Prospective implementation of enhanced recovery after surgery to radical cystectomy at the University of Alberta Hospital

ERAS and Radical cystectomy

Abstract

Title: Prospective implementation of enhanced recovery after surgery to radical cystectomy at the University of Alberta Hospital
Authors: Graeme Follett*1, Niels-Erik Jacobsen1, Heather Ting2, Nupur Agarwal1, Adrian Fairey1 
Affiliations: 1Division of Urology, Department of Surgery, University of Alberta; 2Department of Anesthesia and Pain Medicine, University of Alberta; *Denotes presenting Author
Exhibited: 1. 2019 Canadian Association of Physician Assistant Annual Conference; 2. Canadian Urologic Association annual meeting 2019
Introduction and Objectives: Enhanced recovery after surgery (ERAS) pathways have been introduced in surgical oncology to facilitate postoperative recovery. Patients undergoing radical cystectomy and urinary diversion for bladder cancer may be ideal candidates for an ERAS pathway as the potential for surgical stress and postoperative serious adverse events (SAE) is high. We determined whether implementation of a Cystectomy Enhanced Recovery Pathway (CERP) improved clinical outcomes at the University of Alberta Hospital (UAH).
Materials and Methods: The study was a nonrandomized quasi-experimental design. Data was collected between December 2015 and May 2018. Eligible subjects were those with biopsy-proven bladder cancer (cTanyN1-3M0) undergoing curative intent open radical cystectomy and urinary diversion by 1 of 2 fellowship-trained urologic oncologists at the UAH. The CERP was implemented in August 2017. The CERP included 26 components including same day admission, carbohydrate fluid loading, targeted intraoperative fluid resuscitation, regional postoperative analgesia, cessation of nasogastric tubes, early mobilization, and chewing gum use. The opioid receptor antagonist, alvimopan, was not utilized as this drug does not have Health Canada approval. The primary endpoint was length of hospital stay (LOS). Secondary endpoints were 30-day mortality rate, SAE, and readmission to hospital. Statistical tests were two-sided (p≤0.05).
Results: Data were evaluated for 48 subjects managed with CERP and 51 subjects not managed with CERP. Baseline demographic, clinical, and pathologic characteristics did not differ between groups (all comparisons, p>0.05). Median LOS was 9 days (range, 7-12 days) in the CERP group versus 13 days (range, 9-16) in the non-CERP group (p<0.05). SAE occurred in 3 subjects (6%) in the CERP group versus 6 subjects (12%) in the non-CERP group (p<0.05). 30-day mortality (0% versus 0%) and readmission of hospital (19% versus 16%) did not differ between groups.
Conclusions: The UAH CERP was associated with decreased LOS and SAE with no increase in perioperative mortality or readmission to hospital. CERPs provide an opportunity to improve bladder cancer quality of care.