Robotic-Assisted Radical Cystectomy: Key Risk Factors for Postoperative Intestinal Obstruction Identified and Nursing Interventions Proposed

Robotic-assisted surgery has emerged as a transformative approach in the field of urology, particularly for the treatment of muscle-invasive and high-risk superficial bladder cancer, with radical total cystectomy being the gold standard therapeutic option. However, postoperative complications remain a significant clinical challenge, among which intestinal obstruction stands out as a common issue that can prolong hospital stays, increase medical costs, and hinder the overall recovery process of patients. As the application of robotic-assisted radical cystectomy continues to expand in clinical practice, understanding the risk factors for postoperative intestinal obstruction and formulating targeted nursing interventions have become critical for improving surgical outcomes and patient prognosis. A retrospective clinical study conducted by a research team from the Department of Urology Surgery at the First Affiliated Hospital of Nanjing Medical University has shed light on the core risk factors for intestinal obstruction following robotic-assisted radical cystectomy and put forward evidence-based nursing strategies to mitigate this complication, providing valuable clinical guidance for urological practitioners worldwide.

The study focused on analyzing the clinical data of patients who underwent robotic-assisted radical cystectomy, a procedure that leverages robotic technology’s precision, flexibility, and minimally invasive advantages to optimize surgical outcomes, yet still carries the risk of postoperative intestinal obstruction due to the complexity of pelvic surgery and the physiological changes it induces in the abdominal cavity. Pelvic surgery, such as radical cystectomy, often involves extensive tissue dissection, lymph node dissection, and urinary diversion reconstruction, which can lead to pelvic effusion, intestinal adhesion, and impaired gastrointestinal motility—all of which are potential triggers for intestinal obstruction. Despite the widespread use of robotic-assisted techniques, there has been a lack of in-depth, targeted research on the specific risk factors for postoperative intestinal obstruction in this patient population, making it difficult for clinical teams to implement proactive and personalized nursing care. Addressing this gap, the research team designed a comprehensive retrospective analysis to identify the key factors contributing to intestinal obstruction after robotic-assisted radical cystectomy and establish corresponding nursing intervention measures based on their findings.

For the research, the team retrospectively collected and analyzed the clinical data of 102 patients who received robotic-assisted radical cystectomy at the First Affiliated Hospital of Nanjing Medical University between May 2018 and May 2020. The inclusion criteria for the study were patients who had undergone robotic-assisted radical cystectomy and had a pathological confirmation of bladder cancer, while patients with mental illnesses, cognitive impairments, or intestinal obstruction caused by other underlying diseases were excluded. To ensure the scientific rigor of the research, the patients were divided into two groups based on the occurrence of postoperative intestinal obstruction: the intestinal obstruction group, consisting of 18 patients, and the non-intestinal obstruction group, with 84 patients. This grouping method allowed the team to conduct a comparative analysis of various clinical indicators between the two groups, laying the foundation for identifying risk factors.

The research team conducted a thorough univariate analysis of a wide range of clinical variables, covering preoperative general information, intraoperative surgical parameters, and postoperative recovery indicators. Preoperative indicators included age, gender, body mass index (BMI), smoking history, drinking history, past history of hypertension, diabetes, abdominal surgery, preoperative chemotherapy history, and preoperative serum albumin levels. Intraoperative indicators encompassed surgical method (ureterostomy, ileal conduit neobladder, orthotopic ileal neobladder), operation time, intraoperative blood transfusion, and intraoperative blood loss. Postoperative indicators included 24-hour pelvic drainage volume, postoperative TNM staging, average daily activity, first ambulation time, and pelvic drainage tube retention time. The univariate analysis aimed to screen out indicators with statistically significant differences between the two groups, which would then be included in further multivariate regression analysis to determine independent risk factors.

