AUA 2018: Early Opioid Use in ERAS Pathway in Radical Cystectomy Correlates with Increased Length of Stay and Cost

San Francisco, CA ( ERAS (Early recovery after surgery) pathways have been helping to drastically change historical post-operative recovery norms. With a better understanding of pre-operative, intra-operative and post-operative factors that affect recovery times, we can make modifications to help patients recover sooner. 

An important aspect of the current ERAS pathways for bladder cancer is limiting opiate use – the adverse effects on bowel function and recovery are a reason for delayed recovery. Epidurals, pre-operative mu-receptor blockers, and NSAIDs help limit opiate use.

In this abstract, the authors assess the impact of early opiate use in an ERAS pathway. UCSF has employed the ERAS pathway for a few years. They, therefore, completed a retrospective review of the 100 patients who underwent radical cystectomy (RC) and urinary diversion during a 2-year period (2015-2017). Their specific interest was early opiate usage in the first 2 days post-operatively - opioid administration from admission to post-operative day (POD) 2 were extracted and converted to opioid morphine equivalent (OME) units.

  • Variables accounted for: Demographics, comorbidities (using the ASA score), surgical approach, diversion type, length of stay, cost, insurance type, opioid use
In terms of demographics, the median age was 67, there was a 2:1 male:female ratio. 85% patients underwent ileal conduit and 15% neobladder. 84% of cases were open and 16% were robotic; 85% were ileal conduit, 15% neobladder. 30-day readmission rate was 11%. Total cost was $32,693 on average. 57% of patients were Medicare, only 30% were private insurance.

In terms of opiate use, average opioid use was 332 OME (IQR 170-406) intraoperatively and 561 OME on postoperative days (POD) 1 and 2 (IQR 263-691).  In terms of key outcome measures, median length of stay after surgery was 5.9 days. Median cost was $28,972.36 (IQR $24,874-34,453). 

Looking at correlations, opioid use on POD 1 and 2 was positively correlated with post-operative length of stay (p=0.037) after adjusting for possible confounders including age, length of surgery, BMI, smoking status, gender, surgical approach, type of diversion, ASA score.  Patient comorbidities (excluding a surrogate measure) was not utilized!

Intraoperative opioid use correlated with length of surgery (p=0.006) and inversely correlated with age (p=0.02). Interestingly, overall opioid use was not correlated with length of stay after adjusting for potential confounders. Readmission rates correlated with age (p=0.018) but not opioid use.

Therefore, it would appear that early opiate use, rather than total opiate use, is a key determinant of hospital length of stay – but not early complications and re-admission. I mentioned above, but one factor they did not account for was actual patient comorbidities rather than ASA score. This should be accounted for in future studies.

Presented by: Carissa Chu, Univesity of California, San Francisco, California
Co-Authors: Lee-Lynn Chen, Kirsten Greene, Maxwell Meng, Ann Lazar, Sima Porten

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, @tchandra_uromd at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
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