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Olson J, Mo KC, Schmerler J, Harris AB, Lee JS, Skolasky RL, Kebaish KM, Neuman BJ. AM-PAC Mobility Score <13 Predicts Development of Ileus Following Adult Spinal Deformity Surgery. Clin Spine Surg 2024:01933606-990000000-00279. [PMID: 38490976 DOI: 10.1097/bsd.0000000000001599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 01/22/2024] [Indexed: 03/18/2024]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE To determine whether the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score is associated with the development of postoperative ileus. SUMMARY OF BACKGROUND DATA Adult spinal deformity (ASD) surgery has a high complication rate. One common complication is postoperative ileus, and poor postoperative mobility has been implicated as a modifiable risk factor for this condition. METHODS Eighty-five ASD surgeries in which ≥5 levels were fused were identified in a single institution database. A physical therapist/physiatrist collected patients' daily postoperative AM-PAC scores, for which we assessed first, last, and daily changes. We used multivariable linear regression to determine the marginal effect of ileus on continuous AM-PAC scores; threshold linear regression with Bayesian information criterion to identify a threshold AM-PAC score associated with ileus; and multivariable logistic regression to determine the utility of the score thresholds when controlling for confounding variables. RESULTS Ten of 85 patients (12%) developed ileus. The mean day of developing ileus was postoperative day 3.3±2.35. The mean first and last AM-PAC scores were 16 and 18, respectively. On bivariate analysis, the mean first AM-PAC score was lower in patients with ileus than in those without (13 vs. 16; P<0.01). Ileus was associated with a first AM-PAC score of 3 points lower (Coef. -2.96; P<0.01) than that of patients without ileus. Patients with an AM-PAC score<13 had 8 times greater odds of developing ileus (P=0.023). Neither the last AM-PAC score nor the daily change in AM-PAC score was associated with ileus. CONCLUSIONS In our institutional cohort, a first AM-PAC score of <13, corresponding to an inability to walk or stand for more than 1 minute, was associated with the development of ileus. Early identification of patients who cannot walk or stand after surgery can help determine which patients would benefit from prophylactic management. LEVEL OF EVIDENCE Level-III.
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Affiliation(s)
- Jarod Olson
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
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Ding W, Ji R, Abdelrahim MEA, Wang L. Enhanced pharmaceutical recovery as postoperative standard care after radical cystectomy: A meta-analysis. Actas Urol Esp 2022; 46:447-455. [PMID: 36109315 DOI: 10.1016/j.acuroe.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/11/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION We performed a meta-analysis to evaluate the effect of enhanced pharmaceutical recovery as postoperative standard care after radical cystectomy. METHODS A systematic literature search up to April 2021 was done and 33 studies included 6596 subjects submitted to surgery for radical cystectomy at the start of the study; 3143 of them received enhanced pharmaceutical recovery after surgery and 3453 were controls. The studies reported relationships about the effects of enhanced pharmaceutical recovery as postoperative standard care after radical cystectomy. We calculated the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) to assess the effects of enhanced pharmaceutical recovery as postoperative standard care after radical cystectomy using the dichotomous and continuous methods with a random or fixed-effect model. RESULTS Enhanced pharmaceutical recovery after surgery had significantly lower length of hospital stay (MD, -2.78; 95% CI, -3.59 to -1.97, p < 0.001), complications (OR, 0.75; 95% CI, 0.60-0.94, p = 0.01), readmission within 30 days (OR, 0.80; 95% CI, 0.69-0.94, p = 0.007), and time to defecation (MD, -1.30; 95% CI, -2.22 to -0.37, p = 0.006) compared to control in subjects submitted to radical cystectomy. CONCLUSIONS Enhanced pharmaceutical recovery after surgery may reduce the length of hospital stay, complications, readmission within 30 days, and time to first bowel movement compared to control in subjects with surgery for radical cystectomy. Furthers studies are required to validate these findings.
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Affiliation(s)
- W Ding
- Department of Urology, Jiangyan Hospital of Traditional Chinese Medicine, Taizhou, Jiangsu, China
| | - R Ji
- Department of Urology, Linyi Third People's Hospital, Linyi, Shandong, China
| | - M E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - L Wang
- Department of Emergency Medicine, Wuhan Hospital of Traditional Chinese Medicine, Wuhan, Hubei, China.
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Ding W, Ji R, Abdelrahim M, Wang L. Metaanálisis sobre el protocolo de recuperación acelerada tras la cistectomía radical. Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bollag L, Lim G, Sultan P, Habib AS, Landau R, Zakowski M, Tiouririne M, Bhambhani S, Carvalho B. Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean. Anesth Analg 2021; 132:1362-1377. [PMID: 33177330 DOI: 10.1213/ane.0000000000005257] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.
