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Yanada BA, Dias BH, Corcoran NM, Zargar H, Bishop C, Wallace S, Hayes D, Huang JG. Implementation of the enhanced recovery after surgery protocol for radical cystectomy patients: A single centre experience. Investig Clin Urol 2024; 65:32-39. [PMID: 38197749 PMCID: PMC10789537 DOI: 10.4111/icu.20230282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 10/18/2023] [Accepted: 11/22/2023] [Indexed: 01/11/2024] Open
Abstract
PURPOSE The enhanced recovery after surgery (ERAS) protocol for radical cystectomy aims to facilitate postoperative recovery and hasten a return to normal daily activities. This study aims to report on the perioperative outcomes of implementation of an ERAS protocol at a single Australian institution. MATERIALS AND METHODS We identified 73 patients with pT1-T4 bladder cancer who underwent open radical cystectomy at Western Health, Victoria between June 2016 and August 2021. A retrospective analysis of a prospectively maintained database was performed. Perioperative outcomes included length of hospital stay, nasogastric tube requirement and duration of postoperative ileus. RESULTS The median age was 74 years (interquartile range [IQR] 66-78) for the ERAS group and 70 years (IQR 65-78) for the pre-ERAS group patients. All patients in each group underwent ileal conduit formation. The median length of hospital stay was 7.0 days (IQR 7.0-9.3) for the ERAS group and 12.0 days (IQR 8.0-16.0) for the pre-ERAS group (p=0.003). Within the ERAS group, 25.0% had a postoperative ileus, and 25.0% had a nasogastric tube inserted, compared with 64.9% (p=0.001) and 45.9% (p=0.063) respectively within pre-ERAS group. The median bowel function recovery time, defined as duration from surgery to first bowel action, was 5.0 days (IQR 4.0-7.0) in the ERAS group and 7.5 days (IQR 5.0-8.5) in the pre-ERAS group (p=0.016). CONCLUSIONS Implementation of an ERAS protocol is associated with a reduction in hospital length of stay, postoperative ileus and bowel function recovery time.
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Affiliation(s)
- Brendan A Yanada
- Department of Urology, Western Health, Footscray, VIC, Australia.
| | - Brendan H Dias
- Department of Urology, Western Health, Footscray, VIC, Australia
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
| | - Niall M Corcoran
- Department of Urology, Western Health, Footscray, VIC, Australia
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia
| | - Homayoun Zargar
- Department of Urology, Western Health, Footscray, VIC, Australia
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
| | - Conrad Bishop
- Department of Urology, Western Health, Footscray, VIC, Australia
| | - Sue Wallace
- Department of Urology, Western Health, Footscray, VIC, Australia
| | - Diana Hayes
- Department of Urology, Western Health, Footscray, VIC, Australia
| | - James G Huang
- Department of Urology, Western Health, Footscray, VIC, Australia
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Nordkamp S, Creemers DMJ, Glazemakers S, Ketelaers SHJ, Scholten HJ, van de Calseijde S, Nieuwenhuijzen GAP, Tolenaar JL, Crezee HW, Rutten HJT, Burger JWA, Bloemen JG. Implementation of an Enhanced Recovery after Surgery Protocol in Advanced and Recurrent Rectal Cancer Patients after beyond Total Mesorectal Excision Surgery: A Feasibility Study. Cancers (Basel) 2023; 15:4523. [PMID: 37760492 PMCID: PMC10526990 DOI: 10.3390/cancers15184523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION The implementation of an Enhanced Recovery After Surgery (ERAS) protocol in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) has been deemed unfeasible until now because of the heterogeneity of this disease and low caseloads. Since evidence and experience with ERAS principles in colorectal cancer care are increasing, a modified ERAS protocol for this specific group has been developed. The aim of this study is to evaluate the implementation of a tailored ERAS protocol for patients with LARC or LRRC, requiring beyond total mesorectal excision (bTME) surgery. METHODS Patients who underwent a bTME for LARC or LRRC between October 2021 and December 2022 were prospectively studied. All patients were treated in accordance with the ERAS LARRC protocol, which consisted of 39 ERAS care elements specifically developed for patients with LARC and LRRC. One of the most important adaptations of this protocol was the anaesthesia procedure, which involved the use of total intravenous anaesthesia with intravenous (iv) lidocaine, iv methadone, and iv ketamine instead of epidural anaesthesia. The outcomes showed compliance with ERAS care elements, complications, length of stay, and functional recovery. A follow-up was performed at 30 and 90 days post-surgery. RESULTS Seventy-two patients were selected, all of whom underwent bTME for either LARC (54.2%) or LRRC (45.8%). Total compliance with the adjusted ERAS protocol was 73.6%. Major complications were present in 12 patients (16.7%), and the median length of hospital stay was 9 days (IQR 6.0-14.0). Patients who received multimodal anaesthesia (75.0%) stayed in the hospital for a median of 7.0 days (IQR 6.8-15.5). These patients received fewer opioids on the first three postoperative days than patients who received epidural analgesia (p < 0.001). CONCLUSIONS The implementation of the ERAS LARRC protocol seemed successful according to its compliance rate of >70%. Its complication rate was substantially reduced in comparison with the literature. Multimodal anaesthesia is feasible in beyond TME surgery with promising effects on recovery after surgery.
