Systematic review: The role of bicarbonate therapy after urinary diversion

Radical cystectomy (RC) with urinary diversion remains the standard of care for muscle invasive bladder cancer. While metabolic acidosis (MA) after RC is common, the relationship between MA, post-operative complications, and the impact of bicarbonate supplementation remains unclear.

To review the role of bicarbonate therapy for MA following RC.

We performed a comprehensive systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines analyzing MA after RC. We included randomized controlled trials and cohort studies that reported metabolic acidosis complications and studies that utilized bicarbonate therapy peri-operatively. Our primary outcome was metabolic acidosis or role of metabolic acidosis as it relates to bicarbonate therapy or post-operative complications.

Twenty-nine studies were identified to investigate MA in the setting of postoperative complication rates or the role of bicarbonate treatment in peri-operative pathways. 19 studies evaluated the incidence of MA without intervention, 5 studies supplemented bicarbonate therapy for patients meeting specific criteria, and 5 studies utilized a standardized postoperative bicarbonate therapy regimen. The incidence of post-operative metabolic acidosis ranged from 1-86% after continent urinary diversion and 1-27% after ileal conduit urinary diversion. Post-operative renal function, diabetes, and older age were factors associated with metabolic acidosis. There was lack of uniformity, indications, or consistent outcomes for utilizing postoperative bicarbonate therapy.

There is little uniformity regarding the role of supplemental bicarbonate therapy and its impact on post-operative complications following urinary diversion. Future studies are needed to better evaluate the role MA plays in peri-operative RC pathways.