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Outcomes of an enhanced recovery after radical cystectomy program in a prospective multicenter study: compliance and key components for success

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World Journal of Urology Aims and scope Submit manuscript

Abstract

Objective

To investigate the effect of an Enhanced Recovery After Surgery (ERAS) program on complications and length of stay (LOS) after radical cystectomy (RC) and to assess if the number and type of components of ERAS play a key role on the decrease of surgical morbidity.

Materials and methods

We analyzed the data of 277 patients prospectively recruited in 11 hospitals undergoing RC initially managed according to local practice (Group I) and later within an ERAS program (Group II). Two main outcomes were defined: 90-day complications rate and LOS. As secondary variables we studied 90-day mortality, 30-day readmission and transfusion rate.

Results

Patients in Group II had a higher use of ERAS measures (98.6%) than those in Group I (78.2%) (p < 0.05). Patients in Groups I and II experienced similar complications (70.5% vs. 66%, p = 0.42). LOS was not different between Groups I and II (12.5 and 14 days, respectively, p = 0.59). The risk of having any complication decreases for patients having more than 15 ERAS measures adopted [RR = 0.815; 95% confidence interval (CI) 0.667–0.996; p = 0.045]. Avoidance of transfusion and nasogastric tube, prevention of ileus, early ambulation and a fast uptake of a regular diet are independently associated with the absence of complications.

Conclusions

Complications and LOS after RC were not modified by the introduction of an ERAS program. We hypothesize that at least 15 measures should be applied to maximize the benefit of ERAS

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Abbreviations

RC:

Radical cystectomy

ERAS:

Enhanced recovery after surgery

PRORAC:

Programa de Recuperacion Acelerada en Cistectomia

SLP:

Site’s local practice

LOS:

Length of stay

Hb:

Hemoglobin

CCI:

Charlson Comorbidity Index

TURB:

Transurethral resection of the bladder

QOL:

Quality of life

RCT:

Randomized clinical trial

RR:

Relative risk

IQR:

Interquartile range

CI:

Confidence interval

IRB:

Institutional review board

MIS:

Minimally invasive surgery

References

  1. Shabsigh A, Korets R, Vora KC, Brooks CM, Cronin AM, Savage C et al (2009) Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 55(1):164–174

    Article  Google Scholar 

  2. Llorente C, Guijarro A, Hernandez V, Fernandez-Conejo G, Perez-Fernandez E, Pocock S (2019) Effect of hospital volume on 90-day mortality after radical cystectomy for bladder cancer in Spain. World J Urol

  3. Burkhard FC, Studer UE, Wuethrich PY (2015) Superior functional outcome after radical cystectomy and orthotopic bladder substitution with restrictive intraoperative fluid management: a follow-up study of a randomized clinical trial. J Urol 193(1):173–178

    Article  Google Scholar 

  4. Gouvas N, Tan E, Windsor A, Xynos E, Tekkis PP (2009) Fast-track vs standard care in colorectal surgery: a meta-analysis update. Int J Colorectal Dis 24(10):1119–1131

  5. Sehgal R, Hill A, Deasy J, McNamara DA, Cahill RA (2012) Fast-track for the modern colorectal department. World J Surg 36(10):2473–2480

    Article  Google Scholar 

  6. Karl A, Buchner A, Becker A, Staehler M, Seitz M, Khoder W et al (2014) A new concept for early recovery after surgery for patients undergoing radical cystectomy for bladder cancer: results of a prospective randomized study. J Urol 191(2):335–340

    Article  CAS  Google Scholar 

  7. Tyson MD, Chang SS (2016) Enhanced recovery pathways versus standard care after cystectomy: a meta-analysis of the effect on perioperative outcomes. Eur Urol 70(6):995–1003

    Article  Google Scholar 

  8. Zou G (2004) A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol 159(7):702–706

    Article  Google Scholar 

  9. Studer UE, Burkhard FC, Schumacher M, Kessler TM, Thoeny H, Fleischmann A et al (2006) Twenty years experience with an ileal orthotopic low pressure bladder substitute—lessons to be learned. J Urol 176(1):161–166

    Article  Google Scholar 

  10. Nieuwenhuijzen JA, de Vries RR, Bex A, van der Poel HG, Meinhardt W, Antonini N et al (2008) Urinary diversions after cystectomy: the association of clinical factors, complications and functional results of four different diversions. Eur Urol 53(4):834–42 (discussion 842–4)

  11. Malavaud B, Vaessen C, Mouzin M, Rischmann P, Sarramon J, Schulman C (2001) Complications for radical cystectomy. Impact of the American Society of Anesthesiologists score. Eur Urol 39(1):79–84

  12. Novara G, De Marco V, Aragona M, Boscolo-Berto R, Cavalleri S, Artibani W et al (2009) Complications and mortality after radical cystectomy for bladder transitional cell cancer. J Urol 182(3):914–921

    Article  Google Scholar 

  13. Chahal R, Sundaram SK, Iddenden R, Forman DF, Weston PM, Harrison SC (2003) A study of the morbidity, mortality and long-term survival following radical cystectomy and radical radiotherapy in the treatment of invasive bladder cancer in Yorkshire. Eur Urol 43(3):246–257

