Radical Cystectomy: Enhanced Recovery After Surgery Protocol Video & Transcript
Mark A. Preston, MD, MPH
Department of Urology, Brigham and Women’s Hospital
Instructor in Surgery, Harvard Medical School
A radical cystectomy is an operation performed to remove the bladder, along with the pelvic lymph nodes, and then to create urinary diversion to create an alternate route for urine passage in patients who have muscle-invasive or otherwise aggressive bladder cancer.
Radical cystectomy and urinary diversion for bladder cancer is one of the most complex operations that we perform, with high rates of complications, typically about 50%, along with a prolonged length of stay, which might be seven or eight days on average. On average this surgery is five, six hours or even longer, and it involves multiple body compartments. Removing the bladder and then the prostate in men from deep in the pelvis to working with the small bowels to basically divide them and take a portion to create the urinary diversion and put the bowels back together.
Improved Recovery After Surgery
The bowels are an important aspect of what keeps patients in the hospital, can result in complications, and is also what results in a lot of the symptoms that they have post-operatively. So a lot of what these measures do is try to optimize bowel function.
What we're doing here at Brigham and Women's Hospital is implementing an enhanced recovery after surgery protocol for all our patients undergoing radical cystectomy. What we have found in the patients who have had radical cystectomies on this protocol is a shorter length of stay. The length of stay now is between four to five days as opposed to seven or eight days. And what we do can be broken down into what happens preoperatively, operatively, and post-operatively.
From a preoperative perspective, some of the key differences is that we no longer do a bowel preparation ahead of time. We found that dehydrated patients and resulted in some electrolyte abnormalities. We also provide them with a high-energy carbohydrate drink that they take about two to three hours before surgery, which could provide some additional energy for getting through the course of the day.
And then the key aspects during the operation are multi-modal pain management to minimize the use of narcotics, which could slow the bowel down and create an ileus or basically a bowel that's slow to recover after surgery. It's minimizing fluids during the operation to reduce the fluid overload. And then during to post-operative setting, the key aspects early ambulation and we want to get you up walking frequently.
And then it's earlier feeding. As opposed to not feeding you for five days until you have start passing gas or having bowel movements, we give you clear fluids on day one and then a regular diet on day two. And we found that that can actually maintain your bowel and bodily functions and result in a quicker return home, and what we hope will be less complications.
Engaging Patients in the Recovery Process
Patients are actually very happy with the protocol because a lot of the protocol involves patient engagement. We talk to them in the preoperative setting in the clinic and we say, this is the surgery that you're having. You're going to be on the enhanced recovery protocol with goals of getting you back to your full function is as soon as possible. And what it does is it helps standardize the process so all the key players throughout the care of the patient, from the nurses to the residents to anesthesiologists and the surgeons and the physician assistants are all on board with what needs to happen for that patient. So that they recover as quickly as possible with as few issues as possible.
We are currently at Brigham and Women's Hospital launching an initiative of perioperative care management using these enhanced recovery protocols for radical cystectomies and colorectal surgery. And in addition to that, looking at aspects of sarcoma surgery or plastic surgery or other surgical specialties that might also benefit from some of these evidence-based aspects of this enhanced recovery protocol so that all patients may benefit.