The impact of patient-related nonmodifiable factors on perioperative outcomes following radical cystectomy with enhanced recovery protocol

Background: Enhanced recovery after surgery (ERAS) protocols decrease the length of hospital stay (LOS) and complications following radical cystectomy (RC). However, the impact of non-modifiable patient factors to postoperative outcome is unclear. This study aimed to identify nonmodifiable patient and disease factors predictive of post-RC outcomes with ERAS protocols. Methods: We reviewed our institutional review board-approved prospectively maintained bladder cancer database. Patients with primary urothelial bladder cancer who underwent open RC with ERAS protocol between 2012 and 2016 were identified. Patient demographic and disease-relevant variables were reviewed. Factors predictive of LOS, 30- and 90-day complications and readmission were assessed using univariate and multivariable analyses. Results: A total of 289 patients with a median age of 70 years were included, of whom 80.6% were male, 33.6% had Charlson comorbidity index ⩾2. Median LOS was 4 days and 21.1% received intraoperative transfusion. The 30-day complication and readmission rates were 58.8% and 16.6%, respectively. Age >70 ( p = 0.02), Charlson comorbidity index ⩾2 ( p = 0.005), and intraoperative transfusion ( p = 0.03) were significantly associated with LOS. Intraoperative transfusion was significantly associated with 30-day complication and readmission ( p = 0.008, p = 0.005, respectively). No factor was found to be significantly associated with 90-day complication or readmission. Conclusions: With ERAS protocol, non-modifiable patient and disease factors influence outcomes after RC. Risk adjustment for these factors is important for patient counseling, quality assessment and future reimbursement.

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Evaluation of an enhanced recovery protocol on patients having radical cystectomy for bladder cancer

Canadian Urological Association Journal ◽

10.5489/cuaj.5273 ◽

2018 ◽

Vol 12 (12) ◽

Cited By ~ 4

Author(s):

Bonnie Liu ◽

Trustin Domes ◽

Kunal Jana

Keyword(s):

Bladder Cancer ◽

Radical Cystectomy ◽

Enhanced Recovery ◽

Effective Means ◽

Control Group ◽

Complication Rates ◽

Readmission Rates ◽

Significant Difference ◽

And Gender ◽

Eras Protocol

Introduction: Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care protocols that are designed to shorten recovery time and reduce complication rates.1,2 An ERAS protocol was implemented in the Saskatoon Health region for radical cystectomy patients in 2013. This study evaluates the safety and efficacy of the protocol for patients having radical cystectomy for bladder cancer. Methods: Length of stay (LOS), early in-hospital complication rates, 30-day readmission rates, age, and gender were collected for patients seen for bladder cancer requiring radical cystectomy in Saskatoon between January 2007 and December 2016. Of these patients, 176 were pre-ERAS implementation (control group) and 84 were post-ERAS implementation (experimental group). The data from each variable was compared between the groups using a Z-test. Results: There was no significant difference in age or gender of patients between the groups. Average LOS pre-ERAS was 14.25±14.57 days, which is significantly longer than the post-ERAS average of 10.91±8.56 days (p=0.043). There was no significant difference in 30-day readmission rate (19.87% pre-ERAS vs. 19.05% post-ERAS; p=0.873) or complication rate (51.7% pre-ERAS vs. 46.4% post-ERAS; p=0.425). Conclusions: The implementation of an ERAS protocol for radical cystectomy reduces LOS, with no effect on early complication rates or 30-day readmission rates. This indicates that the protocol is safe for patients when compared to previous practices and is an effective means of reducing LOS.

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Age above 70 years and Charlson Comorbidity Index higher than 3 are associated with reduced survival probabilities after radical cystectomy for bladder cancer. Data from a contemporary series of 334 consecutive patients

Archivio Italiano di Urologia e Andrologia ◽

10.4081/aiua.2021.1.15 ◽

2021 ◽

Vol 93 (1) ◽

pp. 15-20

Author(s):

Massimo Maffezzini ◽

Vincenzo Fontana ◽

Andrea Pacchetti ◽

Federico Dotta ◽

Mattia Cerasuolo ◽

...

Keyword(s):

Bladder Cancer ◽

Radical Cystectomy ◽

Survival Data ◽

Charlson Comorbidity Index ◽

Death Rate ◽

Joint Effect ◽

Cancer Data ◽

Multivariate Modelling ◽

Comorbidity Index ◽

Nonlinear Trends

Objective: To assess the joint effect of age and comorbidities on clinical outcomes of radical cystectomy (RC).Methods: 334 consecutive patients undergoing open RC for bladder cancer (BC) during the years 2005-2015 were analyzed. Pre-, peri- and post-operative parameters, including age at RC (ARC) and Charlson Comorbidity Index (CCI), were evaluated. Overall and cancer-specific survivals (OS, CSS) were assessed by univariate and multivariate modelling. Furthermore, a three-knot restricted cubic spline (RCS) was fitted to survival data to detect dependency between death-rate ratio (HR) and ARC. Results: Median follow-up time was 3.8 years (IQR = 1.3-7.5) while median OS was 5.9 years (95%CL = 3.8-9.1). Globally, 180 patients died in our cohort (53.8%), 112 of which (62.2%) from BC and 68 patients (37.8%) for unrelated causes. After adjusting for preoperative, pathological and perioperative parameters, patients with CCI > 3 showed significantly higher death rates (HR = 1.61; p = 0.022). The highest death rate was recorded in ARC = 71-76 years (HR = 2.25; p = 0.034). After fitting an RCS to both OS and CSS rates, two overlapping nonlinear trends, with common highest risk values included in ARC = 70-75 years, were observed. Conclusions: Age over 70 years and CCI > 3 were significant factors limiting the survival of RC and should both be considered when comparing current RC outcomes.

