Key Words: urinary diversion; colon; antibiotics; polyethylene glycol

Article Outline

MATERIALS AND METHODS

MECHANICAL BOWEL PREPARATION

Polyethylene glycol (PEG) electrolyte solution.

Oral sodium phosphate solution.

IS MECHANICAL BOWEL PREPARATION NECESSARY?

UROLOGICAL GUIDELINES

ANTIBIOTIC BOWEL PREPARATION

Oral versus intravenous antibiotics.

Oral plus intravenous antibiotics:

Dose and timing considerations.

GUIDELINES FOR URINARY DIVERSION SURGERY

CONCLUSIONS

APPENDIX

BOWEL PREPARATION INSTRUCTIONS

References

Escalating costs have mandated the efficient use of medical resources. Pressure to limit the duration of hospitalization prompted us to scrutinize the scientific rationale for mechanical and antibiotic bowel preparation before urinary diversion surgery. Because our search of the urological literature spanning 25 years revealed limited information on bowel preparation for urinary diversion surgery, ¹ we reviewed recent data from related surgical disciplines to extrapolate guidelines for genitourinary procedures.

MATERIALS AND METHODS

We reviewed the literature from 1966 through 2000 on antibiotic and mechanical bowel preparation by researching the MEDLINE database. We also reviewed the bibliographies of select articles for additional references.

MECHANICAL BOWEL PREPARATION

Polyethylene glycol (PEG) electrolyte solution.

Historically cleaning the colon in preparation for surgery was an extensive and complicated procedure requiring several days of clear liquid diet and preoperative hospitalization. ^{2 and 3} The 1987 introduction of PEG electrolyte solution, namely GoLYTELY or NuLYTLEY (Braintree Laboratories, Braintree, Massachusetts), revolutionized bowel preparation.⁴ It dramatically decreased health care costs by limiting or eliminating the hospitalization requirement for mechanical bowel preparation before surgery. ^{5 and 6}

PEG is an isosmotic solution with especially designed electrolyte concentrations that result in virtually no net absorption of ions or water in the gut. Large volumes may be administered without significant fluid or electrolyte alteration. It appears to be extremely safe in most cases, although several isolated cases of serious complications due to PEG have been documented ⁷ and it is contraindicated in patients with known hypersensitivity, gastric retention, gastrointestinal obstruction, suspected bowel perforation, toxic megacolon or ileus.⁸ Care should be taken when PEG is given to patients with impaired gag reflexes. In such cases the solution can be safely administered through a nasogastric tube.

Patients are instructed to drink 8 ounces PEG rapidly every 10 minutes until the stool is completely clear and free of all solid matter. Usually between 3 and 4 l. are consumed to obtain clear effluent. Unfortunately bowel preparation with PEG is often difficult since many patients are unable to drink the required amount of fluid, and nausea, abdominal fullness and bloating are common. Ice, citrus flavoring or a combination enhances compliance but noncompliance has been documented in up to 50% of patients.⁸

Oral sodium phosphate solution.

The emergence of widespread routine colonoscopy for colon cancer screening in the last decade inspired gastroenterologists and colorectal surgeons to explore alternatives to PEG. Oral sodium phosphate, that is Fleet Phospho Soda (C. B. Fleet Co., Lynchburg, Virginia) has now supplanted PEG as the preferred method of mechanical bowel preparation for colonoscopy and colorectal surgery at most centers.⁹

Oral sodium phosphate is safe provided it is used appropriately. ^{10, 11 and 12} Because sodium phosphate acts as an osmotic cathartic, large volumes of water are translocated into the gut, causing diarrhea and colon cleansing. Two 45 ml. doses ingested 4 hours apart the night before surgery have been shown to be safe and effective.¹³ At least 3, 8-ounce glasses of clear liquid should be consumed after each dose with as much additional clear liquid as possible until midnight (table 1).

Table 1.

Preoperative bowel preparation schedule

In 1997 Oliveira et al from the Cleveland Clinic compared sodium phosphate and PEG in a prospective, randomized, surgeon blinded study involving 200 patients undergoing elective colorectal surgery.¹⁴ Sodium phosphate was better tolerated and judged equally effective by the operative surgeon (table 2). Wound complication rates were equal. In 2 other recent reports the safety, efficacy and tolerability of sodium phosphate and PEG were compared in an elderly population with a mean age of 71 years before colonoscopy. ^{15 and 16} Of the patients 91% who had previously used PEG preferred sodium phosphate. Mild hyperphosphatemia occurred in the sodium phosphate group but it was without clinical sequelae.¹⁵ Other reports in the colonoscopy literature provide similar results. ^{17 and 18}

Table 2.