The results of the univariate analysis revealed no statistically significant differences in all preoperative general information indicators between the intestinal obstruction group and the non-intestinal obstruction group (P>0.05). This finding indicated that factors such as age, gender, BMI, and chronic disease history did not have a significant impact on the occurrence of postoperative intestinal obstruction in patients undergoing robotic-assisted radical cystectomy, which was a notable conclusion that helped clinical teams rule out these common preoperative factors as key contributors. In terms of intraoperative parameters, there were also no significant differences in surgical method, operation time, intraoperative blood transfusion, intraoperative blood loss, and postoperative TNM staging between the two groups (P>0.05), suggesting that the complexity of the surgical procedure itself and the extent of tumor staging did not directly lead to an increased risk of intestinal obstruction in this patient cohort.

However, the univariate analysis identified three postoperative indicators with statistically significant differences between the two groups (P<0.05): the 24-hour pelvic drainage volume after surgery, the average daily activity of patients after surgery, and the retention time of the pelvic drainage tube. Specifically, the 24-hour pelvic drainage volume and average daily activity in the intestinal obstruction group were significantly lower than those in the non-intestinal obstruction group, while the retention time of the pelvic drainage tube in the intestinal obstruction group was significantly longer than that in the non-intestinal obstruction group. These results initially indicated that insufficient pelvic drainage, reduced postoperative physical activity, and prolonged indwelling of the pelvic drainage tube were closely associated with the occurrence of postoperative intestinal obstruction, marking them as potential influencing factors that required further validation through multivariate analysis.

To identify the independent risk factors for postoperative intestinal obstruction, the research team included the three statistically significant indicators from the univariate analysis into a binary logistic regression model, with the occurrence of postoperative intestinal obstruction as the dependent variable (0 for no intestinal obstruction, 1 for intestinal obstruction). The results of the multivariate regression analysis further refined the research findings, confirming that two of the three indicators were independent risk factors for intestinal obstruction after robotic-assisted radical cystectomy: low 24-hour pelvic drainage volume after surgery (OR=0.978, 95% CI: 0.957~0.999, P=0.039) and low average daily activity after surgery (OR=0.822, 95% CI: 0.707~0.955, P=0.011). Although the retention time of the pelvic drainage tube was a significant influencing factor in the univariate analysis, it was not identified as an independent risk factor in the multivariate analysis (P=0.319). This result suggested that prolonged indwelling of the drainage tube may be a secondary factor associated with insufficient drainage and reduced activity, rather than an independent cause of intestinal obstruction.

The research team provided a clear clinical explanation for the identified independent risk factors. A low 24-hour pelvic drainage volume after surgery indicates inadequate pelvic drainage, which can lead to the accumulation of pelvic effusion. The accumulated effusion can cause inflammatory reactions in the pelvic cavity, leading to intestinal adhesion—a major pathological mechanism of postoperative intestinal obstruction. Pelvic effusion not only irritates the intestinal serosa and induces adhesion but also affects the normal peristalsis of the intestines, further increasing the risk of obstruction. In addition, low average daily activity after surgery impairs the recovery of gastrointestinal motility. Postoperative immobilization or reduced physical activity slows down intestinal peristalsis, leading to intestinal stasis, which in turn increases the likelihood of intestinal adhesion and obstruction. For patients undergoing robotic-assisted radical cystectomy, the pelvic cavity is in a state of tissue repair after surgery, and adequate physical activity can promote blood circulation in the abdominal and pelvic cavities, reduce inflammatory exudation, and accelerate the recovery of intestinal function, while inactivity exacerbates the risk of intestinal obstruction.

Based on the identified risk factors and their clinical mechanisms, the research team proposed a set of targeted and practical nursing intervention strategies, which are divided into two core aspects: enhancing the effectiveness of pelvic drainage and formulating personalized activity plans for patients. These interventions are designed to address the root causes of postoperative intestinal obstruction and are in line with the concept of enhanced recovery after surgery (ERAS), which has been widely recognized and applied in clinical practice in recent years, focusing on accelerating postoperative recovery and reducing complications through evidence-based perioperative care.

