Washington, DC (UroToday.com) Dr. Siamak Daneshmand presented data on enhanced recovery after surgery (ERAS) protocols in cystectomy patients in this morning’s session on bladder cancer. The goals of ERAS are to reduce complication rates and length of stay (LOS) without increasing readmission rates.
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In cystectomy, the diversion is the driver of complications, and ileus is a significant contributor to increased LOS. Ways to preserve GI function in ERAS protocols include carbohydrate loading, avoidance of nasogastric tubes, avoidance of bowel preps, early enteral feeds, liberal use of laxatives, and use of alvimopam.
Early work on ERAS protocols performed by Dr. Pruthi at UNC in 100 consecutive patients showed that 80% of patients were discharged before day 5. The complication rate in this series was 45%, and readmission rate was 12% (Pruthi et al, J Am Col Surg 2010).
At USC, 221 patients on ERAS protocol had a median time to bowel function of 2 days and median LOS of 4 days. For intra-institutional comparison, LOS in the STAR trial was 8 days. Narcotic use is significantly lower among ERAS patients, and complication rates, ER visits, and readmissions are all similar between ERAS and standard pathway patients. Of note, the rate of GI-specific complications is lower in ERAS patients (21% vs 33%).
Comparison of surgical approaches (open vs robotic) among ERAS patients at USC demonstrated lower EBL (200 vs 450) and higher rate of high grade complications in the robotic group (24 vs 13%), and similar LOS between the two arms.
Dr. Daneshmand concluded that ERAS protocols reduce LOS without increasing readmission or complication rates regardless of the surgical approach. These factors results in a significant cost benefit. Further work is needed to continue to find ways to decrease the overall complication rate after radical cystectomy.
Siamak Daneshmand, MD
University of Southern California
Nikhil Waingankar, MD. from the Society of Urologic Oncology Meeting - December 2 - 4, 2015 – Washington, DC.
Fox Chase Cancer Center, Philadelphia, PA.