Division of Surgery and Interventional Science, University College London, London, UK.
Department of Urology, University College London Hospital, London, UK.
BJU Int. 2018 Apr;121(4):632-639. doi: 10.1111/bju.14073. Epub 2017 Dec 3.
To assess the cumulative effect of an enhanced recovery after surgery (ERAS) pathway and minimally invasive robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) in comparison with open radical cystectomy (ORC) on length of hospital stay (LOS) and peri-operative outcomes.
Between February 2009 and October 2017, 304 radical cystectomy cases were performed at a single institution (ORC, n = 54; robot-assisted radical cystectomy [RARC], n = 250). Data were prospectively collected. We identified 45 consecutive ORC cases performed without ERAS before the commencement of the RARC programme (Cohort A), 50 consecutive iRARC cases performed without ERAS (Cohort B) and 40 iRARC cases with ERAS (Cohort C). The primary outcome measure was LOS, while secondary outcome measures included peri-operative 90-day complications and readmission rate. Complications were accessed using the Clavien-Dindo system.
Patients in all cohorts were evenly matched with regard to age, sex, body mass index, neoadjuvant treatment, tumour stage, lymph node yield, previous pelvic radiotherapy and surgery, peri-operative anaemia, as well as physiological state. Patients who underwent iRARC with ERAS had a significantly higher American Society of Anesthesiologists score (III-IV) and were more likely to receive neobladder reconstruction. The median (interquartile range) LOS was shorter in the iRARC with ERAS group (7 [6-10]) days than in the iRARC without ERAS group (11 [8-15]) days and the ORC group (17 [14-21] days). In a propensity score-matched cohort of patients who underwent iRARC, patients who followed the ERAS pathway had significantly lower 90-day readmission rates. Additionally, implementing ERAS in an iRARC cohort resulted in a significantly lower 90-day all (P < 0.001) and gastrointestinal-related complications (P = 0.001). The ERAS pathway and younger patients were independently associated with an LOS of ≤10 days on multinomial logistic regression.
A comprehensive ERAS programme can significantly reduce LOS in patients undergoing iRARC without increasing 90-day readmission rates. An ERAS programme can augment the benefits of iRARC in improving peri-operative outcomes. In studies comparing ORC and RARC, the presence or absence of an ERAS programme will be a confounding factor and only level 1 evidence can be interpreted reliably.
评估强化术后康复（ERAS）方案联合微创机器人辅助根治性膀胱切除术（iRARC）与开放性根治性膀胱切除术（ORC）在住院时间（LOS）和围手术期结果方面的累积效应。
2009 年 2 月至 2017 年 10 月，在一家机构进行了 304 例根治性膀胱切除术（ORC，n=54；机器人辅助根治性膀胱切除术 [RARC]，n=250）。数据为前瞻性收集。我们确定了 45 例连续进行的无 ERAS 方案的 ORC 病例（A 队列），50 例连续进行的无 ERAS 的 iRARC 病例（B 队列）和 40 例采用 ERAS 的 iRARC 病例（C 队列）。主要观察指标为 LOS，次要观察指标包括围手术期 90 天并发症和再入院率。采用 Clavien-Dindo 系统评估并发症。
所有队列的患者在年龄、性别、体重指数、新辅助治疗、肿瘤分期、淋巴结检出数、盆腔放疗和手术史、围手术期贫血以及生理状态方面均具有可比性。接受 iRARC 联合 ERAS 的患者美国麻醉医师协会评分（III-IV 级）更高，且更有可能接受新膀胱重建。接受 iRARC 联合 ERAS 的患者的中位（四分位间距） LOS 较短（7 [6-10]天），而接受 iRARC 但无 ERAS 的患者的 LOS 较长（11 [8-15]天），接受 ORC 的患者的 LOS 更长（17 [14-21]天）。在接受 iRARC 的患者的倾向评分匹配队列中，采用 ERAS 方案的患者 90 天再入院率显著较低。此外，在 iRARC 队列中实施 ERAS 方案可显著降低 90 天全（P < 0.001）和胃肠道相关并发症（P = 0.001）的发生率。多变量逻辑回归分析显示，ERAS 方案和年轻患者与 LOS≤10 天独立相关。
全面的 ERAS 方案可显著降低接受 iRARC 治疗的患者的 LOS，而不会增加 90 天再入院率。ERAS 方案可增强 iRARC 在改善围手术期结果方面的益处。在比较 ORC 和 RARC 的研究中，ERAS 方案的存在与否是一个混杂因素，只有 1 级证据才能被可靠地解释。
