Enhanced Recovery After Surgery protocols for radical cystectomy surgery: review of current evidence and local protocols

Implementation of the enhanced recovery after surgery protocol for radical cystectomy patients: A single centre experience

PURPOSE

The enhanced recovery after surgery (ERAS) protocol for radical cystectomy aims to facilitate postoperative recovery and hasten a return to normal daily activities. This study aims to report on the perioperative outcomes of implementation of an ERAS protocol at a single Australian institution.

MATERIALS AND METHODS

We identified 73 patients with pT1-T4 bladder cancer who underwent open radical cystectomy at Western Health, Victoria between June 2016 and August 2021. A retrospective analysis of a prospectively maintained database was performed. Perioperative outcomes included length of hospital stay, nasogastric tube requirement and duration of postoperative ileus.

RESULTS

The median age was 74 years (interquartile range [IQR] 66-78) for the ERAS group and 70 years (IQR 65-78) for the pre-ERAS group patients. All patients in each group underwent ileal conduit formation. The median length of hospital stay was 7.0 days (IQR 7.0-9.3) for the ERAS group and 12.0 days (IQR 8.0-16.0) for the pre-ERAS group (p=0.003). Within the ERAS group, 25.0% had a postoperative ileus, and 25.0% had a nasogastric tube inserted, compared with 64.9% (p=0.001) and 45.9% (p=0.063) respectively within pre-ERAS group. The median bowel function recovery time, defined as duration from surgery to first bowel action, was 5.0 days (IQR 4.0-7.0) in the ERAS group and 7.5 days (IQR 5.0-8.5) in the pre-ERAS group (p=0.016).

CONCLUSIONS

Implementation of an ERAS protocol is associated with a reduction in hospital length of stay, postoperative ileus and bowel function recovery time.

Immunonutrition in Radical Cystectomy: State of the Art and Perspectives

Preoperative nutritional status is a pivotal aspect to consider in patients with cancer undergoing radical cystectomy (RC), as those at risk of malnutrition or already malnourished are more prone to post-surgical complications. The loss of muscle mass is a major consequence of cancer-related malnutrition. It is associated with increased risk of hospital readmission, longer hospitalization, and higher mortality. Nowadays, the close relationship between nutritional and immunological aspects under stressful conditions, such as surgery, represents an emerging scientific and clinical issue. Indeed, the synergistic action of reduced food intake and systemic inflammation generates metabolic derangements with tissue catabolism, including skeletal muscle breakdown, which is, in turn, associated with immune system dysfunction. In order to offer an additional immune-nutritional boost to the post-surgical phase, particularly in malnourished patients, nutritional support may include oral nutritional supplements and/or enteral formulas enriched with specific nutrients such as omega-3 fatty acids, arginine, glutamine, and nucleotides, with acknowledged immune-modulating effects. In the present narrative review, we addressed the state of the art of the available scientific literature on the benefit of immunonutrition in patients undergoing RC for cancer and suggest possible future perspectives to be explored. Although the role of immunonutrition was found to be little explored in the context of urologic oncology, the preliminary available data on radical cystectomy, summarized in the present paper, are promising and suggest that it may improve postoperative outcomes through immunomodulation, regardless of nutritional status before surgery.

Potential for optimizing the perioperative care in robotic prostatectomy patients by adoption of enhanced recovery after surgery principles

Several benefits have been reported after applying the principles of enhanced recovery after surgery (ERAS) into the perioperative care of patients undergoing robot-assisted radical prostatectomy (RARP). Nevertheless, there are still barriers. We aimed to identify the key areas by systematically surveying urology departments in Germany and Austria. A 27-question survey on the adoption of ERAS principles for the perioperative care of RARP patients was designed, in compliance with the guidelines on good practice in conducting and reporting of survey research. After positive testing for face and content validity, the survey was distributed via postal mail to 82 departments performing RARP. In total, 39 departments responded to our survey (response rate 48%). The ERAS adoption rates ranged from 21 to 97%, with nine ERAS principles being widely adopted (72-92% of the departments). The lowest adoption rates and, subsequently, the largest potential for optimization were detected for the preoperative nutrition counselling (21%), preoperative pelvic floor physiotherapy (54%), postoperative early initiation of nutrition (44%) and postoperative patient audit for further quality improvement (36%). High-volume centers performed more frequently a perioperative nutrition counselling (8/27; 30%) than low-volume centers (0/12; 0%; p = 0.036). The implementation of the ERAS principles into the perioperative care algorithm were medium-to-high, yet not optimal. Our real-world data assessment revealed four key areas showing low adoption rates (nutrition counselling, preoperative pelvic floor physiotherapy, early initiation of nutrition and patient audit), implying a great potential for further optimization.

