BCa18: Benefits of ERAS following radical cystectomy

09 June 2018

Radical cystectomy is the standard for muscle-invasive bladder cancer and with mostly elderly men as patients, doctors are seeking ways to improved recovery regimes following radical surgeries.

“64% of patients have one or more complications, 13% have a major complication and 20% are re-admitted after surgery,” said James Catto (UK) who discussed the role of Enhanced Recovery After Surgery (ERAS) for patients who underwent radical cystectomy (RC).

Catto mentioned that a typical patient profile is a male who is more than 70 years old with half of them having a history of heavy smoking. Most of these patients also have competed for mortality and co-existing diseases such as cardiovascular, respiratory and other malignant illnesses.

The ERAS protocol discussed by Catto includes pre-operative, operative and post-operative steps. Pre-operative checklist items cover patient counselling, pre-operative medical optimization, oral mechanical bowel preparation, carbohydrate loading, pre-operative fasting, pre-anaesthesia medication and thrombosis prophylaxis.

The operative stage includes a minimally invasive approach, resection site drainage, antimicrobial prophylaxis, a standard anaesthetic protocol, perioperative fluid management, and preventing intraoperative hypothermia.

“Do as much as possible out of hospital, do as little as possible to the patient, and activate the patient,” said Catto in summarizing the basic tenets to an improved ERAS for RC patients.

One of the tips he mentioned regarding patient activation is preparing the patient for admission with counselling on expectations, information sharing on recovery and advising on wearing proper easy clothing. In the operative stage, he noted the selective use of drains and anaesthetic techniques.

Post-surgery, Catto also underlined that the nursing staff should advise the patient to avoid wearing pyjamas, and mentioned the ‘pyjama paralysis’ which makes the patient less inclined to be mobile, making them more passive and ‘depowered.’

He noted that ERAS provides better QoL and faster recovery, lower morbidity (better wound healing), less analgesia, with patients observed to walk sooner and faster. There is, however, no difference in length of hospital stay.

Catto also presented a lecture, on behalf of A. Briganti, which tackled sexual and urinary rehabilitation after radical cystectomy. “There is a lack of strong Level 1 evidence of the different approaches on functional recovery,” he said. “Little is also known regarding the impact of surgical volume/quality on functional outcomes. And there are no standardized protocols to improve functional recovery.”

Article by Joel Vega