The first core nursing intervention is to strengthen the effectiveness of pelvic drainage, aiming to solve the problem of insufficient drainage that leads to pelvic effusion and intestinal adhesion. The research team emphasized that nursing staff should take a series of proactive measures to ensure unobstructed pelvic drainage starting from the moment the patient regains consciousness after anesthesia. First, the head of the bed should be elevated by 30 to 45 degrees to create a favorable body position for pelvic drainage, utilizing the principle of gravity to promote the discharge of pelvic effusion. Second, nursing staff should guide patients to perform ankle pump exercises and turn over left and right every 2 hours while in bed. These passive and active movements can change the patient’s body position, prevent the accumulation of effusion in a single part of the pelvic cavity, and promote comprehensive drainage. Third, the pelvic drainage tube must be properly fixed to avoid displacement, kinking, or compression, which are common causes of drainage tube blockage. Nursing staff should also regularly squeeze the drainage tube to keep it unobstructed, as the compression and squeezing can prevent the blockage of the tube lumen by blood clots, tissue debris, or exudate, ensuring continuous and effective drainage. In clinical practice, these drainage care measures need to be implemented rigorously and continuously, with nursing staff closely monitoring the drainage volume, color, and nature of the drainage fluid to timely detect and address any drainage abnormalities.

The second core nursing intervention is to formulate personalized activity plans for patients, which is targeted at improving the low average daily activity that is an independent risk factor for intestinal obstruction. This part of the intervention is divided into three key components: postoperative pain management, promoting early ambulation, and postoperative nutritional management, all of which are interconnected and jointly contribute to improving patients’ postoperative activity levels and promoting intestinal function recovery.

Postoperative pain management is the foundation for early ambulation, as severe postoperative pain is a major barrier that prevents patients from getting out of bed and moving. The research team proposed a comprehensive pain management strategy that combines pharmacological and non-pharmacological interventions. Nursing staff should administer preemptive analgesic drugs as prescribed by the doctor immediately after the patient returns to the ward after surgery, which can reduce the intensity of postoperative pain and prevent the development of chronic pain. In addition, pain assessment should be conducted dynamically three times a day, and if the pain score is ≥4 points on the numerical rating scale (NRS), the assessment frequency should be increased to once every 4 hours, with corresponding pain nursing measures implemented as prescribed. Non-pharmacological pain relief methods, such as acupressure and acupuncture in collaboration with the traditional Chinese medicine (TCM) department, are also recommended. These TCM interventions have the advantages of being non-invasive and having few side effects, and can effectively alleviate mild to moderate postoperative pain, complementing pharmacological analgesia and further improving the pain relief effect. Effective pain management can significantly reduce patients’ pain perception, increase their willingness to move, and lay the physical foundation for early ambulation.

Promoting early ambulation is the core of improving postoperative activity levels, and the research team proposed the “four-step ambulation principle” to guide clinical nursing practice, ensuring the safety and gradual progress of patients’ ambulation. The four steps are as follows: first, elevate the head of the bed to 60 degrees and have the patient sit quietly for 15 minutes to adapt to the upright position and prevent orthostatic hypotension; second, assist the patient to get out of bed and sit by the bed for 5 minutes to further adapt to the body position change; third, assist the patient to stand by the bed for 3 minutes to test their physical strength and balance; finally, guide the patient to walk in the corridor. This step-by-step approach reduces the risk of falls and dizziness caused by sudden ambulation, making it suitable for elderly patients and patients with poor physical status after major surgery. In addition, in accordance with the ERAS concept, the activity volume should be increased incrementally every day, with quantified activity goals set for each patient. Nursing staff should encourage patients to achieve the maximum daily activity volume through multiple short periods of activity, rather than a single long period of activity, which is more in line with the postoperative physical recovery process of patients and can improve their compliance with activity.

