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Bowel Preparation — Drug-Class Hub

Bowel preparation before urinary diversion, augmentation cystoplasty, and pelvic reconstruction with bowel interposition has shifted away from routine mechanical cleansing. A 2020 review found that 24/25 radical-cystectomy ERAS protocols omitted oral bowel preparation, although seven still used retrograde preparation.[1] Small comparative cystectomy studies found no clear outcome advantage for routine MBP; a 180-patient cohort observed 30-day CDI in 11/105 (10.5%) with GoLYTELY versus 2/75 (2.7%) without preparation (p = 0.08).[4][5][6][7] Recent observational data raise the hypothesis that oral antibiotic bowel preparation (OABP) may help some continent diversions.[2][3]

This article is the drug-class pharmacology hub: PEG formulations, sodium phosphate and its boxed-warning renal liability, oral antibiotics and the Nichols protocol, and the diversion-type-dependent evidence. The clinical workflow decision table (which diversion gets which prep) lives at Postoperative constipation & ileus; use the two together.

For adjacent topics see Perioperative antibiotic prophylaxis, Post-op bowel & ileus management, and ERAS.

The Paradigm Shift — From Universal MBP to Selective Use​

The following cystectomy / ileal-diversion comparisons support omitting routine MBP, although small samples and differing regimens limit claims of equivalence or harm:

StudyDesignFinding
Shafii 2002 (n = 86; retrospective, ileal conduit)No prep (22) vs 4-day prep (64)No differences in wound infection, fistula, anastomotic dehiscence, or sepsis. Prolonged ileus lower without prep (1 vs 12 patients); LOS 22.8 vs 31.6 d[4]
Large 2012 (n = 180; 105 with MBP, 75 without)GoLYTELY 4 L vs no prepUTI, wound dehiscence and perioperative death were similar. Grade III-or-higher abdominal/GI complications occurred in 7/105 (6.7%) with MBP versus 11/75 (14.7%) without (p = 0.08); 30-day CDI occurred in 11/105 (10.5%) versus 2/75 (2.7%) (p = 0.08).[5]
Raynor 2013 (n = 70)Magnesium citrate + enema vs regular diet + enema (no oral cathartic)No differences in GI complications (22% vs 15%), bowel-function recovery, or LOS. Zero anastomotic leaks in either group[6]
Hashad 2012 (n = 40, RCT)3-day prep vs overnight fastingNo complication difference. No-prep group had less bacterial overgrowth (0 vs 5 patients with E. coli > 10⁵; p = 0.04) and less mucosal edema/submucosal congestion (2 vs 9 patients; p = 0.031) on ileal biopsies[7]
Aslan 2013 (118 randomized; 112 evaluable, multicenter RCT)Conventional 3-day prep (diet restriction, oral antibiotics, laxatives, enemas) vs limited prep (liquid diet, sodium phosphate laxative, self-administered enema the day before)No differences; favorable trends for bowel-function recovery, LOS and complications with limited prep. Both arms were prepared.[8]

Wessels 2020 ERAS meta confirmed 96% of included radical-cystectomy ERAS protocols avoided MBP.[1] Daneshmand's widely-cited ERAS protocol is explicit: no MBP.[14] The ERAS Society cystectomy guideline likewise found that bowel preparation did not improve outcomes.[40]

EAU 2026 makes a strong recommendation not to offer preoperative bowel preparation before radical cystectomy. Combined colorectal surgery requires a coordinated plan.[36] The AUA/ASCO/SUO guideline discussion states that clinicians may consider not routinely prescribing mechanical bowel preparation when only small bowel is used for urinary reconstruction.[41]

1. Polyethylene Glycol (PEG) Formulations​

When MBP is used, PEG-electrolyte solutions are generally preferred over sodium phosphate when a patient needs mechanical preparation, but formulations differ. They can still cause dehydration, electrolyte abnormalities, arrhythmias and renal injury; CKD, heart failure and interacting medicines require an individualized fluid / laboratory plan.[9][10]