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Affiliation(s)
- Stefi Nordkamp
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
- Department of GROW, School for Oncology and Reproduction, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Davy M. J. Creemers
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
| | - Sofie Glazemakers
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
| | - Stijn H. J. Ketelaers
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
| | - Harm J. Scholten
- Department of Anaesthesiology, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | | | | | - Jip L. Tolenaar
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
| | - Hendi W. Crezee
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
| | - Harm J. T. Rutten
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
- Department of GROW, School for Oncology and Reproduction, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Jacobus W. A. Burger
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
| | - Johanne G. Bloemen
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
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Huang JTH, Cole AP, Mossanen M, Preston MA, Wang Y, Kibel AS, Chung BI, Huang WJ, Chang SL. Alvimopan Is Associated With a Reduction in Length of Stay and Hospital Costs for Patients Undergoing Radical Cystectomy. Urology 2020; 140:115-121. [DOI: 10.1016/j.urology.2020.01.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/28/2019] [Accepted: 01/06/2020] [Indexed: 12/14/2022]
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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. 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.
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Schulz GB, Grimm T, Buchner A, Jokisch F, Kretschmer A, Casuscelli J, Ziegelmüller B, Stief CG, Karl A. Surgical High-risk Patients With ASA ≥ 3 Undergoing Radical Cystectomy: Morbidity, Mortality, and Predictors for Major Complications in a High-volume Tertiary Center. Clin Genitourin Cancer 2018; 16:e1141-e1149. [PMID: 30174234 DOI: 10.1016/j.clgc.2018.07.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND The purpose of this study was to investigate major complications and risk factors for adverse clinical outcome in surgical high-risk (American Society of Anesthesiologists [ASA] 3-4) patients undergoing radical cystectomy (RC) in a high-volume setting. PATIENTS AND METHODS A total of 1206 patients underwent RC between 2004 and 2017 in our institution and were included. We assessed complications graded by the Clavien-Dindo-Classification system (CDC) in addition to the 90-day mortality rate and stratified results by the ASA classification. In a multivariate analysis, risk factors for high-grade complications (CDC ≥ 3) were tested. Additionally, outcome parameters were compared between 2004 to 2010 and 2010 to 2017. RESULTS Patients with ASA ≥ 3 presented with more locally advanced tumors pT ≥ 3 (52.1% vs. 42.4%; P = .002) and positive lymphatic spread N1 (27.2% vs. 23.5%; P = .001) compared with patients with ASA ≤ 2. High-grade complications were significantly (P < .001) more prevalent in patients with ASA ≥ 3 compared with patients with ASA ≤ 2: CDC3 (14.6% vs. 9.4%), CDC4 (10.2% vs. 5.4%), and CDC5 (2.5% vs. 1.0%). The 90-day mortality rate (7.6% vs. 3.2%; P = .002) and perioperative reinterventions (23.5% vs. 13.1%; P < .001) were elevated in patients with ASA ≥ 3. ASA (odds ratio [OR], 2.701, 95% confidence interval [CI], 1.089-6.703; P = .032), previous abdominal operations (OR, 1.683; 95% CI, 1.188-2.384; P = .003), and body mass index ≥ 30 (OR, 1.533; 95% CI, 1.021-2.304; P = .039) proved to function as independent predictors for major complications. CDC ≥ 3 complications (31.7% vs. 24.3%; P = .029) and 90-day mortality (10.4% vs. 5.6%; P = .018) were significantly lower in the second half of the study period. CONCLUSIONS Mortality and morbidity in surgical high-risk patients with ASA 3 to 4 undergoing RC is about twice as high compared with patients with ASA 1 to 2. ASA, previous abdominal operations, and elevated body mass index independently predict adverse clinical outcome in patients with ASA 3 to 4. Our results may help to weigh the surgical risk of RC in multimorbid patients.