Pathological features of prostate cancer in men treated with robot-assisted radical prostatectomy in the Middle East

Little is known about the pathological features of radical prostatectomy among men living in the Middle East. Although prostate cancer became the most common malignancy among males in some countries in the Middle East, the incidence is much lower compared to western populations. The aim of this study is to analyze pathological features and biochemical recurrence in men who underwent robotic-assisted radical prostatectomy (RARP) in Kuwait. The data on all RARP cases performed by a uro-oncologist (SA) were recorded. A comprehensive database was collected, including demographic, clinical, and pathological data. Between February 2014 and November 2019, 65 RARP cases were performed out of a total of 200 robotic urological procedures. The median follow-up was 41.5 months [inter quartile range (IQR) 27.6-52.7]. Eleven (17%) complications occurred in 7 patients, 64% were early (< 30 days post-operatively) and minor (Clavien I-II). Thirty-five (54%) patients had ≥ pT3 disease. Overall, 12 (18%) patients had a positive surgical margin (PSM), and all had ≥ pT3 disease. Potency and continence rates at 12 months were 82% and 97%, respectively. The mean and SD of the hospital stay were 2.7 ± 1.1 days. Biochemical recurrence (BCR) rate was 10%. Men with prostatic adenocarcinoma treated with RARP in Kuwait show a high incidence of pT3 disease. PSM and BCR rates were similar to multiple reports in the literature. To our knowledge, this is the first report of RARP pathological outcomes in the gulf cooperation council (GCC) region of the Middle East.

Enhanced recovery after surgery review and urology applications in 2020

Purpose: To explore enhanced recovery after surgery (ERAS) components and their current application to major urologic surgeries, barriers to implementation and maintenance of the associated quality improvement. Data Identification: An English language literature search was done using PubMed. Study Selection: After independent review, 55 of the original 214 articles were selected to specifically address the stated purpose. Data Extraction: Clinical trials were included, randomized trials were prioritized, but robust observational studies were also included. Results of Data Synthesis: Many ERAS components have good data to support usage in radical cystectomy (RC) patients. Most ERAS programs include multidisciplinary teams carrying out multimodal pathways to hasten recovery after a major operation. ERAS components generally include preoperative counseling and medical optimization, venous thromboembolism prophylaxis, ileus prevention, avoidance of fluid overload, normothermia maintenance, early mobilization, pain control and early feeding, all leading to early discharge without increased complications or readmissions. Although there may not be specific data pertaining to other major urologic operations, the principles remain similar and ERAS is easily applicable. Conclusion: The benefits of ERAS programs are well established for RC and principles are easily applicable to other major urology operations. Barriers to implantation and maintenance of ERAS must be recognized to continue to maintain the benefits of these programs.

Impact of an enhanced recovery pathway on length of stay and complications in elective radical cystectomy: a before and after cohort study

Background

Enhanced recovery after surgery (ERAS) pathways aim to standardize and integrate perioperative care, incorporating the best available evidence-based practice throughout the perioperative period targeted at attenuating the surgical stress response while optimizing physiologic function, with the goal of facilitating recovery. Radical cystectomy is associated with significant postoperative morbidity, but comprehensive ERAS pathways have not been well studied in this population.

Methods

This is a before and after cohort study of an ERAS pathway for radical cystectomy at a large academic medical center. Following introduction of the ERAS pathway and a wash in period, we prospectively collected data from the next 100 consecutive subjects undergoing radical cystectomy with the ERAS pathway. This cohort was compared to a retrospective cohort of 100 consecutive patients undergoing radical cystectomy with traditional care. The primary outcome was hospital length of stay. Secondary outcomes included perioperative management, time to recovery milestones, complications, and costs.

Results

Implementation of an ERAS pathway for radical cystectomy was associated with reduced hospital length of stay (median LOS 10 days (IQR = 8–18) vs 7 days (IQR = 6–11); p < 0.0001), reduced time to key recovery milestones, including days to first stool (5.83 vs 3.99; p < 0.001) and days to first solid food (9.68 vs 3.2; p < 0.001), reductions in some complications, and a 26.6% reduction in overall costs (p < 0.001).