Mechanism​

PEG-3350 is an inert, non-absorbed polymer of ethylene oxide formulated with balanced electrolytes in an isotonic solution. It passes through the bowel without net absorption or secretion, retaining water in the bowel to produce catharsis.[9] Balanced electrolyte formulations aim to limit net electrolyte shifts.[9]

Formulations​

ProductVolumeCompositionKey features
GoLYTELY (PEG-ELS)4 LPEG-3350 + balanced electrolytesAdult colon-cleansing label; pediatric safety / effectiveness are not established for this product[13]
MoviPrep (PEG + ascorbate)2 L preparation plus additional clear liquidsPEG, electrolytes and ascorbateAdult colonoscopy label; renal / electrolyte and G6PD precautions[12]
PLENVU1 L preparation plus required additional clear liquidsPEG, electrolytes and ascorbateAdult colonoscopy label; low preparation volume does not mean only 1 L total intake[34]
MiraLAX / sports drink (off-label preparation)Regimen variesPEG-3350 mixed with a sports drinkNot equivalent to balanced PEG-ELS; this bowel-prep combination is not FDA-approved. Do not substitute it automatically in patients at electrolyte risk[10]

Safety​

Correct dehydration and electrolyte abnormalities before use. For patients with phenylketonuria, account for MoviPrep's 131 mg or PLENVU's 491 mg of phenylalanine per treatment; both ascorbate-containing formulations require caution in G6PD deficiency.[12][34] Consider baseline / follow-up electrolytes and renal tests in vulnerable patients; assess aspiration risk and the ability to tolerate the prescribed fluid volume. Obstruction, perforation, gastric retention, ileus and toxic colitis / megacolon are contraindications in the cited GoLYTELY label. The standard adult regimen is 8 oz every 10 minutes until 4 L are consumed or the effluent is clear.[12][13][34] PEG preparations may cause mucosal ulcerations.[12][13][34]

Pediatric formulation distinction​

Do not transfer the ≥6-month indication to GoLYTELY. The cited NuLYTELY label, a different electrolyte formulation, includes children ≥6 months and a 25 mL/kg/hour regimen; its label warns about hypoglycemia in children under two and reported dehydration / hypokalemia.[11][13] Pediatric surgical preparation should use the exact product label and a pediatric protocol, not an adult product substitution.[11][13]

Practical role​

GoLYTELY 4 L and MoviPrep 2 L are PEG bowel-preparation regimens; if MBP is selected before urinary diversion, account for each product's additional clear-fluid and renal precautions.[12][13] For most ileal-conduit cases, MBP should simply be omitted.

2. Sodium Phosphate — Avoid in the Diversion Population​

Mechanism​

Hyperosmotic agent that draws water into the intestinal lumen. Low-volume cathartic effect. Produces significant fluid and electrolyte shifts: hyperphosphatemia in up to 40% of healthy patients completing a standard prep.[9]

The FDA boxed warning — acute phosphate nephropathy (APhN)​

FDA Boxed Warning — Acute Phosphate Nephropathy. Hypovolemia-induced avid proximal salt and water reabsorption delivers a massive phosphate load to the distal nephron, causing calcium phosphate precipitation in the distal tubule and collecting duct. Time to onset is typically days but diagnosis can be delayed months. Some cases cause permanent renal impairment requiring long-term dialysis. The tablet label (OsmoPrep pattern, 32 tablets with 2 quarts of clear liquid in two doses) lists as contraindications a history of acute phosphate nephropathy, GI obstruction, gastric bypass or stapling, bowel perforation, toxic colitis and toxic megacolon.[15][16]

Risk factors relevant to diversion candidates​

  • Older age, female sex, hypertension
  • Baseline CKD
  • Hypovolemia
  • Bowel transit abnormalities
  • Concurrent ACE inhibitors, ARBs, diuretics, or NSAIDs[15][16]

Özdemir 2025 clinicopathologic analysis: all 9 patients with biopsy-proven APhN developed CKD; one progressed to ESRD requiring dialysis.[17]

