Postoperative pain and delayed intestinal transit occur frequently in patients who undergo extended pelvic lymph node dissection (PLND) and cystectomy for bladder cancer. Adhesions between the small intestine and the deperitonealized pelvic wall might be one cause of the gastrointestinal symptoms that are observed in up to 30% of patients undergoing this procedure.

A prospective, randomized study performed in Switzerland examined whether a surgical procedure modified to incorporate bilateral reperitonealization of the dorsolateral pelvic walls could reduce pain and expedite recovery of bowel function in the immediate postoperative period.

...reperitonealization ...[expedites] the postoperative recovery of patients...

200 consecutive patients were randomly assigned to surgery either with (group A; n = 100) or without (group B; n = 100) reperitonealization. Briefly, the procedure in group A patients involved the creation of peritoneal flaps during incision of the lateral peritoneal layer dorsomedially to the external iliac vessels. The flaps were then rotated over the iliac vessels down to the distal obturator fossa, fixed to the levator ani and sutured to the peritoneal rim along the rectum. In group B, the incision of the lateral peritoneal layer was made above the iliac vessels, without the creation of peritoneal flaps. Postoperative management for all patients included administration of parasympathomimetic drugs (to stimulate bowel function) and epidural analgesia given at modifiable doses depending on patients' pain scores.

Patients in group A experienced less pain than group B patients on postoperative days 1, 3 and 7 (P <0.05), and required less epidural analgesia on days 1 and 7 (P = 0.002). In terms of bowel function, fewer patients in group A reported nausea on day 7. Flatulence was noted in more group A patients than group B patients on day 3 (P = 0.016), and 95% of group A patients had passed stool by day 7 compared to 84% of patients in group B (P = 0.011).

The authors conclude that reperitonealization after extended PLND and cystectomy is a simple and inexpensive way of expediting the postoperative recovery of patients.