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Affiliation(s)
- Laurent Bollag
- From the Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Grace Lim
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Pervez Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Ruth Landau
- Department of Anesthesiology, Columbia University College of Physicians & Surgeons, New York, New York
| | - Mark Zakowski
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mohamed Tiouririne
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia
| | - Sumita Bhambhani
- Department of Anesthesiology, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California
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Wessels F, Lenhart M, Kowalewski KF, Braun V, Terboven T, Roghmann F, Michel MS, Honeck P, Kriegmair MC. Early recovery after surgery for radical cystectomy: comprehensive assessment and meta-analysis of existing protocols. World J Urol 2020; 38:3139-3153. [PMID: 32124020 PMCID: PMC7716903 DOI: 10.1007/s00345-020-03133-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/09/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose Different enhanced recovery after surgery (ERAS) protocols (EP) for radical cystectomy (RC) have been published. Protocols highly differ in number of included items and specific measures. Materials and methods A systematic review and meta-analysis on EPs in RC were performed using the databases MedLine, Cochrane Library, Web of science, and Google Scholar. The specific ERAS measures of the protocols were extracted, analyzed, and compared. Pooling of available outcome data was performed for length of stay, complications, readmission rate, and time to defecation. Results The search yielded a total of 860 studies of which 25 studies were included in qualitative and 22 in quantitative analysis. Oral bowel preparation (BP) was omitted in 24/25 (96%) EPs, optimized fluid management was administered in 22/25 (88%) EPs and early mobilization (postoperative day 1) in 21/25 (84%). Gum chewing (n = 12, 46%), metoclopramide (n = 11, 44%), and alvimopan (n = 6, 24%) were the most common measures to prevent postoperative ileus. Our meta-analysis revealed a significant benefit in favor of EPs for the outcome parameters length of stay [mean difference (MD) − 3.46 d, 95% confidence interval (CI) − 4.94 to − 1.98, p < 0.01], complications [Odds ratio (OR) = 0.76, 95% CI 0.61–0.94, p = 0.01] and time to defecation (MD − 1.37 d, 95% CI − 2.06 to − 0.69, p < 0.01). Readmission rate did not show a significant difference (OR = 0.73, 95% CI 0.52–1.03, p = 0.07). Conclusion Current EPs focus on omitting oral BP, early mobilization, and optimized fluid management while they differ in methods preventing postoperative ileus. Our meta-analysis revealed a benefit in introducing these protocols into clinical practice.
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Affiliation(s)
- F Wessels
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - M Lenhart
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - K F Kowalewski
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - V Braun
- Library for the Medical Faculty, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68165, Mannheim, Germany
| | - T Terboven
- Department of Anesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68165, Mannheim, Germany
| | - F Roghmann
- Department of Urology, Marien Hospital, Ruhr-University Bochum, Herne, Germany
| | - M S Michel
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - P Honeck
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - M C Kriegmair
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Ghanaat M, Winer AG, Sjoberg DD, Poon BY, Kashan M, Tin AL, Sfakianos JP, Cha EK, Donahue TF, Dalbagni G, Herr HW, Bochner BH, Vickers AJ, Donat SM. Comparison of Postradical Cystectomy Ileus Rates Using GIA-80 Versus GIA-60 Intestinal Stapler Device. Urology 2018; 122:121-126. [PMID: 30244117 DOI: 10.1016/j.urology.2018.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/24/2018] [Accepted: 09/11/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the impact on recovery of bowel function using an 80 mm versus 60 mm gastrointestinal anastomosis (GIA) stapler following radical cystectomy and urinary diversion (RC/UD) for bladder cancer. METHODS We identified 696 patients using a prospectively maintained RC/UD database from January 2006 to November 2010. Two nonrandomized consecutive cohorts were compared. Patients between January 2006- and December 2007 (n = 180) were treated using a 60 mm GIA stapler, and 331 patients between January 2008 and December 2010 were subject to an 80 mm GIA stapler. All patients were treated on the same standardized postoperative recovery pathway. After accounting for baseline patient and perioperative characteristics, using a multivariable logistic regression model, we directly compared rates of postoperative ileus using a standardized definition. RESULTS Of 511 evaluable patients, ileus was observed in 32% (57/180) for 60 mm GIA versus 33% (110/331) for the 80 mm GIA. Preoperative renal function, age, gender, body mass index, and type of diversion were comparable between cohorts. On multivariate analysis, stapler size was not significantly associated with the development of ileus (GIA-60 vs GIA-80: OR 1.11; 95% CI 0.75, 1.66; P = .6). Positive fluid balance was associated with an increased risk (P = .019) and female sex a decreased risk (P = .008) of developing ileus compared to patients with negative fluid balance. CONCLUSION The size of the intestinal bowel anastomosis (GIA 80 mm vs 60 mm) does not independently impact the time to bowel recovery following RC/UD.