Regulatory status​

Oral sodium-phosphate colon-cleansing products carry an acute phosphate nephropathy warning. Consult the exact product label rather than assuming any oral or rectal phosphate product is interchangeable.[9][15]

Practical recommendation​

Sodium phosphate should be avoided before urinary diversion. Many diversion candidates have renal or volume-related risk factors for permanent injury. PEG is the default when MBP is deemed necessary.[15][16] Older urinary-diversion advice (Ferguson 2002) predates the phosphate-nephropathy warnings and favored sodium phosphate for tolerability; it also advised combined oral and parenteral antibiotics for GI-segment reconstruction.[18]

3. Oral Antibiotic Bowel Preparation (OABP)​

The evidence here is colorectal-dominated and diversion-type-dependent. The historical colorectal dogma is strong; its applicability to ileal-conduit versus continent-diversion differs.

The Nichols protocol — historical backbone​

The historical neomycin / erythromycin bowel-decontamination regimen remains described in product labeling: neomycin sulfate 1 g plus erythromycin base 1 g at 1 PM, 2 PM and 11 PM on the day before an 8 AM operation.[19][20]

Neomycin with metronidazole is another commonly used colorectal regimen, but studies differ in dose and timing: the MOBILE trial gave neomycin 2 g at 7 PM and metronidazole 2 g at 11 PM after 2 L of PEG, whereas ORALEV used oral ciprofloxacin 750 mg twice daily plus metronidazole 250 mg three times daily on the day before surgery without MBP.[37][38] Follow the institution’s colorectal / antimicrobial protocol when OABP is indicated; there is no single universally validated regimen for all GU reconstructions.[21]

Pharmacology of the oral antibiotics​

AgentClassCoverageKey safety
NeomycinAminoglycosideAerobic gram-negativeSystemic absorption can occur even with oral use. Boxed warnings include nephrotoxicity, irreversible ototoxicity and neuromuscular blockade with respiratory paralysis; risk rises with renal impairment and prolonged exposure. Anesthetics and neuromuscular blockers increase blockade risk. Intestinal obstruction and inflammatory / ulcerative GI disease are contraindications; the latter can increase absorption. Bowel prep is a brief course, not a two-week regimen.[19]
Erythromycin baseMacrolideAnaerobic + gram-positiveGI intolerance (nausea / vomiting), QT prolongation and idiosyncratic reactions; avoid in prolonged QT, uncorrected hypokalemia or hypomagnesemia, use of class IA/III antiarrhythmics, or coadministration with contraindicated drugs including simvastatin, lovastatin, pimozide and ergot alkaloids.[20]
MetronidazoleNitroimidazoleAnaerobicNeomycin–metronidazole is a studied colorectal OABP regimen. Nausea and GI upset can occur; coadministration with warfarin can prolong prothrombin time and requires INR monitoring.[21][44]