Conclusions

Our data support the use of an ERAS pathway for radical cystectomy and add to the increasing body of literature supporting enhanced recovery over a wide variety of procedures.

Trial registration

Not applicable.

Factors influencing ICU admission and associated outcome in patients undergoing radical cystectomy with enhanced recovery pathway

PURPOSE

To characterize drivers of ICU admission during index hospitalization after Radical Cystectomy (RC) with Enhanced Recovery After Surgery (ERAS) protocol, as well as corresponding outcomes.

METHODS

A retrospective review of an IRB-approved cystectomy database was conducted. All patients who underwent RC with ERAS protocol from 2012 to 2017 were included.

EXCLUSION CRITERIA

adjunct nephrectomy or urethrectomy.

RESULTS

A total of 512 patients were identified. ICU admission in index hospitalization was reported in 33 patients (6.4%), 26 with unplanned ICU transfer after initial non-ICU level of care and 7 with planned direct postoperative ICU admission. Higher age and Charlson Comorbidity Index ≥3 were significant risk factors for unplanned ICU admission. On multivariate analysis, age remained associated (odds ratio 1.05, 95% confidence interval 1.008, 1.1, P = 0.02) and Charlson Comorbidity Index ≥3 kept the trend (odds ratio 2.16, 95% confidence interval 0.86 - 5.07, P = 0.08) with this increased risk of ICU admission. Patients in the unplanned ICU group spent a median of 3 days (range: 0-32) at non-ICU level of care before ICU transfer; cardiac indications were the most common reason for transfer (52%). Patients who required unplanned ICU transfer had a median length of stay of 11.5 days, compared to a length of stay of 5 days (P < 0.01) for non-ICU patients. Ninety-day readmission and mortality rates were higher in the planned ICU cohort when compared to the unplanned ICU cohort. A low rate of ICU admission (2.7%) in the corresponding 90-day postoperative period was reported for the group not requiring ICU admission during index hospitalization.

CONCLUSION

ICU admission is uncommon following RC with ERAS protocol. Advanced age and comorbidity index are significantly associated with unplanned ICU transfer. Planned ICU admissions are not shown to be associated with improved outcomes compared to unplanned ICU admissions. Further efforts to elucidate the role of ICU care in the context of the ERAS protocol is important for targeted care optimization and appropriate postoperative planning.

Optimizing Nutrition Prior to Radical Cystectomy

PURPOSE OF REVIEW

Malnutrition in a prevalent problem in patients undergoing radical cystectomy. Preoperative malnutrition has been shown to contribute to increased rates of postoperative complications. Given the significant morbidity and mortality of the procedure of radical cystectomy, there is potential for improvement in patient outcomes by nutritional intervention.

RECENT FINDINGS

Prospective studies have demonstrated a reduction in postoperative infection rates in patients who receive supplemental immunonutrition prior to major surgery including radical cystectomy. These initial evaluations of nutritional optimization show significant potential for improved outcomes. Additionally, several studies using enhanced recovery after surgery protocols, which include a preoperative nutritional component, have shown a benefit in reducing length of stay. Emerging literature has shown the benefits of preoperative immunonutrition in improving postoperative outcomes of radical cystectomy. However, further work is needed to determine the best mechanism to optimize nutrition prior to radical cystectomy.

Evaluation of an enhanced recovery protocol on patients having radical cystectomy for bladder cancer

INTRODUCTION

Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care protocols that are designed to shorten recovery time and reduce complication rates.^1,2 An ERAS protocol was implemented in the Saskatoon Health region for radical cystectomy patients in 2013. This study evaluates the safety and efficacy of the protocol for patients having radical cystectomy for bladder cancer.

METHODS

Length of stay, early in-hospital complication rates, 30-day readmission rates, age, and gender were collected for patients seen for bladder cancer requiring radical cystectomy in Saskatoon between January 2007 and December 2016. Of these patients, 176 were pre-ERAS implementation (control group) and 84 were post-ERAS implementation (experimental group). The data from each variable was compared between the groups using a Z-test.