Performance characteristics of oral sodium phosphate versus polyethylene glycol for mechanical bowel preparation¹⁴

The use of sodium phosphate is absolutely contraindicated in patients with renal insufficiency, symptomatic congestive heart failure or liver failure with ascites. Most clinical studies exclude patients with serum creatinine greater than 2 mg./dl. ^{14 and 15} Other exclusionary criteria include elevated serum phosphate, decreased serum calcium, impaired gut motility, history of seizures, or myocardial infarction or stroke within the preceding 6 months. ^{14, 15 and 19}

Serious complications can occur if sodium phosphate is used incorrectly. Vukasin et al reported hyperphosphatemia and hypocalcemic tetany after administering 90 ml. sodium phosphate (twice the recommended dose) in a 69-year-old woman with partially obstructing colon cancer. Although Vukasin et al experienced many years of success with this mechanical bowel regimen, this complication prompted them to recommend caution when using sodium phosphate in patients with partial bowel obstruction and ensure that the correct dose is administered.²⁰

IS MECHANICAL BOWEL PREPARATION NECESSARY?

Although the surgical literature is filled with testimonials about the absolute requirement for mechanical bowel preparation before colorectal surgery, data supporting its routine use are not compelling. A 1987 series of 72 consecutive colectomies with primary anastomosis without mechanical bowel preparation revealed no anastomotic leakage and a wound infection rate of 8.3%.²¹ In a 1993 randomized study Burke et al from Dublin evaluated 186 patients undergoing left colon or rectal surgery.²² Only 89 patients underwent mechanical bowel preparation, while the other 97 continued with a regular diet until the night before surgery. No significant difference was noted in the mortality, wound infection or anastomotic leakage rates.

In another prospective randomized trial Santos et al from Brazil evaluated 149 patients undergoing elective colon surgery and identified a wound infection rate of 24% in those with and 12% in those without mechanical bowel preparation.²³ Another series of 100 consecutive colorectal cases with no mechanical bowel preparation treated by a single surgeon indicated acceptable infection and anastomotic leakage rates of 7% and 1%, respectively.²⁴

The only American study addressing the requirement for mechanical bowel preparation was published in 1995, used a dog model and demonstrated no beneficial effect.²⁵ A meta-analysis of studies comparing patients with and without mechanical bowel preparation showed a significant increase in wound infection rates and an elevated anastomotic leakage rate of 8.4% in those with bowel preparation.²⁶ Notwithstanding these data, a 1997 survey of all active board certified colon and rectal surgeons in the United States and Canada showed that 100% of respondents routinely prescribe mechanical bowel preparation.⁹

UROLOGICAL GUIDELINES

The importance of adequate mechanical cleansing of a gastrointestinal segment before its use in urinary diversion is attributed to the prevention of retained particulate matter that may lead to recurrent infection or stone formation. The routine practice of performing mechanical preparation for nonreconstructive urological cases may be over prescribed. If a bowel segment is inadvertently entered, for example, rectal injury during radical prostatectomy, the existing literature indicates that the lack of preoperative mechanical bowel preparation does not affect the rate of wound infection or anastomotic breakdown when appropriate antibiotic bowel preparation has been performed. ^{23 and 26}

We currently use sodium phosphate for mechanical bowel preparation instead of PEG in most patients undergoing urinary diversion with bowel segments. We believe that sodium phosphate is better tolerated and equally effective. We give our patients a written instruction sheet (see Appendix). Patients drink clear liquids on the day before surgery. They ingest the first 45 ml. dose of sodium phosphate at 3:00 p.m. diluted equally into 3, 8 ounce glasses of a cold soft drink which are ingested 20 minutes apart. At least 1 additional 8 ounce glass of water should be ingested every hour. The second sodium phosphate dose is ingested at 9:00 p.m., using the same method used for the first dose. Patients continue drinking at least 1, 8 ounce glass of water every hour until midnight.

PEG is indicated in all patients with evidence of renal insufficiency, or significant heart or liver disease. It should also be used in patients on bisphosphonates since they are at increased risk for hypocalcemia when given sodium phosphate. For outpatient preparation telephone verification to ensure satisfactory preparation is prudent the night before surgery.

