Fast Track Surgery to Reduce Short-Term Complications following Radical Cystectomy and Intestinal Urinary Diversion with Vescica Ileale Padovana Neobladder: Proposal for a Tailored Enhanced Recovery Protocol and Preliminary Report from a Pilot Study

Abstract

Objective: Different fast track programs for patients undergoing radical cystectomy (RC) can be found in the current literature. The aim of this work was to develop a new enhanced recovery protocol (ERP). Patients and Methods: The ERP was designed after a structured literature review focusing on reduced bowel preparation, standardized feeding, postoperative nausea, vomiting and pain control. In order to test the ERP, a pilot observational prospective cohort study was planned, enrolling all patients consecutively undergoing RC and Vescica Ileale Padovana (VIP) neobladder. These patients were compared with a matched group of subjects who had undergone RC and VIP neobladder before implementation of the ERP. To achieve good comparability, a propensity score-matching was performed. The primary aim was to assess the ERP's feasibility; the secondary outcome measures were early morbidity and mortality. Results and Limitations: After an exhaustive literature search and a multidisciplinary consultation, an ERP was designed. Nine consecutive patients participated in the pilot study and were compared to 13 patients treated before implementation of the ERP. We did not find any statistically significant difference in terms of mortality rate (none died peri- or postoperatively in both groups). The complication rate, according to the modified Clavien classification, was significantly lower in the ERP group (22.22 vs. 84.61%, p < 0.004). The major limitations are the low number of patients enrolled to test the protocol and the lack of randomization for the comparative evaluations. Conclusion: The introduction of our ERP was proven to be feasible in the management of patients undergoing RC and intestinal urinary diversion with VIP neobladder. The postoperative course was enhanced by a significant reduction in both nasogastric tube insertion and parenteral nutrition support, with early postoperative feeding. All these findings were associated with no deleterious effect on morbidity or mortality, indeed there was a reduced occurrence of postoperative complication rates.

Introduction of an Enhanced Recovery after Surgery Protocol for Robot-Assisted Laparoscopic Radical Prostatectomy

“…Tang et al [11] reported that the time of first flatus was shorter in fast-track laparoscopic retroperitoneal adrenalectomy compared with the conventional protocol. Cerruto et al [12] reported that the median time of flatus was significantly earlier in fast-track radical cystectomy compared with the conventional protocol. Enforced postoperative early mobilization was an important factor in our study.…”

“…Pierorazio et al [15] reported that ileus caused delayed discharge in 0.28, 0.37, and 1.9% of patients undergoing open radical prostatectomy, laparoscopic prostatectomy, and RALP, respectively ( p < 0.001). Additionally, the reason why ileus developed after RALP was related to the transperitoneal approach and exposure of the abdominal viscera to a chemical irritant where urine leak was present [12] . Other authors have reported that the etiology of postoperative ileus is multifactorial, with bowel function relying on a combination of the enteric and central nervous systems, hormonal influences, neurotransmitters, and local inflammatory pathways [16,17] .…”

The impact of oral nutrition in patients after radical cystectomy: an overview

“…In the case of oral nutrition was insufficient after 5 days, the TPN was set. Cerruto et al . () applied a program with the aim to introduce liquids orally according to patients own tolerance during the first POD, until reaching a 2000 kcal diet in the fourth POD and a free diet in the fifth POD along with the administration of prokinetic drugs. This was not tolerated in all the patients since the symptoms of abdominal distension and PONV made the use of the NGT necessary. Cronin () assumes that program personalisation is important to re‐establish an appropriate oral nutrition by removing food that may cause gastrointestinal problems and may increase the risk of developing PONV.…”

Enhanced Recovery Pathways Versus Standard Care After Cystectomy: A Meta-analysis of the Effect on Perioperative Outcomes

“…Although several studies have been published, striking variation exists in the effect of ERAS protocols on perioperative outcomes [4–15]. For example, some studies show that ERAS pathways can reduce the length of stay [4,6,10,11,14,16], whereas others do not [7,9,12,16]; some studies show that ERAS pathways can shorten the time to recovery of bowel activity [7,9,12], yet others do not [6,11]; some studies show that ERAS pathways can lower the rates of readmission [6,12,13]; but yet again, others do not [9,11,14]. …”