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Affiliation(s)
- Mazyar Ghanaat
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Andrew G Winer
- SUNY Downstate College of Medicine and Kings County Hospital Center, New York, NY
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bing Ying Poon
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mahyar Kashan
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; SUNY Downstate College of Medicine and Kings County Hospital Center, New York, NY
| | - Amy L Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eugene K Cha
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Timothy F Donahue
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Guido Dalbagni
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Harry W Herr
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bernard H Bochner
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - S Machele Donat
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Bazargani ST, Ghodoussipour S, Tse B, Miranda G, Cai J, Schuckman A, Daneshmand S, Djaladat H. The association between intraoperative fluid intake and postoperative complications in patients undergoing radical cystectomy with an enhanced recovery protocol. World J Urol 2018; 36:401-407. [PMID: 29299662 DOI: 10.1007/s00345-017-2164-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 12/26/2017] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To evaluate the association between intraoperative fluid intake and postoperative complications in patients who underwent radical cystectomy (RC) for bladder cancer with an enhanced recovery protocol. METHODS 287 patients underwent open RC with enhanced recovery protocol (ERAS) from 2012 to 2016. 107 were excluded; non-urothelial (30), palliative (37), had adjunct procedures or not-consented (40). We prospectively evaluated intraoperative fluid intake (crystalloid, colloid and blood) and correlated with length of stay, 30- and 90-day complications. RESULTS 180 patients enrolled into the study with median age of 70 years (78% male). 71% underwent orthotopic diversion. Median intraoperative crystalloid and colloid intake were 4000 and 500 cc, respectively. Nineteen percent of patients received blood transfusion. Median length of stay was 4 days. The overall 30- and 90-day complication rates were 59 and 75%, respectively. Multivariate logistic regressions controlling for a subset of clinically relevant variables showed no significant association between intraoperative fluid intake and complications at 30 or 90 days (p = 0.88 and 0.62, respectively). A multivariable linear regression similarly showed no association between total intraoperative fluid intake and length of stay (p = 0.099). CONCLUSION Higher intraoperative fluid intake was not found to independently increase the complication rate following radical cystectomy. Larger studies and prospective trials are needed to determine if fluid optimization may play a role in decreasing morbidity after this major surgery.
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Affiliation(s)
- Soroush T Bazargani
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Saum Ghodoussipour
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Beverly Tse
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Gus Miranda
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Jie Cai
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Anne Schuckman
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Siamak Daneshmand
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Hooman Djaladat
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA.
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Villa G, Bresciani M, Boarin M, Manara DF. The impact of oral nutrition in patients after radical cystectomy: an overview. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2017. [DOI: 10.1111/ijun.12148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Giulia Villa
- School of Nursing; Vita-Salute San Raffaele University; Milan Italy
| | - Martina Bresciani
- Department of Polispecialistic Surgery; San Raffaele Hospital; Milan Italy
| | - Mattia Boarin
- Department of Urology; San Raffaele Hospital; Milan Italy
| | - Duilio F. Manara
- Associate Professor, School of Nursing; Vita-Salute San Raffaele University; Milan Italy
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Zimmermann EF, Dutton TJ, Crundwell MC. Catheter-free nephrectomy: A safe change to routine practice. JOURNAL OF CLINICAL UROLOGY 2017. [DOI: 10.1177/2051415817709655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: British Association of Urological Surgeons (BAUS) published updated guidance on the Enhanced Recovery Programme (ERP) in December 2015 to include avoidance of routine catheterisation and drain insertion in minimally invasive nephrectomy. We changed our practice to ‘catheter-free’ nephrectomy and present a retrospective comparative study of the outcomes in support of this guideline. Aim: The aim of this article is to assess any difference in length of stay (LOS), complications and readmission rates between patients who had catheter-free nephrectomy compared to those who had a catheter inserted as routine peri-operatively. Method: Catheter-free nephrectomy was implemented in May 2014. A retrospective comparative case note review was performed for all eligible patients from January 2013 until May 2015. All partial and radical nephrectomies (laparoscopic or robotic) were included, regardless of pathology. Results: Ninety-two patients were included. Of these, 45 patients had a routine catheter inserted peri-operatively (17 partial, 8 simple, 20 radical), and 47 patients had a catheter-free nephrectomy (22 partial, 2 simple, 23 radical). Mean age difference between groups was non-significant (61.0 vs 60.3 years, p = 0.82). LOS was longer in the catheter group compared to catheter-free group (mean 3.85 vs 2.53 days, median 3 vs 2 days, respectively, p = 0.029). There were 13 complications in the catheter group, two of which were complicated urinary tract infections, causing one readmission. In the catheter-free group there were six postoperative complications and no readmissions; three patients went into acute urinary retention requiring either short-term intermittent self-catheterisation or ‘in/out’ catheterisation. None of these patients were discharged with a catheter. Conclusion: Nephrectomy without routine insertion of a catheter appears to be safe and was associated with a shorter hospital stay and no increase in complications, hence supporting the updated ERP guideline published by BAUS.
