ERAS Society 2019: ERAS Protocol Improves Cancer-Specific and Overall Survival After Elective Radical Cystectomy: A Retrospective Cohort Study
ERAS® protocols have been designed to reduce surgical stress in order to decrease morbidity and length of hospital stay. However, there is a lack of evidence regarding long term benefits on oncological outcomes, especially for urological patients. The aim of the present study was to evaluate the impact of ERAS® on cancer-specific survival (CSS) and overall survival (OS) in patients treated with radical cystectomy for bladder cancer.
Between 2011 and 2017, data from 152 consecutive cystectomies were analyzed. Since 2012 all patients were managed in their center according to ERAS® protocol as standard of care. The prospective ERAS® registry was employed to collect clinical data; pre-ERAS® patients were retrospectively included in the same registry as a comparator group. A multidisciplinary team was created with the objective to continuously improve perioperative management based on ERAS® principles. Simple cystectomy, orthotopic neobladder reconstruction, postoperative follow-up time shorter than 3 months, and patients with the extended nodal stage (pN3) or distant metastasis were excluded. Long term follow-up included date and cause of death. Five-years CSS was calculated using the log-rank Kaplan-Meier method. Competing-risks regression models were used to evaluate mortality.
Eighty-nine patients were considered for the final analysis. Fifty-six (63%) ERAS® patients were compared to 33 (37%) pre-ERAS® patients. The two groups were similar in terms of patient and tumor characteristics, except for a higher morbidity in the ERAS® group (p = 0.004). Median follow-up for patients alive at last follow-up was 33 months (IQR 20-52). At multivariable regression analysis, ERAS® protocol (HR 0.44, p = 0.03), tumor stage (HR 1.50, p = 0.007) and nodal involvement (HR 4.78, p < 0.0001) were all found independent factors of CSS. Five-years CSS rate for ERAS® patients was 73% compared to 49% for the pre-ERAS® group (p=0.04). Patients following the ERAS® protocol had also a better 5-years OS compared to the control population (66% vs 33%, p=0.06). However, ERAS® protocol had no significant impact on OS (HR 0.54, p=0.07). In conclusion, a dedicated ERAS® protocol for radical cystectomy for bladder cancer has a significant impact on CSS and may be associated with improved OS. Further studies using the ERAS® audit system registry are underway to confirm and enhance the generalizability of these findings.
Presented by: Ilaria Lucca, MD, Cheffe de Clinique, University Hospital CHUV, Lausanne, Switzerland
Written by: Stephen B. Williams, MD, Associate Professor, Division of Urology, The University of Texas Medical Branch, Galveston, Texas at the 7th ERAS World Congress, Liverpool, UK, 1-3 May 2019