. Post-operative wound management
  6. Post-operative pain management
  7. Post-operative physical activity
  8. Special care: laparoscopic cystectomy and ileal conduit
Major Outcomes Considered
  • Postoperative morbidity or mortality
  • Time to recovery
  • Weight loss
  • Rate of complications
  • Length of hospital stay

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Literature Search

The data underpinning this document were gathered through a systematic literature search. The focus of this search was to ensure identification of the available high-level data (meta-analyses, randomised controlled trials, Cochrane reviews and other high-quality guidelines documents). A critical assessment of the findings was made, not involving a formal appraisal of the data. Articles were selected from Medline, Cinahl, Scopus, Sciencedirect, PubMed and the Cochrane database, as well as from relevant textbooks and other guidance documents.

Search Keywords

The Working Group first tried to find randomised, controlled trials, reviews or meta-analyses. If these references did not provide enough information, the Working Group continued their search by looking for studies with lower levels of evidence. The evidence found on each topic is shown in the recommendations of each chapter or subchapter. The choice of literature is guided by the expertise and knowledge of the Guidelines Working Group. The question for which the references were searched was: Is there any evidence for incontinent urinary diversion for nursing interventions in different care situations such as preoperative, operative and post operative, acute as well as long term?

The references for these Guidelines were searched using the keywords listed below. Several databases (Medline, PubMed, Embase, Cinahl and Cochrane) were searched as well as private libraries, databases and books of the authors, using the keywords in different combinations. The references were searched by different experts in the field of urostomy. The same reference was often used repeatedly to build up the Guidelines.

Keywords (alphabetical order)

  • Activity of daily living
  • Bricker
  • Colon conduit
  • Coping
  • Cranberry
  • Cystectomy (Mesh)
  • Education
  • Fluid balance
  • Ileal conduit
  • Incontinent urostomy
  • Nursing assessment (Mesh)
  • Nutrition
  • Pain management
  • Patient care planning (Mesh)
  • Patient education
  • Post-operative care
  • Pre-operative care
  • Psychological impact
  • Stoma
  • Stoma care
  • Stoma care nursing
  • Stoma care pouching system
  • Skin care (Mesh)
  • Skin irritation
  • Social issues
  • Stent
  • Stoma
  • Teaching
  • Urethral cutaneous stomy (Cutaneous stoma)
  • Urinary diversion (Mesh)
  • Urinary tract infection
  • Urological nursing
  • Urostomy
  • Wet urostomy
Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

1a Evidence obtained from meta-analysis of randomized trials

1b Evidence obtained from at least one randomized trial

2a Evidence obtained from one well-designed controlled study without randomization

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports

4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

The Working Group included an extensive number of topics, which are not always only applicable to urostomies, but decided to include them because they make the guideline more complete.

The recommendations provided in these documents are based on a rating system modified from that produced by the Oxford Centre for Evidence-based Medicine (see the "Rating Scheme for the Strength of the Evidence" field).

Some of the literature was not easy to grade. If, however, the European Association of Urology Nurses (EAUN) Working Group thought the information would be useful in practice, it was ranked as level of evidence 4 and grade of recommendation C.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
  • The expert panel consisted of a multi-disciplinary team of nurse specialists (e.g., stoma care nurse, wound-continence-stoma care nurse).
  • Whenever possible, the Guidelines Working Group graded treatment recommendations using a three-grade recommendation system (A to C) and inserted levels of evidence to help readers assess the validity of the statements made. The aim of this practice was to ensure a clear transparency between the underlying evidence and a recommendation given.
Rating Scheme for the Strength of the Recommendations

Grades of Recommendation

  1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
  2. Based on well-conducted clinical studies, but without randomized clinical studies
  3. Made despite the absence of directly applicable clinical studies of good quality
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

A draft for review was sent to the European national urological nurses societies, specialised nurses in various European countries, a few urologists, the European Association of Urology (EAU) Guidelines Office and the EAU executive responsible for The European Association of Urology Nurses (EAUN) activities. The document was revised based on the comments received. A final version was presented and approved by the EAUN Board.

Recommendations

Major Recommendations

Definitions for the levels of evidence (LE) (1a-4) and grades of recommendation (GR) (A-C) are provided at the end of the "Major Recommendations" field.

Pre-operative Assessment

Standardising Forms, Documents, Tools

Implement care plans for all patients with an ileal conduit following local documentation recommendations. (LE=4, GR=C)

Nutrition

Pre-operative nutritional assessment of the patient is necessary. (LE=1b, GR=A)

Patient Preparation

Nutrition, Hydration and Bowel Preparation

Nutrition and Hydration

  • The patient should receive verbal and written instructions to ensure compliance with no food intake 8 hours, and no fluid 2 hours, before surgery (Overstreet & Sims, 2006; Maffezzini et al., 2008). (LE=1a, GR=A)
  • Assess the fluid balance of the patient to identify dehydration and start fluid therapy pre-operatively. (LE=1a, GR=B)

Bowel Preparation and Bowel Function

Follow local guidelines. (LE=4, GR=C)

Shaving

To prevent site infection, it is recommended that hair should not be removed from the operative site unless it is to assist surgery. If hair is removed, removal should be immediately before surgery, preferably with electric clippers (Nichols, 2001; National Collaborating Centre for Women's and Children's Health, 2008). (LE=1a, GR=A)

