Prospective Implementation of Enhanced Recovery After Surgery Protocols to Radical Cystectomy

Abstract

Background: Multimodal enhanced recovery after surgery (ERAS) regimens have improved outcomes from colorectal surgery. Objective: We report the application of ERAS to patients undergoing radical cystectomy (RC). Design, setting, and participants: Prospective collection of outcomes from consecutive patients undergoing RC at a single institution. Intervention: Twenty-six components including prehabilitation exercise, same day admission, carbohydrate fluid loading, targeted intraoperative fluid resuscitation, regional local anaesthesia, cessation of nasogastric tubes, omitting oral bowel preparation, avoiding drain use, early mobilisation, chewing gum use, and audit. Outcome measurements and statistical analysis: Primary outcomes were length of stay and readmission rate. Secondary outcomes included intraoperative blood loss, transfusion rates, survival, and histopathological findings. Results and limitations: Four hundred and fifty-three consecutive patients underwent RC, including 393 (87%) with ERAS. Length of stay was shorter with ERAS (median [interquartile range]: 8 [6–13] d) than without (18 [13–25], p < 0.001). Patients with ERAS had lower blood loss (ERAS: 600 [383–969] ml vs 1050 [900–1575] ml for non-ERAS, p < 0.001), lower transfusion rates (ERAS: 8.1% vs 25%, chi-square test, p < 0.001), and fewer readmissions (ERAS: 15% vs 25%, chi-square test, p = 0.04) than those without. Histopathological parameters (eg, tumour stage, node count, and margin state) and survival outcomes did not differ with ERAS use (all p > 0.1). Multivariable analysis revealed ERAS use was (p = 0.002) independently associated with length of stay. Conclusions: The use of ERAS pathways was associated with lower intraoperative blood loss and faster discharge for patients undergoing RC. These changes did not increase readmission rates or alter oncological outcomes. Patient summary: Recovery after major bladder surgery can be improved by using enhanced recovery pathways. Patients managed by these pathways have shorter length of stays, lower blood loss, and lower transfusion rates. Their adoption should be encouraged. We found that changes to the radical cystectomy recovery pathway made dramatic improvements to patient outcomes. In particular, changing recovery pathways lead to shorter length of stay, lower blood loss and transfusion rates, and fewer readmissions after surgery, without impacting on cancer treatment outcomes.