ANTIBIOTIC BOWEL PREPARATION

In 1939 Seley from Mt. Sinai Hospital first reported the use of antibiotics for preventing wound infection.²⁷ Today it is clear that prophylactic antibiotics are indicated for clean contaminated and contaminated procedures. With respect to antibiotic prophylaxis before urinary diversion surgery contemporary practices are again extrapolated from the abundant body of data in the colorectal surgery literature. In the 1970s Nichols et al reported a landmark series showing that prophylactic antibiotics significantly lowered wound infection rates after colorectal surgery. ^{28 and 29} The Nichols-Condon preparation of 1 gm. each of oral neomycin and erythromycin base at 1:00, 2:00 and 11:00 p.m. emerged as the gold standard. By 1981 the meta-analysis of Baum et al of antibiotic versus placebo trials performed before 1980 conclusively demonstrated the benefit of prophylactic antibiotics in colorectal surgery.³⁰ They identified a 60% decrease in mortality and 25% decrease in wound infections with antibiotics and called for an end to all future placebo controlled studies. Subsequent controversy centered only on the type of antibiotics used and the route of administration.

Oral versus intravenous antibiotics.

In 1979 Condon et al for the Veterans Administration Cooperative Study concluded that prophylactic antibiotic coverage with intravenous cephalothin alone fails to decrease adequately the rate of wound infection.³¹ With cephalothin alone the rate was 30% and with oral neomycin-erythromycin base it was only 6%. This wound infection rate in the neomycin-erythromycin base group did not decrease with the addition of cephalothin, a finding interpreted initially as suggesting that adding parenteral antibiotics was unnecessary. Unfortunately this conclusion was flawed due to the choice of a first generation cephalosporin instead of a more appropriate second generation cephalosporin, which attains broader gram-negative coverage. In 1984 Figueras-Felip et al compared oral neomycin-erythromycin base with metronidazole and gentamycin intravenously, and reported a 9% and 27% wound infection rate, respectively.³² A flaw in this study was the lack of adequate gram-positive coverage in the chosen intravenous antibiotics.³³

Although the Nichols-Condon oral neomycin-erythromycin base antibiotic combination remains the most widely used regimen, oral metronidazole has recently been successfully combined with neomycin (1 gm. of each given at 5:00 and 11:00 p.m.) for colon preparation. The neomycin-metronidazole prophylactic bowel regimen is as effective as neomycin-erythromycin base but it is simpler and does not have the gastrointestinal side effects of erythromycin. ^{34, 35, 36 and 37} Furthermore, metronidazole decreases the intestinal concentration of Clostridium difficile, which may lower the risk of antibiotic associated pseudomembranous colitis. ^{34, 38, 39, 40 and 41}

Oral plus intravenous antibiotics:

In 1984 Peck et al reported an 11-year retrospective review of wound infection rates after elective colorectal surgery at a community hospital that demonstrated the evolving use of prophylactic antibiotics.⁴² In the early 1970s most surgeons did not use any type of prophylaxis. By the early 1980s most used a combination of intravenous cephalosporin with oral aminoglycoside plus erythromycin base. The overall infection rate without antibiotic prophylaxis was 45%. The combination of intravenous and oral antibiotics decreased the infection rate to 11%.

Further investigators confirmed the benefit of combining oral and intravenous antibiotic prophylaxis. In a study of approximately 200 patients adding intravenous cefoxitin to oral neomycin-erythromycin base decreased the wound infection rate from 15% to 5%.⁴³ In another series of 241 patients who underwent elective colorectal surgery and were randomized to oral antibiotics (neomycin plus erythromycin base) versus oral plus intravenous cefoxitin, those receiving only oral antibiotic prophylaxis had an 18% wound infection rate, while those receiving oral and intravenous antibiotic prophylaxis had a 6% rate.⁴⁴

Dose and timing considerations.

The timing of intravenous antibiotic is important. Classen et al noted that the relative risk of wound infection is related to the time of antibiotic administration with the optimal time immediately before the surgical incision.⁴⁵ When antibiotics are given more than 2 hours before, the relative risk of infection is 6.7 times higher and when given after the incision is made, the relative risk is 2.4.