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Affiliation(s)
- EF Zimmermann
- University Hospitals Coventry and Warwickshire NHS Trust
| | - TJ Dutton
- Royal Devon & Exeter NHS Foundation Trust, UK
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Casans-Francés R, Roberto-Alcácer AT, García-Lecina AC, Ferrer-Ferrer ML, Subirá-Ríos J, Guillén-Antón J. Impact of an enhanced recovery after surgery programme in radical cystectomy. A cohort-comparative study. ACTA ACUST UNITED AC 2017; 64:313-322. [PMID: 28214097 DOI: 10.1016/j.redar.2016.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 11/25/2016] [Accepted: 12/02/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the results of the implementation of an enhanced recovery program (ERAS) for open approach radical cystectomy compared to the historical cohort of the same hospital. MATERIAL AND METHODS A retrospective analysis of 138 consecutive patients who underwent radical cystectomy with Bricker or Studer ileal derivation (97 historical vs. 41 ERAS). Overall complication rate, Clavien-Dindo stage>2 complications, mortality, hospital and critical care length of stay and readmission rates, as well as need for reoperation, nasogastric intubation, transfusion or parenteral nutrition were compared. RESULTS No statistically significant differences in overall complication rate were found (73.171 vs. 77.32%; OR 1.25, 95% CI 0.54-2.981; P=.601) nor in Clavien-Dindo>2 complications (41.463 vs. 42.268%; OR 1.033, 95% CI 0.492-2.167; P=.93), mortality, lengths of stays readmission and reoperation rates. The need for nasogastric tube insertion was lower in the ERAS group (43.902 vs. 78.351%; OR 4.624, 95% CI 2.112-10.123; P<.0001), as well as the need for total parenteral nutrition (26.829 vs. 34.021%; OR 12.234, 95% CI 5.165-28.92; P<.0001), and time under endotracheal intubation since anaesthesia induction (median [IRQ]=325 (285-355) vs. 540 (360-600) min; P<.0001). CONCLUSION Enhanced recovery programs in radical cystectomy decrease interventionism on the patient without increasing morbidity and mortality.
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Affiliation(s)
- R Casans-Francés
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.
| | - A T Roberto-Alcácer
- Servicio de Urología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - A C García-Lecina
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - M L Ferrer-Ferrer
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J Subirá-Ríos
- Servicio de Urología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J Guillén-Antón
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
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Osawa T, Lee CT, Abe T, Takada N, Hafez KS, Montgomery JS, Weizer AZ, Hollenbeck BK, Skolarus TA, Murai S, Shinohara N, Morgan TM. A Multi-Center International Study Assessing the Impact of Differences in Baseline Characteristics and Perioperative Care Following Radical Cystectomy. Bladder Cancer 2016; 2:251-261. [PMID: 27376144 PMCID: PMC4927825 DOI: 10.3233/blc-150043] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: To identify potential avenues for quality improvement, we compared the variations in clinical practice and their association with perioperative morbidity and mortality following radical cystectomy (RC) for bladder cancer in the United States (US) and Japan. Methods: We reviewed our retrospectively collected database of 2240 patients who underwent RC for bladder cancer at the University of Michigan (n = 1427) and in 21 Japanese institutions (n = 813) between 1997 and 2014. We performed a systematic comparison of clinical and perioperative factors and assessed predictors of perioperative morbidity and mortality. Death within 90 days of surgery was the primary outcome. Results: There were apparent differences between the two study populations. Notably, US patients had a significantly greater BMI and higher ASA score. In Japanese institutions, median postoperative hospital stay was significantly higher (40 days vs. 7 days, p < 0.001) and 90-day readmission rates were significantly lower (0.6% vs. 26.8% , p < 0.001). There was a total of 1372/2240 (61.2%) patients with complications within 90 days and 66/2240 (2.9%) patient deaths. Significant predictors of 90-day mortality were older age (OR 1.04, CI 1.01–1.07), higher body mass index (OR 1.07, CI 1.02–1.12), node-positive disease (OR 3.14, CI 1.78–5.47), increased blood loss (OR 1.02, CI 1.01–1.03), and major (Clavien-grade 3 or greater) complication (OR 3.29, CI 1.88–5.71). Conclusion: Despite major differences in baseline characteristics and care of cystectomy patients between the two study populations, peri-operative mortality rates proved to be comparable. This data supports an exploration of non-traditional factors that may influence mortality after cystectomy.
