Introduction:

Alvimopan is a partial mu-opioid receptor antagonist used to expedite gastrointestinal (GI) recovery following partial bowel resection with primary anastomosis (e.g., small and large bowel resection, including radical cystectomy with ileal conduit) introduced in 2008. Here, we use large-scale national data to characterize alvimopan utilization and surgical outcomes among patients undergoing radical cystectomy for bladder cancer.

Methods:

The Premier Healthcare Database, a large, U.S., hospital-based, all-payer database, was queried for patients undergoing radical cystectomy for a diagnosis of bladder cancer from 2015-2020. Use of alvimopan and anti-emetic medications were determined by charge codes. Logistic regression was used to assess the relationship between alvimopan use and gastrointestinal outcomes, which included anti-emetic medication use, diagnosis of ileus or small bowel obstruction.

Results:

Among 9,181 patients undergoing RC, 39.3% received alvimopan, with a median of 5 doses (IQR 3 to 6 doses). Given that alvimopan is stopped once bowel function returns, this suggests a median return of bowel function at 3 days post-operatively. The alvimopan group had statistically shorter length of stay at 6 days, IQR 5 to 7 days, as compared to 7 days, IQR 5.0 to 10 days, in those not receiving alvimpopan, p<0.001. Patients receiving alvimopan required less anti-emetic medication (mean (SD) of 4.4 doses (5.5) vs 4.6 doses (6.1), p<0.01). Alvimopan was associated with fewer GI complications, multivariable odds ratio for patients not receiving alvimopan as compared to those receiving alvimopan, 1.31 (95% CI 1.17 to 1.48, p<0.001). This included lower odds of being diagnosed with a bowel obstruction/ileus, 21% vs 29%, p<0.001, peritonitis, 1.6% vs 2.3%, p=0.04, and bowel perforation or anastomotic leak, 4.5% vs 6%, p<0.01.

Conclusion:

This study provides a national view of alvimopan use following radical cystectomy, finding that only 39.3% of patients received the medication despite widespread evidence supporting its use. We highlight the median time to alvimopan discontinuation (five doses), suggesting return of bowel function at ~3 days after cystectomy in these patients. Further, we associate alvimopan use with decreased length of stay, lower anti-emetic medication requirement, and less GI morbidity. Despite alvimopan’s cost, these data highlight patient-centered improvement in peri-cystectomy care with alvimopan use.

Funding: N/A