Postoperative nutritional management is an important guarantee for improving patients’ physical strength and activity capacity, and the research team recommended using the Nutritional Risk Screening 2002 (NRS-2002) scale to dynamically assess the nutritional status of patients. Prolonged indwelling of the drainage tube can cause inflammatory reactions in the pelvic tissue, increasing the risk of adhesion, and at the same time, the stress response after surgery and the impact of the drainage tube on the body can lead to nutritional deficiencies in patients. Nutritional deficiencies will reduce patients’ physical strength and tolerance to activity, forming a vicious circle of “malnutrition – reduced activity – increased risk of intestinal obstruction”. Nursing staff should dynamically assess patients’ nutritional status using the NRS-2002 scale, and implement corresponding nutritional support plans according to the screening results. For patients with nutritional risks, enteral or parenteral nutrition support should be provided in a timely manner to supplement protein, energy, and various nutrients, improve patients’ nutritional status, enhance their physical strength, and enable them to better participate in postoperative activities. At the same time, nutritional management can also promote tissue repair in the pelvic cavity, reduce inflammatory exudation, and indirectly reduce the risk of intestinal adhesion and obstruction.

The research findings and nursing interventions proposed by the team have important clinical implications and practical value for the field of urological robotic surgery. First, the identification of low 24-hour pelvic drainage volume and low average daily activity as independent risk factors for postoperative intestinal obstruction provides a clear direction for clinical teams to conduct risk stratification of patients after robotic-assisted radical cystectomy. For patients at high risk of insufficient drainage or reduced activity, proactive preventive measures can be implemented to reduce the incidence of intestinal obstruction. Second, the targeted nursing intervention strategies, including enhanced drainage care and personalized activity plans, are highly operable and can be directly applied in clinical nursing practice, helping nursing staff standardize care processes and improve the quality of postoperative care. Third, the research is consistent with the global development trend of ERAS in surgical care, emphasizing the importance of early intervention, personalized care, and multidisciplinary collaboration (such as collaboration with the TCM department for pain management), which enriches the content of ERAS in urological robotic surgery and provides a reference for the formulation of ERAS protocols for other major abdominal and pelvic surgeries.

In addition, the research team also pointed out the limitations of the study and the direction for future research. The study is a single-center retrospective analysis with a relatively small sample size of 102 patients, and the conclusions need to be further verified by multi-center, large-sample prospective cohort studies. In addition, the study only focused on the clinical indicators of patients, and did not explore the molecular biological mechanisms underlying the occurrence of intestinal obstruction after robotic-assisted radical cystectomy, such as the changes in inflammatory factors and intestinal motility-related hormones in the pelvic cavity, which can be the focus of in-depth research in the future. Furthermore, the long-term effect of the proposed nursing intervention strategies still needs to be evaluated through follow-up studies, to confirm whether these interventions can not only reduce the short-term incidence of postoperative intestinal obstruction but also improve the long-term recovery and quality of life of patients.

The application of robotic-assisted technology in urological surgery is constantly evolving, and with the continuous improvement of surgical techniques and the deepening of clinical research, the prevention and management of postoperative complications will become more precise and personalized. This study by the Nanjing Medical University team not only fills the research gap in the risk factors of intestinal obstruction after robotic-assisted radical cystectomy but also provides evidence-based nursing solutions, which is a valuable contribution to the development of urological robotic surgery and postoperative care. As clinical research continues to advance, it is expected that more optimized surgical and nursing protocols will be developed to further reduce the incidence of postoperative complications, improve surgical outcomes, and bring better treatment experiences and prognosis for patients with bladder cancer undergoing robotic-assisted radical cystectomy.

In the field of global urological oncology, the treatment of bladder cancer is moving towards the direction of minimally invasive, precise, and personalized care, and robotic-assisted radical cystectomy has become an important part of this development trend. The identification of risk factors for postoperative intestinal obstruction and the formulation of targeted nursing interventions are key links in improving the overall quality of robotic-assisted surgery, and are also an important embodiment of the concept of “patient-centered” clinical care. It is believed that with the popularization of these research findings and clinical interventions, the incidence of intestinal obstruction after robotic-assisted radical cystectomy will be significantly reduced, and the postoperative recovery process of patients will be further accelerated, bringing new hope to the clinical treatment of bladder cancer.

Authors: YUAN Yuan, CHEN Qingli, YANG Xiao Affiliation: Department of Urology Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, 210029, China Journal: Journal of Clinical Medicine in Practice DOI: 10.7619/jcmp.20201857

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