SIU 2017: Enhanced Recovery for Renal Surgery - Can Length of Stay Be Further Influenced by Different Anaesthetic Regimes?

Lisbon, Portugal ( With growing interest in ERAS (enhanced recovery after surgery) protocols for bladder cancer and radical cystectomy, there has been an expansion of that interest in other areas of urologic surgery). The specific goal is to modify pre-operative, intra-operative and post-operative standards to help improve perioperative outcomes, including pain control, return to oral diet, hospital stay, and readmission rates. In this specific study, the authors wanted to assess the impact of different intra-operative and post-operative analgesic techniques on post-operative pain control and LOS. 

They completed a retrospective chart review of all patients undergoing renal surgery (for RCC or upper tract TCC) over a 5-year period. Patient demographics and surgical details were collected. 241 total patients were included, who primarily underwent nephrectomy (n=172, 71%). There was a relatively even split of open (51%) or laparoscopic (44%) approach. All patients had a catheter and drain. 

In table 1, the authors listed the various diverse intra-operative and post-operative analgesic methods and medications utilized by the different staff, and correlated them on univariate analysis to hospital LOS. They identified patients with intra-operative diclofenac (8 patients), postoperative local anesthetic to the rectus sheath (65), post-operative diclofenac (15 patients) and post-operative zomorph (26) as having improved LOS. On the other hand, intra-operative epidural (42 patients) actually increased LOS. However, the table is very lacking as it does not list patients median LOS. There is also a large variety of analgesic methods, some with very number of patients. 

On multivariable analysis, early void trial and early drain removal had the biggest impact on LOS – though this may represent less complications and better postoperative course. Postoperative oral tramadol was the only analgesic to significantly effect LOS – though it was not made clear if it improved LOS. 

Based on these results, while use of analgesic does not significantly affect the LOS, they do not recommend any significant changes. The only recommendation is to reduce the use of epidural. 

However, with the lack of most of data being supplied, it is hard to determine the appropriateness of the multivariable analysis. There appears to be significant flaws with the multivariable analysis, likely due to over-saturation with multiple variables. Additionally, the only outcome discussed is hospital LOS – though no discussion of complications, 30-day readmission, pain control scores, etc. This limited analysis makes it difficult to make any strong conclusions.

Presented by: Kaylie Hughes
Affiliation: Whiston Hospital, UK

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 37th Congress of Société Internationale d’Urologie - October 19-22, 2017- Lisbon, Portugal
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