Enhanced Recovery after Robot-Assisted Partial Nephrectomy for Cancer: Is it Better for Patients to Have a Quick Discharge?

The Safety and Feasibility of Ambulatory Minimally Invasive Partial Nephrectomy: A Systematic Review and Meta-Analysis

Purpose: Emerging evidence supports the use of minimally invasive partial nephrectomy (MIPN) in ambulatory settings. We conducted a systematic review and meta-analysis to evaluate differences in perioperative characteristics, complication/readmission rates and satisfaction/cost data between ambulatory and standard-length discharge (SLD) MIPN. Methods: This study was prospectively registered in PROSPERO (CRD42023429854). A systematic literature search of PubMed, Embase, and Web of Science databases was conducted, including studies comparing ambulatory MIPN vs SLD MIPN for patients with renal masses. Studies were assessed for quality using the Methodological Index for Non-Randomized Studies score. Meta-analysis was performed for comparative studies, and non-comparative studies were included narratively. Results: Eleven studies were included with a pooled population of 20,548 patients, of which 1,419 (7%) had a length of stay less than 1 day and were considered the ambulatory group. There were no significant differences in the total complication rates (RR: 0.50, 95% CI: 0.24, 1.04; p = 0.06) or 30-day readmission rates (RR: 0.87, 95% CI: 0.56, 1.35; p = 0.53) between the ambulatory and SLD groups. There were fewer >3 Clavien-Dindo complications in the ambulatory group (RR: 0.34, 95% CI: 0.19, 0.59; p = 0.0002). Few studies reported average health care cost and patient satisfaction. Conclusions: In appropriately selected patients, ambulatory MIPN is safe and feasible. Future studies are needed to quantify cost and patient satisfaction differences and further identify appropriate patient selection criteria for ambulatory MIPN.

Clinical impact of an enhanced recovery protocol implementation for nephrectomy and radical prostatectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) is a combination of multimodal pathways to improve surgical outcomes. Recommendations for radical cystectomy have been published by the ERAS society for the cystectomy but a lack of evidence is observed for urological procedures such as nephrectomy (Ne) and radical prostatectomy (RP). The aim of our study was to evaluate the impact of enhanced recovery protocol implementation for Ne ad RP at our academic institution.

METHODS

We performed a retrospective, monocentric, comparative analysis, pre and post implementation of an enhanced recovery protocol for patients undergoing robotic-assisted radical prostatectomy or nephrectomy (partial or total) for cancer. The primary endpoint was the mean length of stay (LOS). Secondary endpoints included 30-days readmission, postoperative complications, 90 days survival, and oncologic outcome at 6 months.

RESULTS

We included 264 patients between January, 2019, and December, 2020. Statistical analysis was performed separately by type of surgery. The LOS of patients included in the ERP protocol was decreased on average by 1.3 days IC95% [-2.50; -0.08], P<0.001 for nephrectomies and by 2.2 days IC95% [-3.72; -0.62] P<0.001 for prostatectomies, compared to non-ERP patients. There were no more re-admission, death or oncologic recurrence.

CONCLUSION

In our experience, ERP for oncological nephrectomy and prostatectomy reduced the length of stay, without increasing postoperative complications and readmission.

LEVEL OF EVIDENCE

IV.

Application of enhanced recovery after surgery in partial nephrectomy for renal tumors: A systematic review and meta-analysis

Objectives

In recent years, enhanced recovery after surgery (ERAS) has been widely used in the field of urology, especially in radical cystectomy and radical prostatectomy, and has demonstrated its advantages. Although studies on the application of ERAS in partial nephrectomy for renal tumors are increasing, the conclusions are mixed, especially in terms of postoperative complications, etc, and its safety and efficacy are questionable. We conducted a systematic review and meta-analysis to assess the safety and efficacy of ERAS in the application of partial nephrectomy for renal tumors.

Methods

Pubmed, Embase, Cohrance library, Web of science and Chinese databases (CNKI, VIP, Wangfang and CBM) were systematically searched for all published literature related to the application of enhanced recovery after surgery in partial nephrectomy for renal tumors from the date of establishment to July 15, 2022, and the literature was screened by inclusion/exclusion criteria. The quality of the literature was evaluated for each of the included literature. This Meta-analysis was registered on PROSPERO (CRD42022351038) and data were processed using Review Manager 5.4 and Stata 16.0SE. The results were presented and analyzed by weighted mean difference (WMD), Standard Mean Difference (SMD) and risk ratio (RR) at their 95% confidence interval (CI). Finally, the limitations of this study are analyzed in order to provide a more objective view of the results of this study.

Results

This meta-analysis included 35 literature, including 19 retrospective cohort studies and 16 randomized controlled studies with a total of 3171 patients. The ERAS group was found to exhibit advantages in the following outcome indicators: postoperative hospital stay (WMD=-2.88, 95% CI: -3.71 to -2.05, p<0.001), total hospital stay (WMD=-3.35, 95% CI: -3.73 to -2.97, p<0.001), time to first postoperative bed activity (SMD=-3.80, 95% CI: -4.61 to -2.98, p < 0.001), time to first postoperative anal exhaust (SMD=-1.55, 95% CI: -1.92 to -1.18, p < 0.001), time to first postoperative bowel movement (SMD=-1.52, 95% CI: -2.08 to -0.96, p < 0.001), time to first postoperative food intake (SMD=-3.65, 95% CI: -4.59 to -2.71, p<0.001), time to catheter removal (SMD=-3.69, 95% CI: -4.61 to -2.77, p<0.001), time to drainage tube removal (SMD=-2.77, 95% CI: -3.41 to -2.13, p<0.001), total postoperative complication incidence (RR=0.41, 95% CI: 0.35 to 0.49, p<0.001), postoperative hemorrhage incidence (RR=0.41, 95% CI: 0.26 to 0.66, p<0.001), postoperative urinary leakage incidence (RR=0.27, 95% CI: 0.11 to 0.65, p=0.004), deep vein thrombosis incidence (RR=0.14, 95% CI: 0.06 to 0.36, p<0.001), and hospitalization costs (WMD=-0.82, 95% CI: -1.20 to -0.43, p<0.001).

Conclusion

ERAS is safe and effective in partial nephrectomy of renal tumors. In addition, ERAS can improve the turnover rate of hospital beds, reduce medical costs and improve the utilization rate of medical resources.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42022351038.

Enhanced pharmaceutical recovery as postoperative standard care after radical cystectomy: A meta-analysis

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.