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NARUS 2018: Early Recovery after Surgery Protocols and Robotic Cystectomy

Las Vegas, NV (UroToday.com) Dr. Abaza presented on the topic of clinical pathways in robotic surgery in general and specifically in robotic radical cystectomy. Clinical pathways reduce costs, justify robotic approach, improve patient satisfaction, and reduce errors by standardization. 

Several years ago the reported length of stay after robotic radical prostatectomy (RALRP) was 2.2 days. This has recently been shown to decrease to 1.4 days, demonstrating a real world difference with RALRP compared to open radical prostatectomy.  Dr. Abaza showed that 99% of his previous 1500 patients who underwent RALRP had gone home on postoperative day one, with  d/30d readmission rate of 0.6%/2.7%. The RALRP clinical pathway includes several key factors:

  1.  Narcotic avoidance- This reduces ileus and constipation, improves mental status, causes less nausea and faster return to diet, lowers the proportion of time the patient assumes the “sick role”, and results in faster discharge. This is achieved with using Marcaine at the incisions, usage of scheduled Toradol, administration of Tylenol as needed, Percocet for breakthrough, and patient education
  2. Immediate ambulation
  3. Immediate diet
  4. Avoiding drains
  5. Not waiting for flatus before discharge
  6. No need for alteration in different kinds of patients.
The clinical pathway for RALRP is also adopted for additional urologic robotic procedures such as partial nephrectomy, nephrectomy, adrenalectomy, nephroureterectomy, pyeloplasty, and ureteral surgery.

In robotic cystectomy a unique clinical pathway is adopted. It includes:

  1. Narcotic avoidance
  2. Usage of Toradol
  3. Immediate ambulation
  4. Immediate clear fluid diet
  5. Diet is advanced when flatus occurs
  6. Discharge home when patient tolerates regular diet
  7. Usage of Entereg (alvimopan) on a regular basis – causes reduction of opioid side effects.
Dr. Abaza went on and described his initial series of 30 patients that underwent robotic radical cystectomy and had a mean length of stay at the hospital of 3.3 days, with 70% of the patients being home by POD 3.

Dr. Abaza summarized his lecture with these take home messages: clinical pathways are good and can improve RALRP care. According to Dr. Abaza, most patients can even go home by postoperative day 1 after robotic radical cystectomy.

Speaker: Ronney Abaza, OhioHealth Robotic Urologic Surgeon, Ohio, USA

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV