SUO 2017: Enhanced Recovery After Surgery (ERAS) Protocol for Patients Undergoing Radical Cystectomy

Washington, DC (UroToday.com) Dr. Chen and colleagues presented their research assessing the enhanced recovery after surgery (ERAS) protocol for patients undergoing radical cystectomy (RC). ERAS pathways have significantly reduced complications and length of hospital stay after colorectal procedures and similar concepts have been applied to major urological procedures, including RC1. The objective of this study was to determine whether surgical approach is a determinant factor for clinical outcomes after RC and urinary diversion using an ERAS protocol.

Washington, DC (UroToday.com) The authors identified 345 patients undergoing open radical cystectomy (ORC) and 142 patients undergoing robotic-assisted radical cystectomy (RARC) and urinary diversion with ERAS protocol for bladder urothelial carcinoma from May 2012 to December 2016. This data was captured prospectively, including surgical approach and diversion type, length of stay, 30-day and 90-day complications and readmission rates. Outcomes were compared between ORC and RARC. The authors also compared data between patients with length of stay (≤4 days) and extended length of stay (>4 days). Multivariable logistic regression modeling was used to determine predictive factors of extended length of stay.

Patients undergoing ORC had a higher proportion of continent urinary diversion (71.9% vs 40.6%, p<0.001), shorter operative time (5.4 hrs vs 7.3 hrs, p<0.001), but with higher estimated blood loss (500 vs 200 ml, p<0.001), and higher intraoperative (20.9% vs 9.1%, p=0.002) and postoperative transfusion rate (20.0% vs 11.9%, p=0.04). Median length of stay for ORC patients was 4 days (IQR 4-6 days), and median length of stay for RARC patients was 6 days (IQR 4-7 days) (p<0.001). No significant difference was observed in readmission rate within 30 days and 90 days after surgery; however, ORC patients had higher wound complication rate (7.8 vs 2.8%, p=0.04). Patients with extended length of stay were older (73 yrs vs 68 yrs, p<0.001), had more comorbidities (p<0.001), longer operative time (6.3 hrs vs 5.6 hrs, p<0.001), and higher intraoperative (24% vs 9.5%, p<0.001) and postoperative transfusion rate (22.5% vs 11.8%, p=0.002).  On multivariable analysis, age over 70 years (p<0.001), Charlson comorbidity index ≥2 (p=0.03), longer operative time (p=0.03), intraoperative (p<0.001) and postoperative transfusion (p=0.01) were associated with extended length of stay.

The authors concluded that surgical approach is not a determinant factor for clinical outcome following RC, as both ORC and RARC achieve similar clinical outcomes in the context of a well-established ERAS protocol. Use of perioperative patient care protocols is likely a key factor for optimal patient recovery, including decreased operative time and perioperative transfusion rates.

 Reference:
  1. Cerantola Y, Valerio M, Persson B, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS) society recommendations. Clin Nutr 2013;32(6):879-887.
Presented by: Jian Chen, Catherine & Joseph Aresty Department of Urology, University of Southern California Institute of Urology, Los Angeles, CA
Co-Authors: Hooman Djaladat, Anne Schuckman, Gus Miranda, Jie Cai, and Sia Daneshmand 

 Written By: Zachary Klaassen, MD, Society of Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre @zklaassen_md at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC
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