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Affiliation(s)
- Gerald B Schulz
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany.
| | - Tobias Grimm
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany
| | - Alexander Buchner
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany
| | - Friedrich Jokisch
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany
| | | | | | | | - Christian G Stief
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany
| | - Alexander Karl
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany
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Abstract
BACKGROUND Alvimopan is used in abdominal surgery to reduce postoperative ileus in patients undergoing small bowel resections with primary anastomosis. The role and efficacy of alvimopan in patients undergoing radical cystectomy with urinary diversion is not well understood. OBJECTIVES To assess the effects of alvimopan in the context of enhanced recovery pathways compared to enhanced recovery pathways alone for perioperative bowel dysfunction in patients undergoing radical cystectomy. SEARCH METHODS The terms alvimopan and cystectomy were used to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. We also reviewed abstracts from the past four years (2013 to 2016) of the American Urologic Association, Society of Urologic Oncology, and American Society of Clinical Oncology Genitourinary Cancers. SELECTION CRITERIA We searched for randomized controlled trials that compared alvimopan to placebo. DATA COLLECTION AND ANALYSIS This study was based on a published protocol. We performed a comprehensive search of multiple databases including CENTRAL in the Cochrane Library, MEDLINE, Embase, LILACS, Web of Science, Scopus and Biosis, which we last updated on 6 February 2017. We also searched abstract proceedings for major relevant meetings (2013 to 2016), databases of the grey literature, trial registries, citations of relevant reviews and contacted clinical experts and the drug manufacturer.Two independent reviewers screened the literature in two stages (title and abstract, full-text) using Covidence software. Two independent reviewers assessed the risk of bias on a 'per outcome' basis using the Cochrane 'Risk of bias; tool and rated the quality of evidence according to GRADE. Results of the single eligible trial were reported in a 'Summary of findings' table based on an intention-to-treat analysis. MAIN RESULTS Based on a single trial and moderate-quality evidence, alvimopan reduced the time to reach a composite endpoint of tolerance of solid food and documented bowel movements (hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.41 to 2.23). This represents 165 more patients (109 more to 207 more) per 1000 meeting this endpoint within 10 days of surgery. Based on moderate-quality evidence, alvimopan reduced the time to hospital discharge (HR 1.67, 95% CI 1.38 to 2.01). This represents 138 more patients (82 more to 198 more) per 1000 being discharged within 10 days of surgery. Also based on moderate-quality evidence, alvimopan was associated with a reduced risk of major adverse events (risk ratio (RR) 0.28, 95% CI 0.18 to 0.44) representing 355 fewer patients (404 fewer to 276 fewer) with major adverse events per 1000. We downgraded this outcome for indirectness as it included adverse events that we did not consider major.In terms of secondary outcomes, alvimopan did not appear to alter the rate of readmission (RR 0.89, 95% CI 0.59 to 1.33), change the rate of any cardiovascular event (RR 0.54, 95% CI 0.27 to 1.05) or alter the mean narcotic pain medication use (mean difference 0, 95% CI 14.08 fewer to 14.08 more morphine equivalents). The quality of evidence was moderate for all three outcomes. Based on high-quality evidence, alvimopan reduced the rate of nasogastric tube replacement (RR 0.31, 95% CI 0.16 to 0.59). We did not find evidence for the drug's impact on rates of parenteral nutrition. All outcomes were short term and limited to a 30-day time horizon.Based on the existence of only one trial, we were unable to perform any subgroup or sensitivity analyses. AUTHORS' CONCLUSIONS In patients undergoing radical cystectomy and urinary diversion, the use of alvimopan administered as part of an enhanced recovery pathway for a limited duration (up to 15 doses for up to seven days) probably reduces the time to tolerance of solid food, time to hospital discharge and rates of major adverse events. Readmission rates, rates of cardiovascular events and narcotic pain requirements are probably similar. The need for reinsertion of nasogastric tubes is reduced. We found no evidence for the impact on rates of parenteral nutrition within 30 postoperative days.