RESULTS

There was no significant difference in age or gender of patients between the groups. Average length of stay pre-ERAS was 14.25±14.57 days, which is significantly longer than the post-ERAS average of 10.91±8.56 days (p=0.043). There was no significant difference in 30-day readmission rate (19.87% pre-ERAS vs. 19.05% post-ERAS; p=0.873) or complication rate (51.7% pre-ERAS vs. 46.4% post-ERAS; p=0.425).

CONCLUSIONS

The implementation of an ERAS protocol for radical cystectomy reduces length of stay, with no effect on early complication rates or 30-day readmission rates. This indicates that the protocol is safe for patients when compared to previous practices and is an effective means of reducing length of stay.

Enhanced Recovery After Surgery for Radical Cystectomy

Even with advances in perioperative medical care, anesthetic management, and surgical techniques, radical cystectomy (RC) continues to be associated with a high morbidity rate as well as a prolonged length of hospital stay. In recent years, there has been great interest in identifying multimodal and interdisciplinary strategies that help accelerate postoperative convalescence by reducing variation in perioperative care of patients undergoing complex surgeries. Enhanced recovery after surgery (ERAS) attempts to evaluate and incorporate scientific evidence for modifying as many of the factors contributing to the morbidity of RC as possible, and optimize how patients are cared for before and after surgery. In this chapter, we review the preoperative, intraoperative and postoperative elements of using an ERAS protocol for RC.

The Development of Enhanced Recovery After Surgery Across Surgical Specialties

BACKGROUND

Enhanced recovery after surgery (ERAS^®) principles have gained traction in variety of surgical disciplines. The promise of a reduced length of stay without compromising patient safety or increasing readmission rates has produced a body of literature examining the implementation of ERAS in the care of general, thoracic, urologic, and gynecologic surgery patients.

METHODS

We performed a review of the literature pertaining to studies of ERAS implementation across colorectal surgery, general surgery, thoracic surgery, urology, and gynecology. The extent of ERAS implementation and reported outcomes across key studies as well as systematic reviews and meta-analyses in each field were summarized.

RESULTS

The implementation of ERAS protocols has not been uniform across surgical specialties. Despite this, ERAS has produced improvements in patient outcomes. The most commonly described benefit of ERAS application has been reduced length of stay; complication and readmission rates are most consistently decreased in the colorectal literature. Studies have started to measure more nuanced measures of postoperative patient well-being. Efforts are growing to standardize ERAS protocols across diverse fields and call attention to the need for quality control.

CONCLUSIONS

Challenges remain in the study and execution of ERAS. Controlling for adherence to ERAS components and implementing uniform ERAS protocols across studies are burgeoning topics that have significant implications for study design. The practice of ERAS and its benefits to patients are expected to evolve. Assessing improvements in postdischarge quality of life, timing of return to work and independent living, and adherence to scheduled delivery of adjuvant treatments will strengthen future ERAS investigations.

A preliminary oncologic outcome and postoperative complications in patients undergoing robot-assisted radical cystectomy: Initial experience

PURPOSE

Robot-assisted radical cystectomy (RARC) was originally intended to replace open radical cystectomy (ORC) as a minimally invasive surgery for patients with invasive bladder cancer. The purpose of this study was to evaluate the advantages of robotic surgery, comparing perioperative and oncologic outcomes between RARC and ORC.

MATERIALS AND METHODS

Between June 2012 and August 2016, 49 bladder cancer patients were given a radical cystectomy, 21 robotically and 28 by open procedure. We compared the clinical variables between the RARC and ORC groups.

RESULTS

In the RARC group, the median estimated blood loss (EBL) during cystectomy, total EBL, operative time during cystectomy, and total operative time were 0 mL, 457.5 mL, 199 minutes, and 561 minutes, respectively. EBL during cystectomy (p<0.001), total EBL (p<0.001), and operative time during cystectomy (p=0.003) in the RARC group were significantly lower compared with the ORC group. Time to resumption of a regular diet (p<0.001) and length of stay (p=0.017) were also significantly shorter compared with the ORC group. However, total operative time in the RARC group (median, 561 minutes) was significantly longer compared with the ORC group (median, 492.5 minutes; p=0.015).

CONCLUSIONS

This Japanese study presented evidence that RARC yields benefits in terms of BL and time to regular diet, while consuming greater total operative time. RARC may be a minimally invasive surgical alternative to ORC with less EBL and shorter length of stay.