The Exchange

Commentary and Observations from
the Medical Front Lines

Enhanced Recovery After Surgery (ERAS) Protocol Use in Cystectomy for Bladder Cancer

Enhanced Recovery After Surgery (ERAS) Protocol Use in Cystectomy for Bladder Cancer

Bladder cancer affects 64,280 men and 19,450 women annually in the United States. Most are older than age 55, and the majority are older than 73, with multiple comorbid conditions. The gold standard for both muscle invasive and high-risk, non-muscle invasive bladder cancer is radical cystectomy with pelvic lymph node dissection and urinary diversion. To ensure best patient outcomes following cystectomy, most academic centers are considering the use of standardized care pathways; often, this includes a pathway called Enhanced Recovery After Surgery (ERAS).

ERAS is a model of care introduced in 1997 by a group of general surgeons from Northern Europe with experience in colorectal fast track surgery; it was led by Professor Henrik Kehlet. An ERAS serves as a multimodal perioperative care pathway to maintain preoperative organ function and to reduce physiological stress and postoperative organ dysfunction.

The ultimate focus is on faster recovery with earlier discharge and decreased readmissions, which translates into better outcomes for patients as well as cost management. Typically, such protocols include perioperative opioid-sparing analgesia, consideration of a laparoscopic or robotic approach for the resection, avoidance of nasogastric tubes and peritoneal drains, aggressive management of postoperative nausea and vomiting, and early oral feedings and ambulation. While these protocols were first initiated in patients undergoing colorectal surgery, they are very relevant and important for the bladder cancer population as well.

Typically, ERAS protocols include 15-20 elements combined to form a multimodal pathway. These elements span the continuum of the pre-, intra-, and postoperative periods. Separately, individual elements result in modest gains, but when used in a complementary fashion they can decrease postoperative stress responses, thereby reducing the duration of postoperative ileus, surgical complications, incisional pain, recovery time, and length of hospital stay. Of the recommended elements, the relative contribution of each individual element is unknown.

General elements in most ERAS pathways include:

  • Preoperative strategies: medical risk evaluation and patient education, including stoma site selection and management, bowel preparation, and fasting policies
  • Medical risk interventions: optimization of medical comorbidities, including cardiovascular, respiratory, and/or renal disease
  • Addressing social and behavioral factors such as illicit drug use, tobacco use, and alcohol dependency

Elements may also include: diet and fasting guidelines, use of medications (such as alvimopan) that may help in reducing postoperative ileus, intraoperative strategies (including use of certain anesthetic agents, lung protective ventilation, fluid management, temperature regulation, and reduced use of peritoneal drains), and pain management (peri-, intra-, and postoperative) with a focus on decreasing opioid use and strategies that provide good pain relief in the early postoperative days. Still other elements focus on postoperative fluid management; postoperative diet recommendations with early feeding, early mobilization, and avoidance of nasogastric tubes; avoiding infectious complications; and early discharge.

Discharge criteria with ERAS are similar to those of traditional care, but patients following ERAS may meet these discharge criteria sooner.

At my institution, ERAS was first implemented in the colorectal surgery population with significant reductions in length of hospital stay, improved perioperative pain management, and fewer postoperative complications. Now, my institution also uses ERAS protocols for patients undergoing radical cystectomy for bladder cancer.

At my institution there are 4 main stages of this concept:

  1. Intensive preparation to provide information and education to patient and caregivers
  2. Reducing the physical stress of the operation by allowing oral intake up to 2 hours before surgery and avoiding a rigorous bowel prep
  3. Pain relief plan that limits use of opioids to promote comfort and recovery
  4. Early feeding and ambulation after surgery, as soon as medically appropriate

Future trends include ERAS pathways for other urologic surgeries such as radical prostatectomy, as well as for vascular surgeries and thoracic surgeries.

References

Filed under: Urology

Development Widget