EAU 2017: State of the Art Lecture: Enhanced Recovery After Surgery (ERAS) for Bladder Cancer: Non-Surgical Options to Improve Outcomes of Cystectomy

London, England (UroToday.com) In this session, Professor James Catto discussed non-surgical options for improving outcomes of cystectomy. Radical cystectomy is a morbid operation with 64% of patients having any complication, 13% having a major complication, and 20% being readmitted after surgery. Perioperative pathways are being targeted to reduce the potential morbidity associated with the operation. Traditionally, bowel preparation, nil by mouth, nasogastric tubes, central venous lines, and epidural catheters have been employed. However, this encourages a model in which the patient is passive and many of the day to day clinical decision-making is done by a junior medical staff clinician.

Enhanced recovery after surgery (ERAS) is a four-stage model including pre-operative, intraoperative, postoperative, and assessment phases. The general philosophy is to do as much as possible out of the hospital, do as little as possible to the patient, and empower the patient. Prior to radical cystectomy, the patient is mobilized (termed “prehabilitation”). Dr. Catto recommends about 1 hour every day of walking until surgery and involving the next of kin to encourage adherence. As much as possible is done in the clinic including informed consent, counsel with familiar faces, stoma marking, beginning prophylactic anticoagulation, and carbohydrate loading. No oral bowel preparation is given and a diet is encouraged prior to surgery. Fluids are allowed up to 2 hours preoperatively. Patients are prepared for admission and information about recovery is provided in a printed booklet.

Intraoperatively, the incision should be kept small (~10cm) and nasogastric tube drainage is not routinely used. Pelvic drains are not used only selectively. Intraoperative fluid resuscitation is restricted to 1L until the bladder is out and low blood pressures are tolerated with pressor support as needed. This has been demonstrated to reduce blood loss and hospital length of stay.

Postoperatively, the major goal is to reduce pain and get patients back to a “new normal” as soon as possible. Rectus abdominal bupivacaine blocks are used in favor of epidurals. Comfort sips are used on postoperative day 1 along with chewing gum and hard candies. Postoperative day 2 and beyond, free fluid intake is encouraged within comfort levels. If mobile and tolerating liquids, soup and ice cream are offered before flatus. Once flatus has occurred, a full diet is administered. Nasogastric suction is only employed if the patient is vomiting and uncomfortable. Dr. Catto’s protocol is different from other published reports which include alvimopan because it is not yet available in the UK. Post-operative rehabilitation includes a targeted amount of walking per day. Hospital gowns are discouraged in favor of the patient’s own comfortable clothes.

The final phase is to evaluate the effectiveness of the ERAS procedure. For Dr. Catto, the length of stay has been reduced from 20 days to about 6 days. The variation in stay has also decreased. Readmissions have gone down from 50% to about 15%. Blood transfusion rates have declined from 25% in the non-ERAS group to 8.1% in the ERAS group. Lymph node counts, positive margin rates, and survival outcomes have not changed while the ERAS protocol has been introduced. Therefore, Professor Catto advocated for the adoption of ERAS since it improves some important patient outcomes without compromising oncologic safety.

Presented by: Professor James Catto, MB, ChB, Ph.D, FRCS (Urol), Department of Oncology & Metabolism, the University of Sheffield and an Honorary Consultant Urological Surgeon at Sheffield Teaching Hospitals NHS Trust. He holds a post as Honorary Senior Clinical Research fellow at the University of Oxford and Honorary Clinical Professor, Division of Surgery & Interventional Science, University College London. 

Written by: Benjamin T. Ristau, MD, SUO Fellow, Fox Chase Cancer Center, Philadelphia, PA at the #EAU17 -March 24-28, 2017- London, England