    Article  CAS  Google Scholar 

  14. Greer NL, Gunnar WP, Dahm P, Lee AE, MacDonald R, Shaukat A et al (2018) Enhanced recovery protocols for adults undergoing colorectal surgery: a systematic review and meta-analysis. Dis Colon Rectum 61(9):1108–1118

    Article  Google Scholar 

  15. Pang KH, Groves R, Venugopal S, Noon AP, Catto JWF (2017) Prospective implementation of enhanced recovery after surgery protocols to radical cystectomy. Eur Urol S0302–2838(17):30660–30667

    Google Scholar 

  16. Giannarini G, Crestani A, Inferrera A, Rossanese M, Subba E, Novara G et al (2019) Impact of enhanced recovery after surgery protocols versus standard of care on perioperative outcomes of radical cystectomy: a systematic review and meta-analysis of comparative studies. Miner Urol Nefrol 71(4):309–323

    Google Scholar 

  17. Dunkman WJ, Manning MW, Whittle J, Hunting J, Rampersaud EN, Inman BA et al (2019) Impact of an enhanced recovery pathway on length of stay and complications in elective radical cystectomy: a before and after cohort study. Perioper Med (Lond) 22(8):9

    Article  Google Scholar 

Download references

Acknowledgements

The authors are grateful to Mr. Stuart Pocock, Professor of Medical Statistics, University of London, for reviewing the manuscript.

Funding

This study was partly funded by Pharmaceutical Labs ROVI, S.A.

Author information

Authors and Affiliations

  1. Department of Urology, Hospital Universitario Fundación Alcorcón, c\Budapest no. 1, 28922, Alcorcón, Madrid, Spain

    C. Llorente, A. Guijarro, V. Hernández & G. Fernández-Conejo

  2. Department of Urology, Hospital Universitario 12 de Octubre, Madrid, Spain

    J. Passas, L. Aguilar & A. Tejido

  3. Department of Urology, Hospital Universitario Gregorio Marañón, Madrid, Spain

    C. Hernández, M. Moralejo & D. Subirá

  4. Department of Urology, Fundación Jimenez Díaz, Madrid, Spain

    C. González-Enguita & A. Husillos

  5. Department of Urology, Hospital Príncipe de Asturias, Madrid, Spain

    F. Ortiz & M. Sánchez-Chapado

  6. Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain

    J. Carballido & I. Castillón

  7. Department of Urology, Hospital de Getafe, Madrid, Spain

    E. Mateo & I. Romero

  8. Department of Urology, Hospital Universitario de Torrejón, Madrid, Spain

    J. Fernández del Álamo & L. Llanes

  9. Department of Urology, Hospital Universitario Rey Juan Carlos, Madrid, Spain

    C. Blázquez & M. Sánchez-Encinas

  10. Department of Urology, Hospital Severo Ochoa, Madrid, Spain

    J. Borrego & M. Téllez

  11. Department of Urology, Hospital Infanta Leonor, Madrid, Spain

    L. Díez & V. M. Carrero

  12. Department of Research, Hospital Universitario Fundación Alcorcón, Madrid, Spain

    E. Pérez-Fernández

  13. Department of Anesthesiology, Hospital Universitario Fundación Alcorcón, Madrid, Spain

    L. Fuentes-Ramirez & S. García Del Valle

Authors
  1. C. Llorente
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  2. A. Guijarro
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  3. V. Hernández
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  4. G. Fernández-Conejo
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  5. J. Passas
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  6. L. Aguilar
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  7. A. Tejido
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  8. C. Hernández
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  9. M. Moralejo
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  10. D. Subirá
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  11. C. González-Enguita
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  12. A. Husillos
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  13. F. Ortiz
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  14. M. Sánchez-Chapado
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  15. J. Carballido
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  16. I. Castillón
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  17. E. Mateo
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  18. I. Romero
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  19. J. Fernández del Álamo
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  20. L. Llanes
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  21. C. Blázquez
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  22. M. Sánchez-Encinas
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  23. J. Borrego
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  24. M. Téllez
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  25. L. Díez
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  26. V. M. Carrero
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  27. E. Pérez-Fernández
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  28. L. Fuentes-Ramirez
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  29. S. García Del Valle
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Contributions

CL: project development, manuscript writing, and data collection. AG: data collection and manuscript editing. VH: manuscript editing and data collection. GFC: manuscript editing and data collection. JP: data collection. LA: data collection. AT: data collection. CH: data collection. MM: data collection. DS: data collection. CGE: data collection. AH: data collection. FO: data collection. MSC: data collection. JC: data collection. IC: data collection. EM: data collection. IR: data collection. JFA: data collection. LL: data collection. CB: data collection. MSE: data collection. JB: data collection. MT: data collection. LD: data collection. VMC: data collection. EPF: data analysis. LFR: data collection. SGDV: data collection.

Corresponding author

Correspondence to C. Llorente.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in the present study involving human participants were in accordance with the ethical standards of the Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Llorente, C., Guijarro, A., Hernández, V. et al. Outcomes of an enhanced recovery after radical cystectomy program in a prospective multicenter study: compliance and key components for success. World J Urol 38, 3121–3129 (2020). https://doi.org/10.1007/s00345-020-03132-z

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  • DOI: https://doi.org/10.1007/s00345-020-03132-z

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