Because antibiotics ordered on call to the operating room may be administered incorrectly, the operative surgeon should ensure that intravenous antibiotics are given at the ideal time. This practice assures that the maximal antibiotic concentration is present in the tissue at the time of surgical incision. Common pitfalls when ordering intravenous antibiotics include not giving the appropriate dose and not re-dosing at the correct interval. The maximal dose of the antibiotic should be used. ^{46 and 47} The appropriate dose of cefoxitin and cefotetan for most adults is 2 gm. Antibiotics should be re-dosed intraoperatively at an interval equal to twice the half-life. ^{33, 46 and 47} Since the half-life of cefoxitin is approximately 1 hour, additional doses are required intraoperatively every 2 hours and because cefotetan has a half-life of 4 hours, additional doses of cefotetan need only be administered every 8 hours.⁴⁸ Another indication for additional antibiotic administration is blood loss exceeding 1 l.⁴⁶

The recent survey of Nichols et al of all board certified colorectal surgeons in the United States and Canada revealed that 87% use a combination of oral and intravenous antibiotic prophylaxis before elective surgery involving the colon or rectum.⁹ Centers for Disease Control (CDC) guidelines for preventing surgical site infections state that prophylaxis is indicated for all operations that involve entry into a hollow viscus.⁴⁹ The CDC guidelines further recommend using oral and intravenous antibiotics in surgery involving the lower intestinal tract and state that cefoxitin or cefotetan is preferable to cefazolin or cephalothin for surgery on the colon or rectum.⁴⁹ Oral antibiotics should not be given within 2 hours of sodium phosphate mechanical bowel preparation to ensure optimal absorption.

GUIDELINES FOR URINARY DIVERSION SURGERY

In the absence of substantial published data on antibiotic and mechanical bowel preparation for urinary diversion surgery, we believe that it is reasonable to extrapolate guidelines from the large existing body of data in the colorectal literature. Accordingly combining oral and intravenous antibiotics is advised for all urinary reconstructive surgery involving the gastrointestinal tract. Combining oral and intravenous antibiotics is also reasonable for nonreconstructive urological surgery if colorectal injury is likely during the procedure.

Regarding oral antibiotic selection the standard Nichols-Condon preparation is well supported in the literature, although oral neomycin and metronidazole are an attractive alternative regimen. Regarding intravenous antibiotic selection a second generation cephalosporin, such as cefoxitin or cefotetan, is most appropriate for reconstructive surgery involving the gastrointestinal tract due to better gram-negative and anaerobic bacterial coverage than with the commonly used first generation cephalosporin cefazolin. We use cefotetan because it has a longer serum half-life than cefoxitin, a property that simplifies dosing.

To our knowledge the benefit of continued prophylactic antibiotics during the postoperative period is unproved. A single preoperative dose may be as effective as 24 hours of perioperative coverage.⁵⁰ CDC guidelines state that prophylactic antibiotics should not continue for more than 24 hours.⁵⁰

CONCLUSIONS

Mechanical bowel preparation with oral sodium phosphate solution appears to be as effective as with PEG but better tolerated and more amenable to outpatient use. Administering oral antibiotics and a parenteral second generation cephalosporin represents effective prophylaxis for urinary diversion surgery incorporating bowel segments.

REFERENCES

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APPENDIX

BOWEL PREPARATION INSTRUCTIONS

Diet

Drink clear liquids all day. Clear liquids include water, tea, black coffee, soft drinks, noncitrus juices, beef or chicken broth, gelatin and electrolyte containing fluids, for example Gatorade.

It is important that you remain well hydrated. Drink plenty of clear liquids all day and night but take nothing by mouth (including water) after midnight. Morning medications can safely be taken with a sip of water.

You need calories. Beef or chicken broth and gelatin provide an excellent source of calories during your bowel preparation.

Do not drink dairy products or citrus juices.

Medication checklist

Drink the first 45 ml. container of sodium phosphate at 3:00 p.m. diluted equally into 3, 8 ounce glasses of a cold soft drink and drink them 20 minutes apart.

Drink 1, 8 ounce glass of water every hour until midnight. You are encouraged to drink plenty of additional clear liquids until midnight.

Take 1 gm. neomycin and 1 gm. metronidazole at 5:00 p.m.

Take your usual evening medications at 6:00 p.m.

Aspirin should have been stopped 7 days before surgery.

If you are taking other blood thinning medications, such as warfarin, follow surgeon instructions.

Drink the second 45 ml. container of sodium phosphate at 9:00 p.m. using the same method used for the first dose.

Continue drinking 1, 8 ounce glass of water every hour until midnight. You are still encouraged to drink plenty of additional clear liquids until midnight.

Take 1 gm. neomycin and 1 gm. metronidazole at 11:00 p.m.

^* Financial interest and/or other relationship with Ortho-McNeil, Pfizer and C. B. Fleet.