90-Day complication rate in patients undergoing radical cystectomy with enhanced recovery protocol: a prospective cohort study: Beyond the Abstract

The enhanced recovery after surgery (ERAS) protocol is an evidence-based pathway that was originally developed for patients undergoing colorectal surgery, in order to optimize perioperative care and recovery [1]. We adopted an ERAS pathway for radical cystectomy patients that is associated with decreased median length of stay (LOS) following surgery without increasing complication or readmission rate [2]. 

The protocol is highlighted preoperatively by the absence of bowel preparation and inclusion of high-carbohydrate liquid drinks. IV antibiotics started just before surgery and continued for 24 h postoperatively, at which time the patient was transitioned to oral suppressive antibiotics. Intraoperatively, fluid intake has been minimized after clipping the ureters, with careful monitoring of intravascular fluid volume. NG tube was removed at the end of surgery, and patients were started on clears versus cystectomy diet. Patients received a cholinergic drug (neostigmine) and μ-opioid antagonists (alvimopan) until the first bowel movement [2].

The ERAS perioperative protocol was subsequently applied to 169 consecutive patients who underwent open RC for bladder cancer from 2012 to 2014. Patients were followed for 90-day postoperatively or until death (7 patients). Over the 90-day time period, the overall complication rate was 78.1 %. At least one major complication was observed in 24.3 %, while minor complication rate was 53.9 %. The most common complications were infection and gastrointestinal (GI) complications. Infections included UTI, sepsis, pneumonia, clostridium difficile and wound infection and the GI complications comprised of diarrhea, bowel obstruction, ileus, constipation and GI bleeding. 

Reviewing complications per diversion, the 90-day complication rate was 76 % in orthotopic neobladder, 79 % in continent cutaneous diversion and 83 % in ileal conduit, with no significant difference among the groups (p = 0.4). There was no difference in the rate of complications per grade, ER visits or readmission among diversion groups (p = 0.4, p = 0.69 and p = 0.16, respectively). 

Written by: Djaladat H, Katebian B, Bazargani ST, Miranda G, Cai J, Schuckman AK, Daneshmand S.

References:

1.Miller TE et al (2014) Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 118:1052–1061

2.Daneshmand S et al (2014) Enhanced recovery protocol after radical cystectomy for bladder cancer. J Urol 192:50–56

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