Postoperative Pain Management after Radical Cystectomy: Comparing Traditional versus Enhanced Recovery Protocol Pathway

Xu, Wan; Daneshmand, Siamak; Bazargani, Soroush; Cai, Jie; Miranda, Gus; Schuckman, Anne; Djaladat, Hooman

doi:10.1016/j.juro.2015.05.083

Cited by 101 publications

(59 citation statements)

References 22 publications

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“…Overall, utilization of clinical pathways is associated with decreased narcotic usage, lower incidence of postoperative ileus, and shorter hospital length of stay. 22 …”

Section: Treatmentmentioning

confidence: 99%

Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline

et al. 2017

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Purpose This multi-disciplinary, evidence-based guideline for clinically non-metastatic muscle-invasive bladder cancer focuses on the evaluation, treatment, and surveillance of muscle-invasive bladder cancer guided toward curative intent. Materials and Methods A systematic review utilizing research from the Agency for Healthcare Research and Quality (AHRQ) as well as additional supplementation by the authors and consultant methodologists was used to develop the guideline. Evidence-based statements were based on body of evidence strengths Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions. (Table 1) Results For the first time, for any type of malignancy, the American Urological Association (AUA), the American Society of Clinical Oncology (ASCO), the American Society for Radiation Oncology (ASTRO), and the Society of Urologic Oncology (SUO) have formulated an evidence-based guideline based on a risk-stratified clinical framework for the management of muscle-invasive urothelial bladder cancer. This document is designed to be used in conjunction with the associated treatment algorithm. Conclusions The intensity and scope of care for muscle-invasive bladder cancer should focus on the patient, disease, and treatment response characteristics. This guideline attempts to improve a clinician's ability to evaluate and treat each patient, but higher quality evidence in future trials will be essential to improve level of care for these patients.

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“…Overall, utilization of clinical pathways is associated with decreased narcotic usage, lower incidence of postoperative ileus, and shorter hospital length of stay. 22 …”

Section: Treatmentmentioning

confidence: 99%

Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline

et al. 2017

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“…Multimodal opioid-sparing analgesia, combined with regional or local anesthesia, is recommended [1] and aims to provide effective pain management while minimizing the side effects of opioids. Xu et al [44] observed that patients on an ERAS protocol (opioid-sparing analgesics) used significantly less opioid analgesics after RC.…”

Section: Evidence Synthesismentioning

confidence: 99%

Enhanced Recovery after Urological Surgery: A Contemporary Systematic Review of Outcomes, Key Elements, and Research Needs

et al. 2016

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Context Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and reduce recovery times. Objective To overview the use and key elements of ERAS pathways, and define needs for future clinical trials. Evidence acquisition A comprehensive systematic MEDLINE search was performed for English language reports published before May 2015 using the terms “postoperative period,” “postoperative care,” “enhanced recovery after surgery,” “enhanced recovery,” “accelerated recovery,” “fast track recovery,” “recovery program,” “recovery pathway”,“ERAS ” , and “urology” or “cystectomy” or “urologic surgery.” Evidence synthesis We identified 18 eligible articles. Patient counseling, physical conditioning, avoiding excessive alcohol and smoking, and good nutrition appeared to protect against postoperative complications. Fasting from solid food for only 6 h and perioperative liquid – carbohydrate loading up to 2 h prior to surgery appeared to be safe and reduced recovery times. Restricted, balanced, and goal-directed fluid replacement is effective when individualized, depending on patient morbidity and surgical procedure. Decreased intraoperative blood loss may be achieved by several measures. Deep vein thrombosis prophylaxis, antibiotic prophylaxis, and thermoregulation were found to help reduce postsurgical complications, as was a multimodal approach to postoperative nausea, vomiting, and analgesia. Chewing gum, prokinetic agents, oral laxatives, and an early resumption to normal diet appear to aid faster return to normal bowel function. Further studies should compare anesthetic protocols, refine analgesia, and evaluate the importance of robot-assisted surgery and the need/timing for drains and catheters. Conclusions ERAS regimens are multidisciplinary, multimodal pathways that optimize postoperative recovery. Patient summary This review provides an overview of the use and key elements of Enhanced Recovery after Surgery programs, which are multimodal, multidisciplinary care pathways that aim to optimize postoperative recovery. Additional conclusions include identifying effective procedures within Enhanced Recovery after Surgery programs and defining needs for future clinical trials.

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“…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].…”

Section: Introductionmentioning

confidence: 99%

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

2016

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Context Enhanced recovery after surgery (ERAS) protocols aim to improve surgical outcomes by reducing variation in perioperative best practices. However, among published studies, results show a striking variation in the effect of ERAS pathways on perioperative outcomes after cystectomy. Objective To perform a systematic review of the literature and a meta-analysis comparing the effectiveness of ERAS versus standard care on perioperative outcomes after cystectomy. Evidence acquisition We performed a literature search of PubMed, EMBASE, Web of Science, Google Scholar, the Cochrane Library, and the health-related grey literature in February 2016 according to the Preferred Reporting Items for Systematic Review and Meta-analysis and the Cochrane Handbook. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine. Thirteen studies (1493 total patients) met the inclusion criteria (ERAS: 801, standard care: 692). A pooled meta-analysis of all comparative studies was performed using inverse-weighted, fixed-effects models, and random-effects models. Publication bias was graphically assessed using contour-enhanced funnel plots and was formally tested using the Harbord modification of the Egger test. Evidence synthesis Pooled data showed a lower overall complication rate (risk ratio [RR]: 0.85, 95% confidence interval [CI]: 0.74–0.97, p = 0.017, I2 = 35.6%), a shorter length of stay (standardized mean difference: −0.87, 95% CI: −1.31 to −0.42, p = 0.001, I2 = 92.8%), and a faster return of bowel function (standardized mean difference: −1.02, 95% CI: −1.69 to −0.34, p = 0.003, I2 = 92.2%) in the ERAS group. No difference was noted for the overall readmission rates (RR: 0.74, 95% CI: 0.39–1.41, p = 0.36, I2 = 51.4%), although a stratified analysis showed a lower 30-d readmission rate in the ERAS group (RR: 0.39, 95% CI: 0.19–0.83, p = 0.015, I2 = 0%). Conclusions ERAS protocols reduce the length of stay, time-to-bowel function, and rate of complications after cystectomy. Patient summary Enhanced recovery after surgery pathways for cystectomy reduce complications and the amount of time patients spend in the hospital.

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Postoperative Pain Management after Radical Cystectomy: Comparing Traditional versus Enhanced Recovery Protocol Pathway

Abstract: Patients on the protocol of enhanced recovery after surgery used significantly less opioid analgesics, possibly contributing to decreased postoperative ileus and shorter length of hospital stay.

Cited by 101 publications

References 22 publications

Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline

Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline

Enhanced Recovery after Urological Surgery: A Contemporary Systematic Review of Outcomes, Key Elements, and Research Needs

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

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