Introduction: Opioid-receptor antagonists reduce the occurrence of postoperative ileus and shorten length of stay following radical cystectomy (RC), and are a standard component of enhanced recovery after surgery (ERAS) pathways. Although most prior data have studied the use of alvimopan for this indication, naloxegol is a less expensive alternative within the same medication class. We compared differences in postoperative outcomes between patients receiving alvimopan and naloxegol following RC.
Methods: We retrospectively reviewed all patients undergoing RC (open and robotic) and urinary diversion for bladder cancer at an urban, academic cancer center during which the standard practice transitioned from alvimopan to naloxegol without any other changes to our ERAS pathway (November 2019 through July 2021). We utilized bivariate comparisons as well as negative binomial and logistic regression to compare return of bowel function, rates of ileus, and length of stay (LOS) following RC.
Results: There were 86 patients eligible for inclusion, of whom 52 (60.5%) received alvimopan and 34 (39.5%) received naloxegol. There were no significant differences in baseline clinical or demographic characteristics, nor in perioperative factors (Table). Median postoperative LOS was six days with no significant differences between medication groups. There were also no significant differences between alvimopan and naloxegol in time to return of bowel function (3 versus 2 days to flatus, respectively, p =0.09) or rates of postoperative ileus (13 versus 24 percent, respectively, p =0.26). In multivariable models controlling for patient and surgical factors, choice of medication was not a significant predictor of LOS or ileus. Mean cost difference between alvimopan and naloxegol was -$328.22 per day in favor of naloxegol, equivalent to a reduction of $1,969.32 over a six-day hospital stay.
Conclusions: In patients undergoing RC, there were no significant differences in postoperative recovery based on the use of alvimopan versus naloxegol. Substitution of naloxegol for alvimopan may allow for significant cost savings without compromising outcomes.
Source of Funding: This work was supported by intramural funding through the University of Washington Urology Department.
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