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Affiliation(s)
- Takahiro Osawa
- Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA; Department of Urology, Hokkaido University, Sapporo, Japan
| | - Cheryl T Lee
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
| | - Takashige Abe
- Department of Urology, Hokkaido University , Sapporo, Japan
| | | | - Khaled S Hafez
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
| | - Jeffrey S Montgomery
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
| | - Alon Z Weizer
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
| | - Ted A Skolarus
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
| | - Sachiyo Murai
- Department of Urology, Hokkaido University , Sapporo, Japan
| | | | - Todd M Morgan
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
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Cost Analysis of the Enhanced Recovery After Surgery Protocol in Patients Undergoing Radical Cystectomy for Bladder Cancer. Eur Urol Focus 2016; 2:92-96. [DOI: 10.1016/j.euf.2015.06.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/15/2015] [Indexed: 02/04/2023]
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14
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Collins JW, Adding C, Hosseini A, Nyberg T, Pini G, Dey L, Wiklund PN. Introducing an enhanced recovery programme to an established totally intracorporeal robot-assisted radical cystectomy service. Scand J Urol 2015; 50:39-46. [PMID: 26313582 DOI: 10.3109/21681805.2015.1076514] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to assess the effect of introducing an enhanced recovery programme (ERP) to an established robot-assisted radical cystectomy (RARC) service. MATERIALS AND METHODS Data were prospectively collected on 221 consecutive patients undergoing totally intracorporeal RARC between December 2003 and May 2014. The ERP was specifically designed to support an evolving RARC service, where increasing proportions of patients requiring radical cystectomy underwent RARC. Patient demographics and outcomes before and after implementation of the ERP were compared. The primary endpoint was length of stay (LOS). Secondary outcomes included age, American Society of Anesthesiologists (ASA) score, preoperative staging, operative time, complications and readmissions. Differences in outcomes between patients before and after implementation of ERP were tested with the Jonckheere-Terpstra trend test and quantile regression with backward selection. RESULTS Following implementation of the ERP, the demographics of the patients (n = 135) changed, with median age increasing from 66 to 70 years (p < 0.01), higher ASA grade (p < 0.001), higher preoperative stage cancer (pT ≥ 2, p < 0.05) and increased likelihood of undergoing an ileal conduit diversion (p < 0.001). Median LOS before ERP was 9 days [interquartile range (IQR) 8-13 days] and after ERP was 8 days (IQR 6-10 days) (p < 0.001). ASA grade and neoadjuvant chemotherapy also affected LOS (p < 0.05 and p < 0.01, respectively). There was no significant difference in 30 day complication rates, readmission rates or 90 day mortality, with 59% experiencing complications before ERP implementation and 57% after implementation. The majority of complications were low grade. CONCLUSIONS Patient demographics changed as the RARC service evolved from selected patients to a general service. Despite worsening demographics, LOS decreased following ERP implementation. This evidence-based ERP safely standardized perioperative care, resulting in decreased LOS and decreased variability in LOS.
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Affiliation(s)
- Justin W Collins
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Christofer Adding
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Abolfazl Hosseini
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Tommy Nyberg
- b 2 Division of Clinical Cancer Epidemiology, Department of Oncology-Pathology, Karolinska Institutet , Stockholm, Sweden
| | - Giovannalberto Pini
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Linda Dey
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Peter N Wiklund
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
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Understanding Hospital Readmission Intensity after Radical Cystectomy. J Urol 2015; 193:1500-6. [DOI: 10.1016/j.juro.2014.10.107] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2014] [Indexed: 11/18/2022]
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16
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Preston MA, Lerner SP, Kibel AS. New Trends in the Surgical Management of Invasive Bladder Cancer. Hematol Oncol Clin North Am 2015; 29:253-69, viii. [DOI: 10.1016/j.hoc.2014.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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