Cerruto Maria Angela, De Marco Vincenzo, D'Elia Carolina, Bizzotto Leonardo, De Marchi Davide, Cavalleri Stefano, Novella Giovanni, Menestrina Nicola, Artibani Walter
Urology Clinic, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.
Urol Int. 2014;92(1):41-9. doi: 10.1159/000351312. Epub 2013 Aug 28.
Different fast track programs for patients undergoing radical cystectomy (RC) can be found in the current literature. The aim of this work was to develop a new enhanced recovery protocol (ERP).
The ERP was designed after a structured literature review focusing on reduced bowel preparation, standardized feeding, postoperative nausea, vomiting and pain control. In order to test the ERP, a pilot observational prospective cohort study was planned, enrolling all patients consecutively undergoing RC and Vescica Ileale Padovana (VIP) neobladder. These patients were compared with a matched group of subjects who had undergone RC and VIP neobladder before implementation of the ERP. To achieve good comparability, a propensity score-matching was performed. The primary aim was to assess the ERP's feasibility; the secondary outcome measures were early morbidity and mortality.
After an exhaustive literature search and a multidisciplinary consultation, an ERP was designed. Nine consecutive patients participated in the pilot study and were compared to 13 patients treated before implementation of the ERP. We did not find any statistically significant difference in terms of mortality rate (none died peri- or postoperatively in both groups). The complication rate, according to the modified Clavien classification, was significantly lower in the ERP group (22.22 vs. 84.61%, p < 0.004). The major limitations are the low number of patients enrolled to test the protocol and the lack of randomization for the comparative evaluations.
The introduction of our ERP was proven to be feasible in the management of patients undergoing RC and intestinal urinary diversion with VIP neobladder. The postoperative course was enhanced by a significant reduction in both nasogastric tube insertion and parenteral nutrition support, with early postoperative feeding. All these findings were associated with no deleterious effect on morbidity or mortality, indeed there was a reduced occurrence of postoperative complication rates.
目前文献中存在针对接受根治性膀胱切除术（RC）患者的不同快速康复方案。本研究的目的是制定一种新的强化康复方案（ERP）。
ERP是在对聚焦于减少肠道准备、标准化喂养、术后恶心、呕吐及疼痛控制的文献进行结构化综述后设计的。为测试ERP，计划开展一项前瞻性观察性队列试验研究，纳入所有连续接受RC及帕多瓦回肠膀胱术（VIP）新膀胱术的患者。将这些患者与ERP实施前接受RC及VIP新膀胱术的匹配对照组进行比较。为实现良好的可比性，进行了倾向得分匹配。主要目的是评估ERP的可行性；次要观察指标为早期发病率和死亡率。
经过全面的文献检索和多学科会诊，设计了ERP。9例连续患者参与了该试验研究，并与ERP实施前治疗的13例患者进行比较。两组在死亡率方面未发现任何统计学显著差异（两组围手术期及术后均无死亡）。根据改良Clavien分类法，ERP组的并发症发生率显著更低（22.22%对84.61%，p<0.004）。主要局限性在于参与测试该方案的患者数量较少，且比较评估缺乏随机化。
在接受RC及采用VIP新膀胱术进行肠道尿流改道的患者管理中，引入我们的ERP已被证明是可行的。通过显著减少鼻胃管插入和肠外营养支持，并早期进行术后喂养，术后恢复过程得到了改善。所有这些结果均未对发病率或死亡率产生有害影响，实际上术后并发症发生率有所降低。
