Abstract
Purpose of Review
The purpose of the study is to review and summarize major additions to the literature as pertains to enhanced recovery protocols after radical cystectomy in the past year.
Recent Findings
Enhanced recovery after surgery protocols is multimodal pathways that include elements to optimize all stages of care including preoperative, intraoperative and postoperative measures. Several authors have recently presented their results with initial implementation of an enhanced recovery protocol after radical cystectomy, while others have begun to examine outcomes beyond the index admission and to refine the various targeted components of the protocol.
Summary
Enhanced recovery after surgery protocols has revolutionized patient care following radical cystectomy, a procedure still burdened by high complication rates and lengthy hospital stay. Although still lacking in universal implementation and standardization of the protocol, significant advancements are made each year as we move towards best practice.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin. 2017;67(1):7–30.
Kim SP, Shah ND, Karnes RJ, Weight CJ, Frank I, Moriarty JP, et al. The implications of hospital acquired adverse events on mortality, length of stay and costs for patients undergoing radical cystectomy for bladder cancer. J Urol. 2012;187(6):2011–7.
Shabsigh A, Korets R, Vora KC, Brooks CM, Cronin AM, Savage C, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol. 2009;55(1):164–74.
Sun M, Ravi P, Karakiewicz PI, Sukumar S, Sammon J, Bianchi M, et al. Is there a relationship between leapfrog volume thresholds and perioperative outcomes after radical cystectomy? Urol Oncol. 2014;32(1):27.e7–13.
Arumainayagam N, McGrath J, Jefferson KP, Gillatt DA. Introduction of an enhanced recovery protocol for radical cystectomy. BJU Int. 2008;101(6):698–701.
Taub DA, Dunn RL, Miller DC, Wei JT, Hollenbeck BK. Discharge practice patterns following cystectomy for bladder cancer: evidence for the shifting of the burden of care. J Urol. 2006;176(6 Pt 1):2612–7 discussion 7-8.
Zainfeld D, Shah A, Daneshmand S. Enhanced recovery after surgery pathways: role and outcomes in the management of muscle invasive bladder cancer. Urol Clin North Am. 2018;45(2):229–39.
Zainfeld D, Djaladat H. Enhanced recovery after urologic surgery-current applications and future directions. J Surg Oncol. 2017;116(5):630–7.
Daneshmand S, Ahmadi H, Schuckman AK, Mitra AP, Cai J, Miranda G, et al. Enhanced recovery protocol after radical cystectomy for bladder cancer. J Urol. 2014;192(1):50–5.
Tyson MD, Chang SS. Enhanced recovery pathways versus standard care after cystectomy: a meta-analysis of the effect on perioperative outcomes. Eur Urol. 2016;70(6):995–1003.
Baack Kukreja JE, Messing EM, Shah JB. Are we doing “better”? The discrepancy between perception and practice of enhanced recovery after cystectomy principles among urologic oncologists. Urol Oncol. 2016;34(3):120.e17–21.
• Pang KH, Groves R, Venugopal S, Noon AP, JWF C. Prospective implementation of enhanced recovery after surgery protocols to radical cystectomy. Eur Urol. 2018;73(3):363–71 In this large prospective cohort from the United Kingdom, an enhanced reovery protocol was used to shorten LOS from a median of 18 to 8 days while also lowering readmission rates. These results showed improved recovery for patients with an enhanced reocovery protocol in a system without financial incentive for early discharge.
Lin T, Li K, Liu H, Xue X, Xu N, Wei Y, et al. Enhanced recovery after surgery for radical cystectomy with ileal urinary diversion: a multi-institutional, randomized, controlled trial from the Chinese bladder cancer consortium. World J Urol. 2018;36(1):41–50.
Baack Kukreja JE, Kiernan M, Schempp B, Siebert A, Hontar A, Nelson B, et al. Quality improvement in cystectomy care with enhanced recovery (QUICCER) study. BJU Int. 2017;119(1):38–49.
Miller C, Campain NJ, Dbeis R, Daugherty M, Batchelor N, Waine E, et al. Introduction of robot-assisted radical cystectomy within an established enhanced recovery programme. BJU Int. 2017;120(2):265–72.
Tan WS, Tan MY, Lamb BW, Sridhar A, Mohammed A, Baker H, et al. Intracorporeal robot-assisted radical cystectomy, together with an enhanced recovery programme, improves postoperative outcomes by aggregating marginal gains. BJU Int. 2018;121(4):632–9.
Zainfeld D, Cai J, Miranda G, Schuckman A, Daneshmand S, Djaladat H. PD36-02 impact of non-modifiable patient factors on perioperative outcome following radical cystectomy with enhanced recovery protocol. J Urol. 2017;197(4):e668–e9.
Osawa T, Ambani SN, Olugbade K Jr, Skolarus TA, Weizer AZ, Montgomery JS, et al. Potential implications of shortening length of stay following radical cystectomy in a pre-ERAS population. Urology. 2017;102:92–9.
Lorentz CA, Gilbert K, Alemozaffar M, Patil D, Filson CP. Risk of readmission after uncomplicated hospitalization after radical cystectomy. Clin Genitourin Cancer. 2018;16:e705–10.
Altobelli E, Buscarini M, Gill HS, Skinner EC. Readmission rate and causes at 90-day after radical cystectomy in patients on early recovery after surgery protocol. Bladder cancer (Amsterdam, Netherlands). 2017;3(1):51–6.