Colorectal evidence — strong​

SourceFinding
Güenaga 2011 Cochrane (18 RCTs, 5,805 participants)MBP vs no MBP: no significant difference in anastomotic leakage (4.4% vs 4.5%) or wound infection; cleansing can be omitted in colonic surgery, and rectal-surgery data are limited[39]
Willis 2023 Cochrane (21 RCTs / 5,264 participants overall; SSI comparison 16 / 3,917)Compared with MBP alone, adding oral antibiotics probably reduced SSI (RR 0.56; 95% CI 0.42–0.74; moderate certainty). Comparisons against oral antibiotics alone or no prep were much less certain[21]
Rollins 2019 meta (40 studies, n = 69,517; 28 RCTs, n = 6,437, plus 12 cohorts)MBP plus oral antibiotics versus MBP alone was associated with lower pooled SSI (RR 0.51), anastomotic leak (RR 0.62), 30-day mortality (RR 0.58) and ileus (RR 0.72); in RCT-only analyses, only SSI was significantly lower (RR 0.57). CDI did not differ significantly.[24]
MOBILE 2019 RCT (n = 396 analyzed)MBP + oral neomycin/metronidazole vs no prep in elective colectomy: SSI 7% vs 11%, not significant (p = 0.17); anastomotic dehiscence 4% in both[37]
MOBILE2 2024 RCT (n = 565 elective rectal-tumor resections with primary anastomosis)MBP plus oral neomycin/metronidazole versus MBP plus placebo: 30-day SSI 23/277 (8.3%) versus 48/288 (16.7%); median Comprehensive Complication Index 0 versus 8.66 (p < 0.001).[46]
ORALEV 2020 RCT (n = 536 analyzed)Oral antibiotics alone (no MBP) vs none, all with IV prophylaxis: SSI 5% vs 11% (OR 0.41; 95% CI 0.20–0.80)[38]
Vo 2018 JAMA Surg (retrospective, n = 89)In left-colon/rectal-cancer resections, adding oral antibiotics to MBP was associated with 30-day SSI in 3/40 (8%) versus 13/49 (27%) with MBP alone (p = 0.03).[27]
ASCRS/SAGES ERAS 2023Strong recommendation (1B) for MBP + oral antibiotics before elective colorectal resection[25]
ASCRS SSI Guidelines 2024Strong for oral antibiotics + MBP; conditional for oral antibiotics alone when MBP contraindicated[26]
WHO 2016Conditional (moderate-certainty) suggestion for oral antibiotics plus MBP in adult elective colorectal surgery; strong (moderate-certainty) recommendation against MBP alone to reduce SSI[23]

Urology-specific evidence — the nuance​

The ileo-ileal anastomosis of a conduit is not a colo-colonic anastomosis. The bacterial load, anastomotic-leak risk, and procedural time differ. Contemporary urology-specific data show a diversion-type-dependent signal:

StudyPopulationFinding
Simhal 2025 NSQIP (n = 2,054)Modern cystectomy cohort — 71% no bowel regimen, 21.3% MBP only, 5.3% both, 2.4% OABP onlyIleal conduit: OABP associated with ↑ LOS. Neobladder: bowel regimens not associated with worse outcomes and associated with ↓ LOS[2]
Simhal 2023 ASCO (n = 3,894 overall; 357 [9.2%] received OABP)Cystectomy cohort stratified by diversion typeContinent diversion: OABP associated with ↓ sepsis after adjustment and ↓ ureteral-fistula rate in univariate subgroup analysis. Ileal conduit: OABP associated with ↑ LOS on univariate analysis[3]

These are observational analyses, and the 2023 report is a conference abstract. A 2019–2022 retrospective NSQIP cystectomy analysis (n = 5,098; 6.5% received OABP) associated OABP with higher odds of 30-day postoperative ileus versus no OABP (adjusted OR 1.69; 95% CI 1.14–2.51; p = 0.009); diversion type was unavailable.[42]

OABP does not replace IV prophylaxis​

Oral antibiotic prep is an adjunct, not a substitute for procedure-appropriate IV prophylaxis. Agent selection should cover the expected flora and account for allergy, colonization, renal function and local susceptibility. Ertapenem does not provide MRSA coverage. Most prophylactic agents are administered within 60 minutes before incision; agents requiring longer infusions have different start windows. Use the companion hub for the exact regimen and timing.[22][23] See Perioperative antibiotic prophylaxis.

4. Clostridioides difficile in the Urinary-Diversion Population​

CDI after radical cystectomy is dramatically more common than after other urologic operations, and bowel prep choices interact with CDI risk:

