New Protocol Leads to Shorter Stays and Potentially Better Outcomes after Radical Cystectomies
A new surgical approach at Brigham and Women’s Hospital (BWH) enhances healing and speeds patient recovery following radical cystectomy and urinary diversion, a procedure normally associated with significant morbidity and long hospital stays.
“The goal of the evidence-based Enhanced Recovery After Surgery (ERAS) protocol is to reduce length-of-stay and improve patient outcomes after radical cystectomies performed either by open procedure or robotic-assisted technique. The protocol is aimed at decreasing the risk for ileus, surgical site infections, fluid overload, and associated cardiac complications,” explained urologist Mark A. Preston, MD, MPH, Division of Urology at BWH. “The protocol helps the body to heal in the immediate perioperative period by using evidence-based practices to maintain homeostasis and normal body functioning.”
BWH is one of only few programs in the country that has established the ERAS protocol as standard practice for all cases of elective radical cystectomy and surgeons must specifically opt out for extenuating circumstances.
“In the preoperative setting, we want patients to maintain the best nutrition possible, focusing on everything from smoking cessation to following a healthy diet. There is no bowel prep at all, because that dehydrates patients and creates electrolyte abnormalities,” Dr. Preston said.
The protocol focuses on optimizing care at each stage of the process through the coordinated efforts of urologists, anesthesiologists, nurses, physician assistants and preoperative evaluation specialists.
Following Through From Pre-op Planning to Post-op Care
The protocol begins with staff members from the Weiner Center for Preoperative Evaluation at BWH, who follow patients scheduled for cystectomy to ensure that they have an adequate carbohydrate load, nutritional support, follow an aerobic and resistance exercise regimen, stop smoking, and reduce alcohol consumption. Unlike other pre-operative management protocols, patients are not required to fast prior to the surgery.
“Patients can eat the night before and we give them a high-energy carbohydrate drink three hours before surgery,” explained Dr. Preston.
In the perioperative period, the care team works to ensure fluid optimization to minimize postoperative edema, and provides multimodal pain management with the goal of maximizing pain control while minimizing the use of opioids, which slow bowel processes and can significantly delay healing. Pain management may include the use of epidural anesthesia and analgesic agents such as gabapentin, acetaminophen, celecoxib and alvimopan, a peripherally-acting opioid antagonist that can lessen the negative effects on bowel function caused by standard opioids such as morphine. In addition, patients do not receive nasogastric tubes following surgery, which are uncomfortable and without evidence of benefit when used in a routine fashion.
The day after surgery, patients are started on clear fluids, and they begin to eat solid foods on the second post-operative day.
“We’re feeding patients much sooner than we used to,” Dr. Preston said. “It’s a change in definition of the return of bowel function. Previously we defined return of bowel function when patients passed gas or had a bowel movement. Now, it’s defined as tolerating an oral diet. Patients also have early and frequent ambulation to further stimulate return of bowel function.”
Length-of-stay in these cases is dramatically shorter, on the order of four or five days, noted Dr. Preston. In contrast, lengths-of-stay following conventional radical cystectomy and urinary diversion can be seven to eight days.
Dr. Preston and colleagues are collecting data prospectively and expect to find that adoption of the protocol is associated with significant improvements in patient outcomes and lower overall costs related to shorter lengths of stay and fewer perioperative and/or post-operative complications.