CUA 2018: Postoperative Ileus and Complications Outcomes in the Enhanced Recovery Protocol after Radical Cystectomy for Bladder Cancer

Halifax, Nova Scotia (UroToday.com)  Radical cystectomy (RC) is a complex procedure associated with high morbidity rates of approximately 50% of cases.1,2 Enhanced Recovery After Surgery (ERAS) programs were developed to standardize and decrease length of stay (LOS), postoperative ileus (POI), pain, and readmissions in colorectal surgery.3-5  ERAS protocols have been adapted to radical cystectomy6. ERAS protocols allow fluid and carbohydrate loading up to two hours preoperatively and encourage early oral postoperative nutrition. The authors present a study aiming to assess POI, oral feeding, and complication outcomes in patients who underwent the ERAS protocol and patients who underwent traditional management after RC in their institution. 



The authors reviewed 40 patients who underwent RC under an ERAS protocol and 40 patients under conservative management at the Hôtel-Dieu de Québec between 2016 and 2017. 

When comparing both groups (Figure 1), POI rates were higher in the ERAS group (57.5 vs. 47.5%). Slightly more patients underwent nasogastric tube insertion in the ERAS group (52.5% vs. 45%, p=0.6549). Use of TPN was less frequent in the ERAS group (27.5 vs. 37.5%; p=0.4743). However, median TPN duration was greater in the ERAS group compared to the control (13 vs. 6 days). Within a week from RC, 65% of ERAS patients tolerated oral nutrition compared to 52.5% of control patients (p=0.4978). Median LOS, complication, and readmission rates were similar in both groups. 

The small number of patients in this study is a significant limitation, affecting the results, that demonstrate no significant improvements in outcomes in patients under ERAS protocols for RC. Larger studies comparing these two managements strategies should be performed to fully assess whether ERAS leads to improved outcomes of RC patients. 

Figure 1 – Comparison of post-operative ileus, nasogastric tube and total parental nutrition use in both groups: 
Screen Shot 2018 06 25 at 11.59.06 AM


Presented By: Fugaru Ioana, Universite Laval, Quebec, Canada

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, Twitter: @GoldbergHanan  at the 73rd Canadian Urological Association Annual Meeting - June 23 - 26, 2018 - Halifax, Nova Scotia

References: 
[1] Roth B, Birkhauser FD, Zehnder, P, et al. Parenteral nutrition does not improve postoperative recovery from radical cystectomy: Results of a prospective randomised trial. Eur Urol 2013;63:475-82. https://doi.org/10.1016/j.eururo.2012.05.052 
[2] Shabsigh A, Korets R, Vora K, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009;55:164-74. https://doi.org/10.1016/j.eururo.2008.07.031 
[3] Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005;24:466-77. https://doi.org/10.1016/j.clnu.2005.02.002 
[4] Lemanu DP, Singh PP, Stowers MD, et al. A systematic review to assess cost effectiveness of enhanced recovery after surgery programmes in colorectal surgery. Colorectal Dis 2014;16:338-46. https://doi.org/10.1111/codi.12505 
[5] Sarin A, Litonius ES, Naidu, R, et al. Successful implementation of an Enhanced Recovery After Surgery program shortens length of stay and improves postoperative pain, and bowel and bladder function after colorectal surgery. BMC Anesthesiol 2016;16:55. https://doi.org/10.1186/s12871-016-0223-0 
[6] Patel HR, Cerantola Y, Valerio M, et al. Enhanced recovery after surgery: are we ready, and can we afford not to implement these pathways for patients undergoing radical cystectomy? Eur Urol 2014;65:263-6. https://doi.org/10.1016/j.eururo.2013.10.011 


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