Data pointDetail
Cystectomy CDI incidence2.72% vs 0.19% for other urologic procedures — 14× higher[28]
Risk factorsPreoperative renal failure (OR 5.30); blood loss requiring transfusion (OR 1.67)[28]
MBP and CDILarge 2012 — trend toward ↑ CDI with GoLYTELY MBP (10.5% vs 2.7%; p = 0.08)[5]
Preoperative C. diff screeningCalaway 2019 single-center prospective program compared 380 historical controls with 386 screening-era cystectomy patients, matched on five clinical factors. In the intent-to-screen analysis, CDI was 9.4% in controls versus 5.5% in the screening era (OR 0.52; p = 0.027). Screening, isolation and metronidazole were bundled.[29]
Colorectal OABP and CDIA propensity-matched colectomy analysis associated MBP plus oral antibiotics with lower CDI than no preparation (0.5% vs 1.8%; p = 0.01). A four-RCT meta-analysis estimated higher odds with oral antibiotics (OR 4.46; 95% CI 0.96–20.66; 11 events among 2,753 patients).[30] Another meta-analysis found no CDI-rate difference for MBP plus oral antibiotics versus MBP alone.[24]

Do not routinely screen or treat asymptomatic patients for C. difficile on this evidence. IDSA/SHEA recommends against testing asymptomatic patients outside epidemiologic studies and finds insufficient evidence for routine asymptomatic-carriage screening / isolation.[35] Symptomatic infection should follow current CDI diagnostic and treatment guidance, not prophylactic metronidazole for a positive screen.[35]

5. Bowel Preparation Before Augmentation Cystoplasty​

Limited pediatric augmentation evidence supports omitting routine MBP.

  • Gundeti 2006 (n = 46 peds). Sodium picosulfate plus phosphate enema MBP versus no prep before ileal cystoplasty: no significant differences in LOS (5 versus 4 d), UTI (3 versus 2), or wound infection (1 versus 1). Oral fluids began earlier without prep (24 versus 48 h), but NG-tube use also differed by protocol.[31]
  • Feng 2015 APSA survey of elective pediatric colorectal surgery (313 respondents). Among responding surgeons, 31.1% reported MBP alone, 26.8% diet modification only, 19.6% MBP plus oral antibiotics, and 12.2% no preparation or dietary modification. Respondents reported shifts toward diet modification or no preparation and away from MBP alone. The most common oral antibiotic regimen was neomycin plus erythromycin (55.9%).[32]
  • Laparoscopic augmentation. Lorenzo and colleagues' pediatric intracorporeal technique includes thorough preoperative MBP.[33]

Current Evidence-Based Recommendations​

Clinical scenarioApproachEvidence
Routine cystectomy / ileal conduitOmit routine bowel preparation; coordinate exceptionsEAU 2026 strong recommendation; older comparisons are small[36][1][4][5][6][7][8]
Continent diversionDo not adopt routine OABP solely from database associationsHypothesis-generating observational / abstract evidence[2][3]
Pediatric augmentation cystoplastyOmission is reasonable in a pediatric surgical protocolLimited consecutive-patient comparison; protocol-dependent use[31]
Laparoscopic / robotic cystoplastyIndividualize if the surgeon identifies a specific needExpert opinion; not routine evidence-based requirement[33]
Urethral / prolapse / incontinence surgery without planned bowel resectionRoutine MBP usually unnecessary; assess the actual planned operationA randomized trial of 150 women scheduled for vaginal apical suspension plus posterior colporrhaphy found excellent/good surgeon-rated field quality in 61/72 (85%) with clear liquids plus two enemas versus 66/73 (90%) with regular diet; complete satisfaction was lower with preparation (46/70 [66%] vs 67/71 [94%]).[43] A meta-analysis of 13 randomized studies (n = 1,715) in benign laparoscopic or vaginal gynecologic surgery found no improvement in surgical field view (RR 1.01; 95% CI 0.97–1.05) and lower satisfaction with MBP (RR 0.68; 95% CI 0.53–0.87).[47] The 2026 ERAS gynecologic oncology guideline strongly recommends omitting bowel preparation in benign gynecologic surgery without anticipated colorectal resection.[48]
Reconstruction with planned colonic resection / colonic conduitCoordinate a procedure-specific bowel plan with colorectal surgeryASCRS/SAGES 2023 strongly recommends MBP plus oral antibiotics before elective colorectal resection.[25] A Cochrane review and meta-analysis report fewer SSIs when oral antibiotics are added to MBP.[21][24] ERAS Society 2025 advises against routine MBP for colonic surgery, considers it for rectal surgery with a diverting stoma, and recommends oral antibiotics if MBP is used.[45]
Any diversion in patient with renal impairment or ACEi / ARB / NSAID useAvoid sodium phosphate; use PEG if MBP deemed necessaryStrong — FDA boxed warning[15][16]