Post-operative Care

Stents

  • The nurse should assess stent function. Stents should drain urine all the time. (LE=4, GR=C)
  • Decreased urine output should be investigated. It can be caused by mucus plugs or dehydration. (LE=4, GR=C)
  • Assessment of fluid input and urine output and measuring recent serum creatinine levels are recommended. (Overstreet & Sims, 2006) (LE=4, GR=C)
  • If stents are producing no urine, they should be flushed with 5-7 ml NaCl 0.9% using a sterile technique, because mucus plugs could lead to undue tension on a surgical anastomosis. (LE=4, GR=C)

Fluid Balance

  • Daily weighing in the post-operative period. (LE=1b, GR=C)
  • Fluid balance documented on charts daily. (LE=4, GR=C)
  • Clinical observation of the patient to identify fluid overload or dehydration. (LE=4, GR=C)

Nutrition

  • Daily observation of the bowel function. (LE=4, GR=C)
  • Daily screening of the patient's oral intake with a view to supplying with artificial nutrition. (LE=1a, GR=A)
  • Counselling of the patient to involve the patient in the post-operative nutritional strategy. (LE=4, GR=C)

Post-operative Wound Management

  • Protect the incision with a sterile dressing for 24 to 48 hours postoperatively. (LE=1b, GR=B)
  • Wash hands before and after dressing changes and any contact with the surgical site. (LE=1b, GR=B)
  • When changing an incision dressing, use sterile technique. (LE=1b, GR=C)
  • Educate the patient and family regarding proper incision care, symptoms of surgical site infection (SSI) and the need to report such symptoms. (LE=1b, GR=C)

Post-operative Pain Management

  • Provide pre-operative information about the pain strategy, including the patient and nurse role. (LE=4, GR=C)
  • Carry out pain assessment using a visual analog scale both at rest and during activity. (LE=4, GR=C)
  • Evaluate the effects of prescribed analgesics. (LE=4, GR=C)

Special Care: Laparoscopic Cystectomy and Ileal Conduit

Pre-operative bowel preparation is decreased in patients undergoing laparoscopic surgery. (LE=4, GR=C)

Definitions:

Levels of Evidence (LE)

1a Evidence obtained from meta-analysis of randomized trials

1b Evidence obtained from at least one randomized trial

2a Evidence obtained from one well-designed controlled study without randomization

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports

4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Grades of Recommendations (GR)

  1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
  2. Based on well-conducted clinical studies, but without randomized clinical studies
  3. Made despite the absence of directly applicable clinical studies of good quality
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Pre-operative and post-operative care reduces patient morbidity and improves recovery.

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

These guidelines are not meant to be proscriptive, nor will adherence to these guidelines guarantee a successful outcome in all cases. Ultimately, decisions regarding care must be made on a case-by-case basis by health care professionals after consultation with their patients using their clinical judgement, knowledge and expertise.

Limitations of Document

The European Association of Urology Nurses (EAUN) acknowledge and accept the limitations of this document. It has to be emphasised that the current guidelines provide information about the treatment of an individual patient according to a standardised approach. The information should be considered as providing recommendations without legal implications. The intended readership is the pan-European practising urology nurse and nurses working in a related field. This guidelines document is of limited use to, for example, urologists, other healthcare providers or third-party payers. Cost-effectiveness considerations and non-clinical questions are best addressed locally and therefore fall outside the remit of these guidelines. Other stakeholders, including patient representatives, have not been involved in producing this document.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Mobile Device Resources
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Cystectomy: indications and pre- and post-operative care. In: Geng V, Cobussen-Boekhorst H, Fillingham S, Holroyd S, Kiesbye B, Vahr S. Incontinent urostomy. Arnhem (The Netherlands): European Association of Urology Nurses (EAUN); 2009 Mar. p. 5-18.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Mar
Guideline Developer(s)
European Association of Urology Nurses - Medical Specialty Society
Source(s) of Funding

European Association of Urology
Hollister Incorporated

Guideline Committee

European Association of Urology Nurses Guidelines Working Group for Urostomy

Composition of Group That Authored the Guideline

Primary Authors: V. Geng; H. Cobussen-Boekhorst; S. Fillingham; S. Holroyd; B. Kiesbye; S. Vahr

Financial Disclosures/Conflicts of Interest

The European Association of Urology Nurses (EAUN) Guidelines Working Group members have provided disclosure statements of all relationships that might be a potential source of conflict of interest. The information has been stored in the European Association of Urology (EAU) database. This Guidelines document was developed with the financial support of the EAU and Hollister Incorporated. The EAUN is a non-profit organisation and funding is limited to administrative assistance and travel and meeting expenses. No honoraria or other reimbursements have been provided.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the European Association of Urology Nurses (EAUN) Web site External Web Site Policy. Also available as an E-book External Web Site Policy and handheld version External Web Site Policy from the EAUN Web site.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands. E-mail: eaun@uroweb.org.

Availability of Companion Documents

A Quality of Life Evaluation Form can be obtained through contacting the European Association of Urology Nurses (EAUN) External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC guideline was completed by ECRI Institute on August 17, 2010. The information was verified by the guideline developer on September 21, 2010.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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