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A preliminary outcome of modified enhanced recovery protocol versus standard of care in radical cystectomy: an Indonesian experience

African Journal of Urology ◽

10.1186/s12301-021-00213-2 ◽

2021 ◽

Vol 27 (1) ◽

Author(s):

Ahmad Zulfan Hendri ◽

Said Alfin Khalilullah ◽

Gede Andi Aditya

Keyword(s):

Length Of Stay ◽

Radical Cystectomy ◽

Enhanced Recovery ◽

Standard Of Care ◽

Postoperative Recovery ◽

Perioperative Outcomes ◽

Drain Removal ◽

Enhanced Recovery Protocol ◽

Movement Mobilization ◽

Eras Protocol

Abstract Background This study aimed to evaluate the outcomes of modified Enhanced Recovery After Surgery (ERAS) protocol and standard of care (SC) in bladder cancer patients who underwent radical cystectomy (RC). The length of stay and complications rates were the primary outcomes. Time functional recovery, bowel movement, mobilization, drain removal, and other perioperative outcomes were the secondary outcomes. Methods A cohort retrospective study was conducted to investigate the effectiveness of the modified ERAS protocol compared to SC in 61 patients who underwent RC (36 ERAS vs. 25 SC). Results The modified ERAS protocol was associated with shorter length of stay (9.3 ± 5.0 days vs. 12.6 ± 6.7 days, P = 0.032) and reduction in important postoperative milestones, including days to first solid diet (3.5 ± 1.6 vs. 5.5 ± 1.5, P = 0.000), days to first defecation (4.8 ± 2.4 vs. 7.2 ± 2.4, P = 0.001), days to first walking (4.7 ± 2.2 vs. 7.9 ± 2.4, P = 0.000), and days to drain removal (3.9 ± 1.3 vs. 5.9 ± 2.5 P = 0.001). Postoperative complications rates were lower in the modified ERAS groups, but the result was not statistically significant (P = 0.282). Also, there were no significant differences between transfusion requiring, intensive care monitoring, re-operation, and re-admission between groups. Conclusion This study demonstrated that the modified ERAS protocol for RC can accelerate postoperative recovery without any adverse effects on morbidity and mortality.

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Enhanced recovery after robotic assisted radical cystectomy negates the impact of sarcopenia on perioperative outcomes

European Urology Supplements ◽

10.1016/s1569-9056(18)32728-3 ◽

2018 ◽

Vol 17 (7) ◽

pp. e2349

Author(s):

P. Pavlakis ◽

M. Kusuma ◽

P. Alexopoulou ◽

S. Sarkar ◽

C. Jones ◽

...

Keyword(s):

Radical Cystectomy ◽

Enhanced Recovery ◽

Perioperative Outcomes ◽

Robotic Assisted ◽

The Impact

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Sarcopenia as a predictor of perioperative outcomes following radical cystectomy in a contemporary cohort of patients with bladder cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.e16031 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. e16031-e16031

Author(s):

Nicholas Brent Drury ◽

William Mills Worrilow ◽

Hamza Mustafa Beano ◽

Myra M. Robinson ◽

Jeffrey Ignatoff ◽

...

Keyword(s):

Bladder Cancer ◽

Radical Cystectomy ◽

Care Pathway ◽

Perioperative Outcomes ◽

International Consensus ◽

Consensus Definition ◽

Cancer Specific Survival ◽

Perioperative Care Pathway ◽

The Impact

e16031 Background: Sarcopenia has gained considerable recognition as an important prognostic factor for complications, longer hospital stay, and survival following cystectomy for bladder cancer. However, inconsistent cutoff values to define sarcopenia have been utilized throughout the literature. Our aim was to evaluate sarcopenia as a predictor of outcomes following radical cystectomy with urinary diversion (RCUD) using the international consensus definition, Martin criteria, and Mayr criteria, as a standardized cutoff value would potentially reduce bias across studies. Methods: A retrospective analysis of patients treated with RCUD at our institution between 2010 and 2017 was performed. Sarcopenia was defined according to the aforementioned criteria and assessed by measuring total psoas area (TPA) on preoperative computerized tomography. The impact of sarcopenia on perioperative outcomes, cancer-specific survival (CSS), and overall survival (OS) was evaluated with univariate and multivariate regression models. Results: Of 258 patients who underwent RCUD, 195 had available computed tomography scans within 90 days of surgery. The median TPA scores among men and women were 578.0 and 459.6 mm2/mm2, respectively. The overall incidence of sarcopenia according to the international consensus definition, Martin criteria, and Mayr criteria was 36.4% (71/195), 24.1% (47/195), and 31.3% (61/195), respectively. Regardless of definition, significant differences were not observed in length of stay, high grade complications, readmissions, and discharge destination (all P > .05). Furthermore, sarcopenia was not significantly associated with CSS or OS. The median follow-up time was 4.1 years (95% CI: 3.6 - 4.4). The 5-year CSS and OS were 46.3% and 66.2%, respectively. Conclusions: Irrespective of definition, we were unable to externally validate sarcopenia as a predictor of perioperative outcomes in our contemporary cohort. Future studies will evaluate the impact of our evolving perioperative care pathway on oncological outcomes, including its ability to mitigate the effects of sarcopenia through reducing the physiological and mental demands of surgery.

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