Practical Pearls​

  • Separate mechanical preparation from oral and IV antibiotics. Evidence for omitting routine MBP does not justify omitting IV surgical prophylaxis.[22][36]
  • Use the actual operation to guide preparation. Routine cystectomy is different from a reconstruction requiring colorectal resection.[2][25][26]
  • PEG is not risk-free. Choose the exact formulation, prescribed additional clear fluids and monitoring plan; avoid sodium phosphate in patients at renal / electrolyte risk.[12][13][16][34]
  • Do not infer pediatric labeling from a brand family. NuLYTELY’s pediatric regimen cannot be assigned to GoLYTELY.[11][13]
  • Do not routinely treat asymptomatic C. difficile carriage.[29][35]

See Also​

References​

1. Wessels F, Lenhart M, Kowalewski KF, et al. "Early recovery after surgery for radical cystectomy: comprehensive assessment and meta-analysis of existing protocols." World J Urol. 2020;38(12):3139–3153. doi:10.1007/s00345-020-03133-y

2. Simhal RK, McPartland C, Wang KR, et al. "Bowel regimens before radical cystectomy: an analysis of a modern cohort." Int J Urol. 2025;32(4):402–408. doi:10.1111/iju.15668

3. Simhal R, Wang K, Poluch M, et al. "Preoperative oral antibiotic bowel preparation regimens in radical cystectomies with continent diversion." J Clin Oncol. 2023;41(Suppl 16):e16610. doi:10.1200/JCO.2023.41.16_suppl.e16610

4. Shafii M, Murphy DM, Donovan MG, Hickey DP. "Is mechanical bowel preparation necessary in patients undergoing cystectomy and urinary diversion?" BJU Int. 2002;89(9):879–881. doi:10.1046/j.1464-410x.2002.02780.x

5. Large MC, Kiriluk KJ, DeCastro GJ, et al. "The impact of mechanical bowel preparation on postoperative complications for patients undergoing cystectomy and urinary diversion." J Urol. 2012;188(5):1801–1805. doi:10.1016/j.juro.2012.07.039

6. Raynor MC, Lavien G, Nielsen M, Wallen EM, Pruthi RS. "Elimination of preoperative mechanical bowel preparation in patients undergoing cystectomy and urinary diversion." Urol Oncol. 2013;31(1):32–35. doi:10.1016/j.urolonc.2010.11.002

7. Hashad MM, Atta M, Elabbady A, et al. "Safety of no bowel preparation before ileal urinary diversion." BJU Int. 2012;110(11 Pt C):E1109–E1113. doi:10.1111/j.1464-410X.2012.11415.x

8. Aslan G, Baltaci S, Akdogan B, et al. "A prospective randomized multicenter study of Turkish Society of Urooncology comparing two different mechanical bowel preparation methods for radical cystectomy." Urol Oncol. 2013;31(5):664–670. doi:10.1016/j.urolonc.2011.03.009

9. Saltzman JR, Cash BD, Pasha SF, et al. "Bowel preparation before colonoscopy." Gastrointest Endosc. 2015;81(4):781–794. doi:10.1016/j.gie.2014.09.048

10. Jacobson BC, Anderson JC, Burke CA, et al. "Optimizing bowel preparation quality for colonoscopy: consensus recommendations by the US Multi-Society Task Force on Colorectal Cancer." Gastroenterology. 2025;168(4):798–829. doi:10.1053/j.gastro.2025.02.002

11. NuLYTELY: product labeling; pediatric formulation-specific dosing and precautions. Label. Accessed September 12, 2026.

