Introduction of an enhanced recovery protocol for radical cystectomy

Abstract

OBJECTIVE To describe and assess an enhanced recovery protocol (ERP) for the peri‐operative management of patients undergoing radical cystectomy (RC), which was started at our institution on 1 October 2005, as RC is associated with increased morbidity and longer inpatient stays than other major urological procedures. PATIENTS AND METHODS An ERP was introduced in our institution that focused on reduced bowel preparation, and standardized feeding and analgesic regimens. In all, 112 consecutive patients were compared, i.e. 56 before implementing the ERP and 56 since introducing the ERP. The primary outcome measures were duration of total inpatient stay and interval from surgery to discharge, and the morbidity and mortality. Data were analysed retrospectively from cancer network and hospital records. RESULTS The demographics of the two groups showed no significant difference in age, gender distribution, American Society of Anesthesiologists grade, or type of urinary diversion. Re‐admission, mortality and morbidity rates showed no statistically significant difference between the groups. The median (interquartile range) duration of hospital stay was 17 (15–23) days in the no‐ERP group, and 13 (11–17) days in the ERP group (significantly different, P < 0.001, Wilcoxon rank‐sum test). The median duration of recovery after RC was 15 (13–21) days in the no‐ERP group and 12 (10–15) days in the ERP group (significantly different, P = 0.001, Wilcoxon rank‐sum test). CONCLUSION The introduction of an ERP was associated with significantly reduced hospital stay, with no deleterious effect on morbidity or mortality.

A Single-centre Early Phase Randomised Controlled Three-arm Trial of Open, Robotic, and Laparoscopic Radical Cystectomy (CORAL)

“…All patients underwent a standardised Enhanced Recovery Pathway for RC [12]. After discharge, patients were reviewed at 2 wk, 3, 6, and 12 mo, and then yearly.…”

Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

“…7,8,15 These programs attempt to modify the physiological and psychological responses to major surgery, 16 and have been shown to lead to a reduction in complications and hospital stay, improvements in cardiopulmonary function, earlier return of bowel function and earlier resumption of normal activities. 9,10 The key principles of the ERAS protocol include preoperative counselling , preoperative nutrition, avoidance of perioperative fasting and carbohydrate loading up to 2 hours preoperatively, standardized anesthetic and analgesic regimens (epidural and non-opiod analgesia) and early mobilization (Fig.…”

“…The introduction of ERAS in a centre in the United Kingdom lead to a significant reduction enhanced recovery after surgery protocols in hospital stay and equivalent morbidity in radical cystectomy patients, compared to traditional approaches. 7,15 The protocol focused on reduced bowel preparation, standardized feeding schedule and standardized analgesic regimens (Table 1). Similar findings have been replicated in a small number of other urological publications.…”

“…3,7,67,68 The etiology of postoperative ileus is multifactoral, with bowel function relying on a combination of the enteric and central nervous systems, hormonal influences, neurotransmitters and local inflammatory pathways. 69 Surgical stress, bowel handling, opioids and intraoperative fluid resuscitation can disrupt these normal arrangements within the gastrointestinal tract and lead to postoperative ileus and impaired gastrointestinal absorptive function.…”

“…The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. [4][5][6][7][8] Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, 9,10 they challenge traditional surgical doctrine, and as a result their implementation has been slow. Although much of the data arise from colorectal surgery, the evidence is applicable to major urological surgery, in particular radical cystectomy.…”