Djaladat H, Katebian B, Bazargani ST, Miranda G, Cai J, Schuckman AK, et al. 90-day complication rate in patients undergoing radical cystectomy with enhanced recovery protocol: a prospective cohort study. World J Urol. 2017;35(6):907–11.
•• Chipollini J, Tang DH, Hussein K, Patel SY, Garcia-Getting RE, Pow-Sang JM, et al. Does implementing an enhanced recovery after surgery protocol increase hospital charges? Comparisons from a radical cystectomy program at a specialty cancer center. Urology. 2017;105:108–12 This study highlights the ability of enhanced recovery protocols to reduce variance in charges with standardization of care. Despite higher medication costs with the protocol, costs were higher for all other measured categories and with greater distribution in patients undergoing cystectomy without an enhanced recovery protocol.
Semerjian A, Milbar N, Kates M, Gorin MA, Patel HD, Chalfin HJ, et al. Hospital charges and length of stay following radical cystectomy in the enhanced recovery after surgery era. Urology. 2018;111:86–91.
• Kukreja JB, Shi Q, Chang CM, Seif MA, Sterling BM, Chen TY, et al. Patient-reported outcomes are associated with enhanced recovery status in patients with bladder cancer undergoing radical cystectomy. Surg Innov. 2018;25(3):242–50 This study focused on immediate patient reported outcomes after cystectomy, showing a greater subjective patient experience following cystectomy with an enhanced recovery protocol compared to without. This highligts a need to examine outcomes beyond routine objective measures or long term patient reported ones.
Frees SK, Aning J, Black P, Struss W, Bell R, Chavez-Munoz C, et al. A prospective randomized pilot study evaluating an ERAS protocol versus a standard protocol for patients treated with radical cystectomy and urinary diversion for bladder cancer. World J Urol. 2018;36(2):215–20.
Raynor MC, Pruthi RS. Postoperative ileus after radical cystectomy: looking for answers to an age-old problem. Eur Urol. 2014;66(2):273–4.
Pruthi RS, Nielsen M, Smith A, Nix J, Schultz H, Wallen EM. Fast track program in patients undergoing radical cystectomy: results in 362 consecutive patients. J Am Coll Surg. 2010;210(1):93–9.
Bazargani ST, Djaladat H, Ahmadi H, Miranda G, Cai J, Schuckman AK, et al. Gastrointestinal complications following radical cystectomy using enhanced recovery protocol. Eur Urol Focus. 2017. https://doi.org/10.1016/j.euf.2017.04.003.
Sultan S, Coles B, Dahm P. Alvimopan for recovery of bowel function after radical cystectomy. Cochrane Database Syst Rev. 2017;5:Cd012111.
Lee CT, Chang SS, Kamat AM, Amiel G, Beard TL, Fergany A, et al. Alvimopan accelerates gastrointestinal recovery after radical cystectomy: a multicenter randomized placebo-controlled trial. Eur Urol. 2014;66(2):265–72.
Palumbo V, Giannarini G, Crestani A, Rossanese M, Calandriello M, Ficarra V. Enhanced recovery after surgery pathway in patients undergoing open radical cystectomy is safe and accelerates bowel function recovery. Urology. 2018;115:125–32.
Voskuilen CS, van de Putte EEF, der Hulst JB, van Werkhoven E, de Blok WM, van Rhijn BWG, et al. Short-term outcome after cystectomy: comparison of early oral feeding in an enhanced recovery protocol and feeding using Bengmark nasojejunal tube. World J Urol. 2018;36(2):221–9.
Wen Wu FM, Burkhard F, Turri F, Furrer M, Loeffel L, Thalmann G, et al. Renal outcome after radical cystectomy and urinary diversion performed with restrictive hydration and vasopressor administration in the frame of an enhanced recovery program: a follow-up study of a randomized clinical trial. Urol Oncol. 2017;35(10):602.e11–7.
Bazargani ST, Ghodoussipour S, Tse B, Miranda G, Cai J, Schuckman A, et al. The association between intraoperative fluid intake and postoperative complications in patients undergoing radical cystectomy with an enhanced recovery protocol. World J Urol. 2018;36(3):401–7.
•• Myles PS, Bellomo R, Corcoran T, Forbes A, Peyton P, Story D, et al. Restrictive versus liberal fluid therapy for major abdominal surgery. N Engl J Med. 2018;378(24):2263–74 A large international randomized controlled trial that showed a restrictive intraoperative fluid regimen during major abdominal surgery was not associated with improved outcomes compared to a liberal one but was associated with increased risk of kidney injury. This adds to a growing body of evidence that optimal intraoperative fluid management consists of measures other than fluid restriction.
Van Horn C, Xu W, Cai J, Miranda G, Schuckman A, Daneshmand S, et al. MP10-12 urinary tract infection following radical cystectomy with an enhanced recovery protocol. J Urol. 2018;199(4):e121.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Saum Ghodoussipour and Hooman Djaladat each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Urothelial Cancer
Rights and permissions
About this article
Cite this article
Ghodoussipour, S., Djaladat, H. An Update in Enhanced Recovery Following Radical Cystectomy. Curr Urol Rep 19, 98 (2018). https://doi.org/10.1007/s11934-018-0855-3
Published:
DOI: https://doi.org/10.1007/s11934-018-0855-3