12. MoviPrep: US prescribing information, October 31, 2025. Label. Accessed September 12, 2026.

13. GoLYTELY: US prescribing information. Label. Accessed September 12, 2026.

14. Daneshmand S, Ahmadi H, Schuckman AK, et al. "Enhanced recovery protocol after radical cystectomy for bladder cancer." J Urol. 2014;192(1):50–55. doi:10.1016/j.juro.2014.01.097

15. Markowitz GS, Perazella MA. "Acute phosphate nephropathy." Kidney Int. 2009;76(10):1027–1034. doi:10.1038/ki.2009.308

16. Monobasic sodium phosphate / dibasic sodium phosphate: US prescribing information; acute phosphate nephropathy boxed warning. Label. Accessed September 12, 2026.

17. Özdemir E, Özdemir P, Yadigar S, et al. "An overlooked etiology of acute kidney injury: a clinicopathological analysis of phosphate nephropathy and review of the literature." J Clin Med. 2025;14(12):4081. doi:10.3390/jcm14124081

18. Ferguson KH, McNeil JJ, Morey AF. "Mechanical and antibiotic bowel preparation for urinary diversion surgery." J Urol. 2002;167(6):2352–2356. doi:10.1016/s0022-5347(05)64983-x. PMID 11992036

19. Neomycin sulfate tablets: US prescribing information. Label. Accessed September 12, 2026.

20. ERY-TAB erythromycin delayed-release tablets: US prescribing information. Label. Accessed September 12, 2026.

21. Willis MA, Toews I, Soltau SL, et al. "Preoperative combined mechanical and oral antibiotic bowel preparation for preventing complications in elective colorectal surgery." Cochrane Database Syst Rev. 2023;2:CD014909. doi:10.1002/14651858.CD014909.pub2

22. Bratzler DW, Dellinger EP, Olsen KM, et al. "Clinical practice guidelines for antimicrobial prophylaxis in surgery." Am J Health Syst Pharm. 2013;70(3):195–283. doi:10.2146/ajhp120568

23. Allegranzi B, Bischoff P, de Jonge S, et al. "New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective." Lancet Infect Dis. 2016;16(12):e276–e287. doi:10.1016/S1473-3099(16)30398-X

24. Rollins KE, Javanmard-Emamghissi H, Acheson AG, Lobo DN. "The role of oral antibiotic preparation in elective colorectal surgery: a meta-analysis." Ann Surg. 2019;270(1):43–58. doi:10.1097/SLA.0000000000003145

25. Irani JL, Hedrick TL, Miller TE, et al. "Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons." Surg Endosc. 2023;37(1):5–30. doi:10.1007/s00464-022-09758-x

26. Shogan BD, Vogel JD, Davis BR, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for preventing surgical site infection." Dis Colon Rectum. 2024;67(11):1368–1382. doi:10.1097/DCR.0000000000003450

27. Vo E, Massarweh NN, Chai CY, et al. "Association of the addition of oral antibiotics to mechanical bowel preparation for left colon and rectal cancer resections with reduction of surgical site infections." JAMA Surg. 2018;153(2):114–121. doi:10.1001/jamasurg.2017.3827

28. Nguyen KA, Le DQ, Bui YT, et al. "Incidence, risk factors, and outcome of Clostridioides difficile infection following urological surgeries." World J Urol. 2021;39(8):2995–3003. doi:10.1007/s00345-020-03551-y

29. Calaway AC, Jacob JM, Tong Y, et al. "A prospective program to reduce the clinical incidence of Clostridium difficile colitis infection after cystectomy." J Urol. 2019;201(2):342–349. doi:10.1016/j.juro.2018.09.030

30. Poylin V, Hawkins AT, Bhama AR, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of Clostridioides difficile infection." Dis Colon Rectum. 2021;64(6):650–668. doi:10.1097/DCR.0000000000002047

31. Gundeti MS, Godbole PP, Wilcox DT. "Is bowel preparation required before cystoplasty in children?" J Urol. 2006;176(4 Pt 1):1574–1576. doi:10.1016/j.juro.2006.06.034