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Affiliation(s)
- Shahnaz Sultan
- Minneapolis VA Health Care SystemGastroenterology Section III‐DOne Veterans DriveMinneapolisMinnesotaUSA55417
- University of MinnesotaDepartment of Medicine, Division of Gastroenterology, Hepatology and Nutrition420 Delaware Street SEMMC 36MinneapolisMinnesotaUSA55455
| | - Bernadette Coles
- Cardiff University Library ServicesVelindre NHS TrustVelindre Cancer CentreWhitchurchCardiffUKCF14 2TL
| | - Philipp Dahm
- Minneapolis VA Health Care SystemUrology SectionOne Veterans DriveMail Code 112DMinneapolisMinnesotaUSA55417
- University of MinnesotaDepartment of Urology420 Delaware Street SEMMC 394MinneapolisMinnesotaUSA55455
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Albisinni S, Oderda M, Fossion L, Varca V, Rassweiler J, Cathelineau X, Chlosta P, De la Taille A, Gaboardi F, Piechaud T, Rimington P, Salomon L, Sanchez-Salas R, Stolzenburg JU, Teber D, Van Velthoven R. The morbidity of laparoscopic radical cystectomy: analysis of postoperative complications in a multicenter cohort by the European Association of Urology (EAU)-Section of Uro-Technology. World J Urol 2015; 34:149-56. [PMID: 26135307 DOI: 10.1007/s00345-015-1633-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 06/24/2015] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To analyze postoperative complications after laparoscopic radical cystectomy (LRC) and evaluate its risk factors in a large prospective cohort built by the ESUT across European centers involved in minimally invasive urology in the last decade. METHODS Patients were prospectively enrolled, and data were retrospectively analyzed. Only oncologic cases were included. There were no formal contraindications for LRC: Also patients with locally advanced tumors (pT4a), serious comorbidities, and previous major abdominal surgery were enrolled. All procedures were performed via a standard laparoscopic approach, with no robotic assistance. Early and late postoperative complications were graded according to the modified Clavien-Dindo classification. Multivariate logistic regression was performed to explore possible risk factors for developing complications. RESULTS A total of 548 patients were available for final analysis, of which 258 (47%) experienced early complications during the first 90 days after LRC. Infectious, gastrointestinal, and genitourinary were, respectively, the most frequent systems involved. Postoperative ileus occurred in 51/548 (9.3%) patients. A total of 65/548 (12%) patients underwent surgical re-operation, and 10/548 (2%) patients died in the early postoperative period. Increased BMI (p = 0.024), blood loss (p = 0.021), and neoadjuvant treatment (p = 0.016) were significantly associated with a greater overall risk of experiencing complications on multivariate logistic regression. Long-term complications were documented in 64/548 (12%), and involved mainly stenosis of the uretero-ileal anastomosis or incisional hernias. CONCLUSIONS In this multicenter, prospective, large database, LRC appears to be a safe but morbid procedure. Standardized complication reporting should be encouraged to evaluate objectively a surgical procedure and permit comparison across studies.
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Affiliation(s)
- Simone Albisinni
- Department of Urology, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium. .,Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Boulevard de Waterloo 121, Brussels, Belgium.
| | - Marco Oderda
- Department of Urology, Clinique Saint Augustin, Bordeaux, France
| | - Laurent Fossion
- Department of Urology, Maxima Medisch Centrum, Eindhoven, The Netherlands
| | - Virginia Varca
- Department of Urology, Ospedale Luigi Sacco, Milan, Italy
| | | | | | - Piotr Chlosta
- Department of Urology, Jagiellonian University, Kraków, Poland
| | | | | | - Thierry Piechaud
- Department of Urology, Clinique Saint Augustin, Bordeaux, France
| | - Peter Rimington
- Department of Urology, East Sussex Healthcare NHS Trust, Eastbourne, UK
| | | | | | | | - Dogu Teber
- Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - Roland Van Velthoven
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Boulevard de Waterloo 121, Brussels, Belgium
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