32. Feng C, Sidhwa F, Anandalwar S, et al. "Contemporary practice among pediatric surgeons in the use of bowel preparation for elective colorectal surgery: a survey of the American Pediatric Surgical Association." J Pediatr Surg. 2015;50(10):1636–1640. doi:10.1016/j.jpedsurg.2015.04.005

33. Lorenzo AJ, Cerveira J, Farhat WA. "Pediatric laparoscopic ileal cystoplasty: complete intracorporeal surgical technique." Urology. 2007;69(5):977–981. doi:10.1016/j.urology.2007.02.029

34. PLENVU: US prescribing information. Primary source. Accessed September 12, 2026.

35. IDSA/SHEA. CDI guideline 2017 update: asymptomatic testing / screening recommendations IX and XXIV. Primary source. Accessed September 12, 2026.

36. EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer 2026: perioperative preparation. Primary source. Accessed September 12, 2026.

37. Koskenvuo L, Lehtonen T, Koskensalo S, et al. "Mechanical and oral antibiotic bowel preparation versus no bowel preparation for elective colectomy (MOBILE): a multicentre, randomised, parallel, single-blinded trial." Lancet. 2019;394(10201):840–848. doi:10.1016/S0140-6736(19)31269-3

38. Espin Basany E, Solís-Peña A, Pellino G, et al. "Preoperative oral antibiotics and surgical-site infections in colon surgery (ORALEV): a multicentre, single-blind, pragmatic, randomised controlled trial." Lancet Gastroenterol Hepatol. 2020;5(8):729–738. doi:10.1016/S2468-1253(20)30075-3

39. Güenaga KF, Matos D, Wille-Jørgensen P. "Mechanical bowel preparation for elective colorectal surgery." Cochrane Database Syst Rev. 2011;2011(9):CD001544. doi:10.1002/14651858.CD001544.pub4

40. Cerantola Y, Valerio M, Persson B, et al. "Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS) society recommendations." Clin Nutr. 2013;32(6):879–887. doi:10.1016/j.clnu.2013.09.014

41. Holzbeierlein J, Bixler BR, Buckley DI, et al. Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/SUO Guideline (2017; Amended 2020, 2024). J Urol. 2024;212(1):3-10. doi:10.1097/JU.0000000000003981

42. Manivasagam SS, Clark JY, Raman JD. "Unintended consequences of antibiotic practices: the relationship between bowel preparation, prolonged prophylaxis, and ileus after radical cystectomy." Can J Urol. 2026;33(4):865–871. doi:10.32604/cju.2026.078196

43. Ballard AC, Parker-Autry CY, Markland AD, Varner RE, Huisingh C, Richter HE. "Bowel preparation before vaginal prolapse surgery: a randomized controlled trial." Obstet Gynecol. 2014;123(2 Pt 1):232–238. doi:10.1097/AOG.0000000000000081

44. RemedyRepack Inc. Metronidazole tablets, USP (250 mg and 500 mg): US prescribing information. Updated July 7, 2026. DailyMed label.

45. Gustafsson UO, Rockall TA, Wexner S, et al. "Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations 2025." Surgery. 2025;184:109397. doi:10.1016/j.surg.2025.109397

46. Koskenvuo L, Lunkka P, Varpe P, et al. "Morbidity After Mechanical Bowel Preparation and Oral Antibiotics Prior to Rectal Resection: The MOBILE2 Randomized Clinical Trial." JAMA Surg. 2024;159(6):606–614. doi:10.1001/jamasurg.2024.0184

47. Cardaillac C, Genest R, Gauthier C, et al. "Preoperative Mechanical Bowel Preparation for Gynecologic Surgeries: A Systematic Review with Meta-analysis." J Minim Invasive Gynecol. 2023;30(9):695–704. doi:10.1016/j.jmig.2023.05.001

48. Nelson G, Altman AD, Metcalfe A, et al. "Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: 2026 update." Gynecol Oncol. 2026;210:153–173. doi:10.1016/j.ygyno.2026.05.022